A new breed of sports warriors is emerging. Well-informed, highly motivated and competitive, these young and middle-aged professionals are usually engaged in the busy occupations during weekdays that leave them with little time to exercise. Come the weekend and these men and women undergo a metamorphosis! Inspired by the likes of Beckham, Owen, Tiger Woods and Michelle Wie, they literally take to the fields; pounding the tracks, crowding the gyms, converging on the greens and meeting on the courts. A certain bravado tends to overtake them coupled with a sense of invincibility perhaps borne out of the freedom of a weekend - hence the term weekend warriors. Our warriors usually do well after the first 9 holes or 5km run. Unaccustomed to such rigors of sports, fatigue sets in easily yet they push on. This is when injuries occur, either catastrophically or gradually.

Mr SMK is an army regular well into his forties who plays badminton competitively. On landing after a smash he twisted his right knee and immediately felt a sharp pain as his knee gave way. Investigations revealed a torn anterior cruciate ligament (ACL) and surgery to reconstruct the ACL had to be performed.

Mr JP is a more typical weekend warrior. An NSman in his thirties, he hardly has time to exercise, except on weekends when inspired by the upcoming IPPT, he runs without warming up. He experienced excruciating anterior knee pain that stopped him from further training. He is currently on physiotherapy and it will be another 3-6 months before he can train vigorously again.

Mr CG has just ORD and was feeling fit as a fiddle. Now doing his tertiary studies, he resumed his basketball with religious fervor but neglected muscle conditioning altogether. His unstable shoulder dislocated again after a game, and he is now waiting for surgery to stabilise his shoulder.

These are typical examples of weekend warriors, individuals who to their credit, pursue sports to maintain a healthy lifestyle, but fail to do so regularly and without proper conditioning.

Knee Injuries
Being a nation of lower limb sports (soccer, running & jogging, cycling), knee injuries are common. Anterior knee pain is a common symptom. This is pain experienced behind the knee cap, and is worse on squatting, jumping and stairclimbing. This can be caused by patella maltracking (tilted knee cap), chondromalacia patella (softening of the knee cap cartilage) or patella tendonitis (overuse inflammation of the patella tendon). Anterior knee pain is usually relieved with rest and physiotherapy to strengthen the quadriceps muscle. Occasionally, arthroscopy (keyhole surgery) may be needed to ‘balance’ the knee cap or debride degenerate tissues.

Meniscus injuries are the most common injuries seen, followed by anterior cruciate ligament (ACL) tears. These can occur together, when a load is applied on a rotated knee, like landing on a twisted knee. The menisci are C-shaped structures that help to cushion and distribute loads in the knee joint, and can act as door-wedges to help stabilise the knee. Meniscus tears that cause pain and instability need arthroscopic surgery to either resect the torn edges or repair them. Repair can be done with bio-absorbable anchors with sutures with very favourable outcomes. ACL tears need to be reconstructed arthroscopically, that is, new grafts fashioned from hamstring tendons or patellar tendons are tunneled to replace the torn ligament. About 80% of patients who had ACL reconstruction in SGH have good to excellent outcomes, many of them returning to pre-injury sports. A novel technique was first introduced in Singapore by Dr Denny Lie and Dr Paul Chang in SGH in 2004, in which two bundles of the graft were reconstructed to better simulate the intact ACL. This resulted in better control of knee rotation. Another innovation is the use of computer navigation during ACL reconstruction to improve surgical precision. Dr Denny Lie was the first in the region to do so in SGH in October 2005.

Shoulder Injuries
Recurrent shoulder dislocations and pain are seen among overhead athletes especially if they have unstable shoulders. Sports at risk include basketball, baseball, tennis, badminton and occasionally, swimming. Patients may complain of subluxation (the feeling of loose shoulder) or outright dislocation, and may have difficulties doing push-ups and chin-ups. Athletes who dislocate their shoulders when they are 20 years old or younger have up to 90% risk of recurrent dislocations, and would probably need surgery to stabilise the shoulder. Physiotherapy is attempted for first-time dislocaters to build up muscle bulk. If needed, surgery is mostly done by arthroscopic technique, in which only 3 small 1cm incisions are made. Surrounding the glenoid is a stabilising rim, the labrum, which is torn after a dislocation. This labrum is re-attached during surgery and augmented by capsular shift to further tighten the shoulder and reduce the joint volume. Long term studies show good results in 85% of patients; our 1-year followup of patients with arthroscopic stabilisation had no recurrence so far.

Ankle Injuries
Lured by the lush greenery, weekend warriors are fond of cross-country running (MacRitchie reservoir) but may overlook the dangers of running on uneven surfaces. Ankle sprains and instability are common even among regular joggers and military personnel. Recurrent sprains tend to stretch out or tear the lateral ligaments (on the outside of the ankle) resulting in further ankle instability. Pain is another symptom, especially when squatting is attempted. Ankle sprains can be stabilised by strengthening the peronei muscles and propioceptive training. If surgery is needed, the Brostrom-Gould repair plicates the torn ligament and uses a periosteal flap to further strengthen the repair. Athletes do return to sports after such procedures without loss of motion.

Prevention: Basic Science to Practice
Ligaments act as tensile restraints, like ropes, and thus fail on compression. They have a limited elastic range, that is, are able to stretch very minimally. Before they can stretch however, the collagen fibres need to overcome ‘crimp’ (that is, straighten out). This is one of the reasons how ‘warming up’ before exercises can prevent injury. Training and conditioning can strengthen ligaments, improve performance and prevent injuries. The basis of this is because ligaments are able to adapt, increasing their stiffness and strength by repetitive conditioning.

Armed with such knowledge, weekend warriors can formulate strategies to achieve a sustainable exercise programme, maintain fitness and yet minimise injuries. Some of these measures include:

1. Baseline fitness: recognise one’s level of fitness and any prevailing illnesses before setting out a goal. If in doubt, consult one’s doctor first. Chronological age alone is not a hindrance; one can be fit even in the seventies!

2. Set a realistic and achievable goal within a realistic time frame. An unrealistic goal is not only discouraging, but would lead to failure and precipitate in injuries.

3. Have proper guidance and motivation. Gym instructors and PTIs are trained to properly and gradually improve one’s training and performance. Motivation is equally important to sustain the momentum. The target alone (IPPT, marathons) may not be sufficient, training with friends helps to encourage each other.

4. Warming up and down before each training period is important.

5. A balance of exercises is recommended, comprising cardiovascular exercises, muscle training and flexibility.

6. Proper attire and shoes

7. Adequate re-hydration especially if one is training in the afternoons.

In summary, although there is an increasing trend of injuries among weekend warriors, these injuries need not be incapacitating. It is important to first recognise some of these injuries as described in this article. Secondly, adopt some strategies to prevent them, as pointed out above. Finally, if in doubt, consult an orthopaedic sports surgeon or sports physician early, remember, professional medical help is never far away in Singapore! In the meantime, may the breed of weekend warriors flourish – go forth and exercise!

The Orthopaedic Sports Medicine Service offered at Singapore General Hospital manages injuries sustained in sporting activities with an emphasis on arthroscopic surgery for injuries of the knee, shoulder and ankle. For more information, please call 6321 4603 (during office hours) or visit http://www.sgh.com.sg.

Dr Denny Lie is also a visiting consultant to the SAF Medical Corps and runs an Orthopaedic Sports Clinic at MMI fortnightly on a voluntary basis.