All right, so I guess thanks again for having me back. I got asked to give this talk this year. So if you didn't like the first talk, now is a good time to take a break because it'll be in very similar vein to the last talk. As Dr. Gill just mentioned, we're going to talk about a lot of things. Again, I don't have anything to disclose for this talk. But in the next hour, we're going to try to cover head injury and concussion, which I just mentioned to someone else I've spent, actually, multiple day conferences on. So we'll give you what we think is pertinent and what you could be tested on. We'll talk about some dental issues that occur in sports, eye injuries in sports, abdominal trauma in sport. And that'll take you back to the last lecture we just had, somewhat with infectious mononucleosis. And I'm going to briefly talk about some of the injection things that may show up, although you should be much more familiar with some of this data, I would imagine, than some of these medical issues that we're going to talk about here in this next hour. So what do we know about head injury in sport? It's a really important topic that we still don't know a lot about. And in fact, the numbers of questions that you can get will be somewhat limited because of some of the controversy that exists about head injury in sport. We don't know about the prevalence or incidence of head injury in sport because many of them are not reported by the athlete, right? So still in this day and age, when we have much better education and we're much more vigilant, do a much better job diagnosing head injury in sport, we still don't know the true incidence and prevalence. The good news is that most head injuries in sport are minor and recoverable. And so although there is a lot out there, and most recently in the literature, about the risk of CTE in football players and catastrophic damage from head injury in sport, the reality is that most head injury in sport is minor. And in fact, sports in adolescent athletes is the third leading cause of head injury behind motor vehicle accidents and falls or other accidents. But it is that in sport the most common head injury is a concussion. So what do we need to know about head injury in general? We need to know that there's two types of head injury. Focal head injury is usually due to blunt trauma. And that's usually associated with things like loss of consciousness and focal neurologic deficits. So what we're talking about here are things like subdural hematomas, epidural hematomas, cerebral contusions, and intracerebral hemorrhages. These are rare in sport. They can occur, and I'm going to draw your attention to some warning signs here in a little bit that you want to pay attention to, but they're rare. They are neurosurgical emergencies, and you need to be aware of them, obviously. But they're rare when we talk about head injury in sport. Much more commonly are diffuse head injuries, which are not associated with focal intracranial injuries. These can vary in their severity depending on the amount of anatomic disruption to the neuron and axonal disruption that occurs. And that's what a concussion is. So I mentioned to you that concussions are the most common head injury in sports. It's been around for a long, long time and was first described as an abnormal physiologic state without gross traumatic lesions of the brain. And we could probably use that same definition today, although we've become much more complicated in how we define concussion. And we still, even today, don't understand everything about the pathophysiology about concussion. So by way of definition, this will capture a lot of what concussion is and is not for you. It's a complex physiological process that affects the brain induced by traumatic biomechanical forces. And I just talked to you about that, and we'll spend a slide here in a little bit going over that mechanism. It can be caused by a direct blow to the head, face, neck, or elsewhere on the body with an impulsive force transmitted to the head. So you don't actually have to get hit in the head to have a concussion. It typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. It can result in neuropathological changes reflecting a functional disturbance rather than a structural injury. Graded set of clinical syndromes that may or may not involve loss of consciousness. And so I'll review that with you here in a little bit. But 15, 20 years ago, most grading systems for concussion used loss of consciousness to determine severity. And we know now that that has no bearing on the severity of the head injury. And concussion, in general, is associated with grossly normal neuroimaging studies. One of the things you're going to want to pay attention to is the anatomy of a concussion. And so this slide is provided for you. But there's two types of concussion described by impact forces. And again, remember, this is the impact that the force that is transmitted to the brain. So you don't have to necessarily get hit in the head in order for a concussion to occur. So there's linear concussion mechanism, which is a direct impact that stops the head's forward motion. But inside the skull, the brain continues to move, colliding with the inside of the skull. And it can injure the frontal lobe. And then, as you know, with the counter-coup mechanism, you can get an injury that causes injury to the occipital lobe. This is the type of concussion mechanism that is thought to occur in those folks that present with concussion symptoms that don't report one significant injury. So it might be the football player that said, man, I don't remember one hit, or I don't remember one thing. But after this practice, or after doing this drill, I just got jarred a bunch of times and kept getting hit in the front of the head. That may be a reason for concussion. More significant, usually more significant for injury, is a rotational injury from a lateral impact. So just imagine a boxer or an MMA fighter getting hit in the side of the face. That spins the brain on its axis, stretching or tearing neurons. And that is thought to be much more significant for injury in concussion. So rotational impact is thought to be more damaging than linear impact for anatomy of head injury or concussion. This slide's busy, but you'll want to pay attention to it because it describes for you some of the signs, symptoms, that you want to be aware of for someone that has a concussion. So there are cognitive deficits. And we know now that amnesia, and highlighting amnesia, antegrade and retrograde amnesia, is one of the telltale signs that someone has suffered a concussion. Again, we've de-emphasized, or loss of consciousness has been de-emphasized as importance for concussion. All of these other disoriented feelings, vacant stare, excessive drowsiness, slurred, incoherent speech, all things that can occur with concussion. There's lots of somatic symptoms that occur that I'm sure you're aware of. Headaches, dizziness, balance disruption, which you'll see is an important part of the evaluation for concussion, short-term nausea and vomiting, visual disturbances, photophobia, blurred double vision, and then phonophobia, or the aggravation of hearing loud sounds. One of the most important things about concussion is there's an affective component. So this may be the athlete that becomes very irritated, agitated, aggressive, may be crying, may have emotional lability, may have a lot of anxiety. And then certainly early on in a concussion when we're making the diagnosis, there's lots of issues with sleep. Trouble falling asleep, sometimes after a couple of days sleeping more than normal or sleeping less than usual. So lots of symptoms that can be suggestive of concussion. What you do want to pay attention to are those signs and symptoms that suggest there may be a more significant head injury. So in your role as a sports medicine physician, team physician, when should you be thinking that there's something more going on than just concussion? And these are some things to pay attention to. That progressive worsening headache, or the worst headache of my life, that is not usually concussion and needs to be evaluated. If someone's becoming very drowsy or cannot be easily awakened, we certainly worry about one of those other conditions we talked about, bleed, intracranial process. If you can't recognize people or places that significant recurrent nausea or vomiting behaves unusually, more confused, irritable, or deterioration in neurocognitive function. Seizure is something you want to pay attention to. Seizure is not normal for concussion, so that patient needs to be evaluated for a more significant head injury. Certainly weakness or numbness in arms and legs, and there's been more emphasis now in concussion management placed on the evaluation of the cervical spine. And I'll mention that here in a minute when we talk about the evaluation of the concussion. And then slurred speech or unsteadiness of gait. So these quote, unquote, red flags are signs and symptoms you want to pay attention to. If presented to you in a clinical vignette, you'll want to know that these may be significant for something more than concussion and may require more than evaluation for concussion. When we evaluate concussion, the standard concussion assessment tool, or SCAT 3, and now SCAT 5 is out, although I didn't put it into this talk because it wasn't released until the end of April or May. So I doubt that it will show up on your examination this year. And there's only a few differences in SCAT 5 that I'll mention here today. It combines a cognitive assessment. So the first part of the evaluation here you see are the MADX questions. And these MADX questions are useful at the time of injury. So these are the classic questions that you may be asking, for example, at the time of concussion. What month is it? What's the date? What's the day of the week? What year is it? What time is it right now? And then there is things that have to do with memory because we know that memory is important for the evaluation of concussion. So to evaluate immediate memory with different trials and then concentration, looking at digits and being able to evaluate successive complexity in forward and backward fashion, and then being able to use months in reverse order, coming up with a concentration score, and then a delayed recall score. This is part of the cognitive assessment of concussion, but that's not where concussion assessment ends. There's a symptom assessment, and this is something that should be baselined and then looked at for each athlete when they have a concussion. And so you'll see all these symptoms. But again, monitoring the symptoms and following them forward in time is important. All of these tools that I'm showing you are effective for about 7 to 10 days after concussion and then lose their effectiveness for evaluating concussion. But you'll see here in a moment that sport concussion symptoms over 90% of the time resolve within about 7 to 10 days. And then balance plays a large issue in the evaluation of concussion as well. So that multimodal assessment, cognitive assessment, symptom assessment, and balance assessment, very important when you're acutely evaluating an athlete that you think may have a concussion. And you'll see here some of the best testing that's well known and done in tandem gait testing. In addition, in SCAT 5, which I do not think you will be asked about, there is a section now on cervical spine and screening so that we do not forget about the cervical spine and the head injured athlete. There is also some questions that ask about general neurologic function. Again, nonspecific, but draw our attention to deteriorating status and some of those red flags that I mentioned there. But otherwise, SCAT 5, other than other descriptions and other instructions for patients, looks very similar to what I'm presenting you here today. So I don't think there'll be anything else on your exam that you would miss from the evaluation of concussion that I haven't presented here. What do we need to know about return to play? If you take nothing else away from concussion, it is standard of care that you cannot return to sport or play on the same day as a concussion. That's true by the US Team Physician Consensus Statement since 2010. That's been a bylaw from the NCAA, and now legislation which started with the Lysert Law in the state of Washington with Stan Herring and Zach Lysert, and now is law in 50 states. So you cannot return an athlete on the same day that they suffer a suspected concussion or a concussion. That's really important to know. There's probably nothing else more important to know about a concussion for a sports medicine physician than that. The other thing you want to pay attention to is duration of symptoms. Sports concussion symptoms resolve over 90% to 95% of the time in 7 to 10 days. If you have prolonged symptoms, you are now entering what's called post-concussive syndrome. And that is a complete different entity that we are not going to discuss here today than concussion or concussion in sport. Again, concussion needs to have that multimodal assessment that I mentioned to you. So you want to pay attention to the cognitive function. You want to pay attention to symptoms. And you want to pay attention to balance and look for deficits there. What do we do for return to play? How do we return an athlete to play? And Berlin 2017 has reiterated that there needs to be a stepwise return to play criteria that's enacted when we return an athlete to play progression. Many people say that you need to wait 24 hours in between these steps. But there is no validated time requirement. You can't just say in two minutes, let's go on to the next step. But the standard of care is to wait at least a day in between these steps. But the steps do have five, usually, steps before you return to game competition, no activity for recovery, then light aerobic exercise, sports-specific exercise, non-contact training drills, and then full-contact practice. And then you can return to game play. So again, you could be expected to know this progression of activity for return to play for concussion, knowing that you cannot return an athlete just once they feel better, hey, go back to sport. Go get your helmet. Go back to play. I'm going to mention neuropsychological testing because it comes up. It's been shown to be of value when evaluating concussion. But you need baseline testing. Normative data is not effective for evaluating athletes with neuropsychological testing. And you need periodic baseline updates as well, usually annually to biannually for these tests to be effective. Players can return to baseline testing while still symptomatic. So these are not foolproofs. They're only an aid to your clinical decision-making. So all of the COGSport and IMPACT and all the tests that you use is not a fail-safe that, hey, once you return to normal on this test, you're cleared and ready to go back from concussion. It is a piece of that multimodal assessment that allows you to have an aid in clinical decision-making, but is not a definitive test in allowing someone to return to sport following concussion. Neuroimaging, I mentioned to you in the definition for neuroimaging that neuroimaging is not abnormal in concussion and oftentimes is not needed unless you are suspecting that there is some other injury. If you do suspect there's another injury or if you get one of those red flags, the initial scan of choice, as you're probably aware, is a CT scan to look for acute bleeds. And then if something's persisting beyond 48 hours, MRI becomes more sensitive and specific. But the initial study of choice, if you are presented with one of those red flags, would be a CT scan. There's lots of newer modalities that many of you may be familiar with, PET scans, functional MRIs. They're very promising. They're used in research areas. But again, we don't have normative data. We don't really know what to do with those for the evaluation and treatment of concussion. And so they're not established for use in concussion. And I don't think you'll see questions on that neuroimaging. Why do we worry about concussion? Well, there can be serious risk. And I doubt that you'll be asked about CTE, but you could be asked about second impact syndrome because it is a risk for morbidity and mortality following a concussion. It's considered to be the most serious risk of premature return to play following a concussion. And it is suggested that any insult to the head following premature return to play causes instantaneous collapse and death during second impact syndrome. It has been documented. It's thought to be due to the loss of the auto-regulation of the brain's blood supply, which doesn't return, usually, for about seven to 10 days after the concussion. So that resolution takes some time. And that's the risk if you return somebody too early to play. There's lots of researchers that have questioned the existence of this syndrome because it's only reported in case reports, but it has been documented, and so you need to be aware of it. What else do you need to be aware of about concussion? Well, that prevention is probably the most important thing about concussion. And there's multiple factors that can help with head injury prevention in sport. Equipment modification is one of those, but I would draw to your attention that there is no helmet on the market in any sport today that can prevent concussion. Unless you're talking about NASCAR and some of the helmets that they use, which have been shown to decrease the incidence of concussion, but there is no helmet today that you can say decreases the incidence or prevalence of concussion. Probably the biggest impact that we can make in sport is rule enforcement and changes as necessary, best illustrated by, in college football, for example, the change in kickoff yardage so that the kickoff return is eliminated, which is one of the highest incident plays for concussion. And then education of proper sport-specific techniques, tackling techniques, those sorts of things to decrease the incidence of concussion. But there is no clinical evidence that we can eliminate the risk of concussion in sport. So there's nothing out there that just eliminates that risk, especially in those athletes where head trauma is likely. So what types of questions could you see on concussion? And probably there'll be less on concussion than you might think, because there is so much disparity amongst clinicians on some of the issues with concussion. But this is one thing that you could see. A collegiate women's soccer player suffers a head injury during the first half of a game. As the event physician, you are asked to assess her ability to return to play in the second half of the game. Which of the following is the most appropriate course for her return to play? And of course, the key to this question is in the second half of the game. She may return if she's asymptomatic. She may return if she is willing to sign a waiver. She may return if she passes a sideline graded exercise challenge and is asymptomatic. And she should not return to play for this game under any circumstances once diagnosed with a concussion. And I've told you if you took nothing else away from the concussion talk, is that she should not return to play for this game under any circumstances once diagnosed with a concussion. So that may not be standard of care for what you're used to, but that is standard of care for concussion. How about a second question? I mentioned to you a high school football player suffers a concussion during a game. Which of the following symptoms suggest a more serious head injury? And again, recognition of symptoms. So dizziness, a brief episode of vomiting, seizure, blurred vision or amnesia. And I did mention to you that seizure is concerning for more significant head trauma. The rest of these symptoms can be seen in concussion and can be monitored. So those are the areas where I think for head injury in sport and concussion, that you wanna be aware of potential questions for your examination. Spent a little bit of time now talking about dental injuries. And dental injuries in sport are secondary to trauma. So you gotta basically get hit in the mouth to have dental injury in sport. There are avulsions, fractures, luxations, lacerations, temporal mandibular joint pain, and contact sports as I just mentioned have the highest incidence. But the three highest incidents are actually baseball, basketball, and ice hockey. So you can know a lot about dental injuries if you just pay attention a little bit for 20 seconds to the anatomy of the tooth. And you can see the outer crown here covered with enamel, the next layer being the dentin, and the next layer being the pulp. That'll be important when we talk about dental fractures. You'll wanna pay attention to the root as well. And then obviously you can see that that sits in bone and so some of the luxation injuries that we'll briefly talk about as well. But paying attention to this anatomy will help you as you think about dental injuries that can occur in athletes. So dental fractures are common in athletes. They can involve all three layers as I just mentioned, the enamel, the dentin, and the pulp. They're associated with pain when exposed to air, cold drinks, or touch. So any of you that have had a dental fracture know what this feels like. Oftentimes if you have a loose tooth fragment, you wanna try to save that so you can place it in a Hank's solution, milk, or a saline solution. If you only have a fracture of the enamel, that is not a dental emergency. That's the only fracture I'm gonna talk about that's not a dental emergency. So if someone just has a fracture and it only involves the enamel, they can continue to play and they need to see the dentist within 24 hours. All the rest of these I'm gonna talk to you about are dental emergencies and really, in order to save the tooth, they need to be seen sooner. So what about dental fractures that get down to involve the dentin or especially the pulp? Those are very serious and can require immediate referral and if not treated can lead to pulpal necrosis and loss of the tooth. So again, the expectation as a team physician or sports physician is that you would be able to recognize this injury and know that if left untreated, it can lead to loss of the tooth. There's lots of treatment options that you don't need to know about, but you need to know about the seriousness of the injury itself. What about dental fractures that involve the root? In a short sentence, all of them are bad. There's lots of crown mobility. If you can move that tooth around and there's tenderness to percussion, they need to see a dentist immediately. There's three different types and it's the cervical root fractures that are more close to the tooth that have the worst prognosis, but they need immediate dental referral. So if you can move the tooth, they have pain to percussion and there's a suspected root fracture, that needs immediate dental referral. What about dental luxation or a tooth luxation? Luxation, that's considered kind of a concussion to the tooth, so you can have a subluxation, which is mobility of the tooth without any clinical or radiographic evidence of dislodgement. You can have extrusion of the tooth where you have this partial avulsion from the bone and you do want to attempt to reposition that tooth and then get the person to the dentist and you'll see why in just a moment. Lateral luxation where the tooth is moved laterally. Intrusion injuries where they're displaced into the socket. Any of these injuries need to see a dentist. They cannot wait, okay? Dental avulsions are common and commonly asked about in sport because it's really important that you do something in order to save the tooth. So this is when the tooth itself is displaced completely out of the socket. And this accounts for 21% of all dental and 10% of sport dental injuries. It's really important, if you can, to get that tooth re-implanted within 15 to 20 minutes because we know if you do that, there's about a 90% chance that the tooth will be retained for the rest of the person's life. If you don't get the tooth implanted, there's a 90% chance that they're going to lose that tooth. So if you can't re-implant the tooth, you should put it in, if you have it, Hank's Balance Salt Solution, which comes in most of the tooth preservation kits that are included in medical kits, or cool milk, or saline, or saliva, and then get an emergent dental referral. So you want to get teeth re-implanted quickly so that you don't lose the tooth. And this is commonly asked about because it occurs often in sports. What about dental injury prevention? Mouth guards are good. What are mouth guards not good for? Preventing concussion. So I mentioned concussion. So if you're going to wear a mouth guard, it's because the mouth guard is really helpful for preventing dental trauma. And it's recommended by the American Academy of Pediatric Dentistry and the American Dental Association that all children and youth wear mouth guards for any sport to protect against dental trauma. They have been shown to reduce oral facial injuries, and custom molded mouth guards per the Academy of Sports Dentistry are recommended. So mouth guards are good. They offer prevention and can prevent tooth trauma. But they do not prevent concussion. So what types of questions could you get on dental trauma? A collegiate rugby player suffers a dental fracture. Which of the following does not require urgent referral to a dentist? A dental fracture involving dentin, one involving pulp, one involving enamel, one involving the middle root, or one involving the cervical root? And I told you the only dental fracture that it's okay to continue to play with is one that involves enamel. All of the rest of these would require immediate dental referral. How about this question? I think this is very likely if you get a question, a dental question, the type of question that would show up. A collegiate women's hockey player suffers a tooth avulsion. Which of the following is appropriate management regarding this condition? Have the athletic trainer pack the tooth in ice and follow up with the dentist in 24 hours? Attempt to re-implant the tooth. If not successful, place the tooth in Hank's basic salt solution and immediately refer to a dentist. Re-implant the tooth and allow immediate return to play. Follow up with a dentist after the game is finished. Or discard the tooth. It is not viable following avulsion injury. And we just talked about this, but in order to save that tooth, you want to attempt to re-implant it within 15 to 20 minutes. Remember I told you that 90% of those will go on to be retained for life, and then if you don't, they will oftentimes not be retained. And if not, place it in an appropriate solution and refer to a dentist. This is the type of thing that you'd be expected to know as a sports medicine physician if you're covering athletes that could have dental trauma. That's all I know about dentistry. I hope that's all you need to know about dentistry as well. Let's talk about ocular injuries. Again, eye injuries are important. Again, recognition pattern is important. Knowing the types of injuries, whether you can return to play, and what needs referral. So risk of sport obviously is important, and this list will just give you an identity of sports that have high risk of ocular trauma. So it makes a lot of sense that if you're playing without goggles and you have a BB gun or paintball, you could be in big trouble for ocular trauma. Basketball and baseball again. Softball and ice hockey, high incidence of ocular trauma. And then you can see more moderate injuries. Certainly ball sports where there's no facial protection, where the ball can enter the ocular socket is important to pay attention to. And then you'll see some of the lower sports here. An eye safe is considered exercise, which is jogging, running, walking, or aerobics. And that'll become important when we talk about the functionally one-eyed athlete, which you need to know about as well. So it's important when you have ocular eye injuries in sports that you understand what the mechanism of injury is. It's much more likely that you'd have different diagnoses, depending if you get hit in the eye with something, a high-velocity penetrating object, such as a finger versus blunt force, ball or something else hitting the ocular socket, which can lead to blowout fractures and other injuries, retro ball bar hemorrhages, globe ruptures. Athletes that complain of forward body sensations, decreased visual acuity, blurred vision, or diplopia, they have to be evaluated for an ocular injury. So what is your responsibility as a sports medicine physician? Well, it's to try to establish some sort of ocular examination. So certainly, the most important thing is visual acuity. So you ought to have availability and know how to use a Snellen chart to see if there's been a significant loss of visual acuity. You want to know about visual fields. So all those fun exams you used to do with your fingers back in medical school to look at lateral field vision, you want to go back and review those. You certainly want to pay attention to the pupils. Not only their reactiveness for afferent and efferent patterns, but also for distortion of the pupils. So a teardrop pupil being a sign of a globe rupture. So you want to look for asymmetry of pupils. You certainly want to examine the conjunctiva and look at the cornea as well, and then certainly do an examination consistent with looking for facial or maxillary bones fractures. So what sorts of injuries occur? Corneal abrasions. This is a defect in the corneal epithelium. Very common, especially if someone gets poked in the eye, a foreign object to the eye. Sharp pain, lots of tearing, photophobia, this foreign body sensation. Oftentimes, you don't find a foreign body. The test you wanted to use is a fluorescein dye test, which will show you the actual corneal abrasion or corneal defect. The treatment for corneal abrasions is topical antibiotics. And occasionally, you can use cycloplegics to help with discomfort. What you do not do with corneal abrasions is patch the eye. That is not considered a standard of care. And so you don't want to put pressure or patch, excuse me, on the eye if you have a corneal abrasion. You do want to make certain that you don't allow folks to wear contact lenses until it's healed. So they may need polycarbonate goggles or something else in order to participate. And you only need to refer, obviously, if there's significance to this. But this is a common injury that you'll see in athletes. Orbital wall fractures or orbital blowout fractures. You do want to know about these because they're common with mid-face trauma and with trauma to the eye. It follows blunt eye trauma. Very commonly, this clinical scenario you'll be given is someone's playing a ball sport, racquetball, tennis, something like that. And they don't have on any eye protection. And they get hit in the eye with the ball. Oftentimes, these folks complain of blurred vision or diplopia. And that's due to extraocular muscle entrapment, secondary to the fracture. Oftentimes, they'll describe to you in the clinical vignette numbness on the cheek, which is due to infraorbital nerve involvement in the fracture. You want to make certain that you don't allow these athletes to blow their nose. They can increase intraocular pressure and cause worsening if they have a globe injury, retinal detachment. So you don't want to allow them to blow their nose. CT scan is obviously the study of choice to evaluate for this fracture. And it needs referral. But knowing these sorts of clinical highlights about this injury will help you make the diagnosis and then be certain that you get appropriate treatment. Hyphema is something that you want to know about and gets commonly asked about, because it can be a cause of blindness, increased intraocular pressure, and acute glaucoma in athletes, especially athletes that get poked in the eye. It's secondary to shearing forces, to vessels of the iris. And what you want to remember about hyphema is there's a layering of gross blood in the anterior chamber. So you can see here, this is a really good depiction of a hyphema. Oftentimes, if you're looking at somebody with a dark iris, looking straight on, you won't see that blood. But if you look at them perpendicularly with a pen light, you will see some of that blood accumulating in the anterior chamber. You want to make certain you immediately rest that athlete. Have their head elevated to at least 30 degrees. You probably will not administer cycloplegic drops. That'll probably be done by an ophthalmologist. There is a large risk of re-bleeding if they go back to activity and acute glaucoma, which can lead to blindness. And so this is the sort of injury that they want you to know about because there's permanent dysfunction or blindness that's caused by it. Globe ruptures, you want to know about globe ruptures. This is the classic racquetball injury to the globe. There's oftentimes pain, visual loss, a hyphema, a pupil irregularity. So I mentioned to you, if they mention, show you, or say anything about a teardrop pupil, the answer is globe rupture. Anything you see that mentions a teardrop pupil, the answer to the question is a globe rupture. If you see a diffuse 360-degree subconjunctival hemorrhage, so a picture similar to this, where the entire conjunctiva shows hemorrhage, the answer is globe rupture. They need a prompt referral, and they need an eye shield. They do not need an eye patch. You do not want to apply pressure to the eye. And obviously, there's a high risk for serious infection and blindness. One of the other conditions that I don't mention here, but if you see proptosis or a picture of proptosis or a mention of proptosis in the clinical vignette, the answer is retrobulbar hemorrhage because there's blood accumulating behind the eye. They're not going to talk a lot about the visual problems with the stretch to the optic nerve or the disruption to the ophthalmic artery, but they will mention proptosis because when you have bleeding behind the eye, you will see that eye moving forward. And so if they mention proptosis or show you a picture of somebody with proptosis, the answer is retrobulbar hemorrhage. Retinal trauma or detachment, you need to know about this because this is common. This can occur because of direct trauma to the orbit or significant head trauma. So this is the classic person with a concussion that has a visual problem, and you miss it because you really didn't do a good visual exam or pay attention to the symptoms that they're talking about. So these folks complain about floaters, flashing lights, blind spot on the edge of the visual field, and they require urgent referral to ophthalmology, but it's the recognition that you need to be aware of for a retinal detachment, especially in an athlete that's suffered head trauma. And I'll show that to you here in a question in a minute. So what about return to play guidelines? I provided you with this chart, which is fairly easy to follow for return to play. And you can take a look at this. Oftentimes, as I mentioned to you, many of these should not return to play until they've been seen by a physician or an ophthalmologist and cleared. I do want to mention the monocular athlete because you could see a question on this very similar to what Dr. Best has mentioned earlier in the pre-participation examination. It's very important. The ocular exam is a very important part of that examination. And understanding the monocular athlete, again, not putting an athlete at risk for permanent blindness. So for the athlete who's functionally blind in one eye, they have to have polycarbonate goggles to protect the remaining eye and should be recommended at the time of the pre-participation exam. So this could show up as a combination between PPE and ocular trauma. Under no circumstances, even with polycarbonate lenses, are they allowed to participate in boxing, full contact martial arts, which includes MMA. And functionally one eyed, what does that mean? The best corrected functional acuity of no better than 20, 40 in the poor seeing eye. So if you can't correct the vision in the poor seeing eye to better than 20 and 40, you have a monocular athlete or a functionally blind athlete. And you'll want to remember that number. That could be important in test question. So let me just give you a couple of questions here and just kind of show you how this may relate to sports medicine. So you're seeing a 12-year-old male for his PPE prior to the basketball season. And his visual acuity screen results are the following, 20, 30 right eye and 20, 100 left eye. So we have an eye that's worse than 20, 40. And you're going to remember that number and know that this is a monocular athlete or a functionally one eyed athlete. And which of the following is appropriate advice for the upcoming season? And you may very well see a question like this because, again, it's your advice that may prevent this athlete from becoming blind or functionally blind. He may not play basketball because of risk of eye injury. Well, disqualification is never usually a very good answer. He must wear contact lenses in order to play. So that's saying, can we correct his vision? He should follow up to have his vision further evaluated but can play basketball immediately. He is required to wear polycarbonate goggles since he is functionally one eyed and should have appropriate follow up for visual acuity deficit. And so that is the appropriate answer. Or he does not need any follow up and can play basketball without restrictions. So being allowed to play, if you see someone and their vision's not corrected at the time of that evaluation, you should recommend polycarbonate goggles and that they have appropriate follow up for visual screen. And then this question, a football player presents to you acutely on the sideline with complaints of loss of vision in the lateral visual field of his right eye. He was hit on the right side of the head and immediately had the sensation of seeing flashing lights in the right eye. Which of the following is the most appropriate treatment at this time? And as you know, this is the classic two step question. They want you to come to the diagnosis of retinal injury or retinal detachment and then know what you should do for that injury. So this is not a corneal abrasion. So prescribe topical antibiotics and continue play. Finish the game and then assess visual acuity. Place a pressure dressing on the right eye and send to the emergency room. Monitor on the sideline and if symptoms improve, allow them to return to the game. Or emergent transfer and referral to ophthalmologist for evaluation and treatment. And you know that for a retinal detachment, you need an emergent referral. Remember again, no pressure dressings for the eye. Increased interocular pressure is bad. All right, we are on the home stretch here of these medical issues and issues for athletes. Let's talk about some abdominal injuries. And I mentioned some of this in my previous talk when we talked about infectious mononucleosis. And we'll talk a little bit about abdominal trauma. But common abdominal injuries in athletes and what you may need to know about. Rectus sheath hematomas are very common. Fortunately, they're usually uncomplicated. As you know, that's bleeding into the rectus sheath, secondary to blunt trauma and injury to an epigastric artery. Oftentimes, the athlete complains of pain. There may be a palpable mass there. There may be some tenderness when you palpate that. But oftentimes, these are self-limited. Tensing abdominal muscles can increase pain if these are large, although very rare, can be associated with signs of shock. If you need to evaluate them, ultrasound can evaluate these for you. Or if you're more concerned about other abdominal injuries, a CT scan of the abdomen is used. As I mentioned, treatment is self-limiting. But if you have a patient who's having worsening symptoms, they may require surgical consultation if the patient is unstable. We've talked about splenic rupture. And so when things show up in one or more areas, you're likely or more likely to have a question about it. I mentioned the risk with infectious mononucleosis. But even without infectious mononucleosis, spleen is the most common abdominal organ injured in sports activity. Liver is second. So hepatic lacerations are the second most common injury. And then the pancreas is third, so much more rare to have the pancreas injured. But the spleen is the most common abdominal organ injured in sports activity. Oftentimes, it's due to a deceleration injury. So you don't necessarily have to have trauma to injure the spleen. There can be shearing forces on the capsule and vessels, which can lead to splenic injury. Obviously, blunt trauma to the left upper quadrant can lead to injury. But if you remember back to what I said to you about infectious mononucleosis in my last talk, most splenic injuries in athletes that have infectious mononucleosis are atraumatic. And that's because most splenic injuries in sport are due to deceleration injuries or shearing forces on the capsule and the vessels. So this is hopefully just kind of driving home that point to you of why you can't return to exercise with infectious mono. What are the symptoms of a splenic rupture? You need to know this, because you could be presented with these in a clinical vignette. Obviously, left upper quadrant abdominal pain can be very sharp and then become dull. What's classically described as KERR sign, or the KERR sign, which is irritation of the left shoulder due to diaphragmatic irritation from bleeding from the spleen. And so you'll want to pay attention to that. Nonspecific signs, nausea, vomiting, tachycardia, orthostatic hypotension, all things that could suggest intra-abdominal trauma. And then certainly associated rib fractures. So if you're getting a rib series and they report lower rib fractures on the left side, you want to be worried or concerned about splenic trauma in an athlete. Imaging, I mentioned before. Focused abdominal ultrasound is used to identify hematoma or fracture, but it is not good for splenomegaly. So ultrasound can be used to look at injury, but what I mentioned to you before with use of ultrasound to determine the resolution of splenomegaly in infectious mononucleosis still holds. It's not beneficial. CT study is the study of choice, obviously, for stable patients and looking for other injuries. The management is oftentimes conservative. It depends on the hemodynamic status, obviously. Hopefully, these patients, and most of them do, recover without surgical intervention. Sometimes they require angioembolism to stop bleeding, and more rarely, a splenectomy. What you do need to know about those patients that require splenectomy is that they have immunizations that they need to receive sooner than other folks, especially strep pneumoniae and Neisseria meningitidis. So those could be asked, if you have a patient with a splenectomy from sport, what needs to be recommended to them in their follow-up care? And it's that they need those immunizations sooner than their counterparts that still have their spleen. Let me mention renal trauma, because this is common. And oftentimes, questions come up about renal trauma in athletes. Again, the kidneys are normally well-protected and oftentimes are not injured. But the kidney, again, with a blow to the flank, can have this coup-countercoup injury, which can lead to injury, which can be anything from a capsule or hematoma to actual fracture of the kidney. The most common symptoms for a renal injury are flank pain and hematuria. So if you get a question where they present an athlete to you with flank pain and peeing blood, they have a kidney injury. Renal contusion is the most common injury in sport. More significant injuries are rare, and you have to monitor them for hypovolemic shock. So they need hemodynamic monitoring. This is not somebody you send home and say, come back in the morning. They obviously cannot return to play, either, if they have this injury. CT scan, again, is the imaging study of choice. And management, although often conservative, you need to have observation and fluid volume management. And you need to have resolution of hematuria before you can even consider return to play. I doubt they'll ask you about the specific grades. There's five grades of renal trauma, renal lacerations, and fracture, and when they can be returned to play, and how long those take to recover, and all of those things. But I think you could be presented with a scenario where you would be expected to identify someone with renal trauma and what the appropriate treatment and management would be. Testicular trauma. Testicular trauma is also common. And again, if you're catching a theme here, what they want you to know on test is things that can cause mortality or morbidity to athletes, especially in these areas. So if you're a team or sports medicine physician, how can you prevent these permanent injuries? So testicular trauma is one of those areas. You can have contusions, which are very common and self limited. Torsion or fracture is a urologic emergency. And you'll be expected to understand those emergencies here. If you are presented with a question about testicular trauma in any way, the first study that you get is an ultrasound of the scrotum or the testes. So that is the study of choice. It is not a CT scan, MRI scan, other tests. And this is commonly asked. With a contusion, obviously, rest, ice, and compression. But all other injuries are emergencies, as I mentioned. And you need an urgent referral. And if left untreated, you will very often end up with loss of the testes, loss of reproductive function, and that is not a good thing. So they want you to obviously recognize that. So we've kind of talked about that. If you think about dental injuries, you don't want people to have permanent loss of their teeth. Ocular injuries, permanent loss of vision, or loss of eye function. Now, obviously, with renal or testicular trauma, very similarly, the same thing. So let's put this in the context of a couple of questions here. You're seeing a rugby player who's complaining of left upper quadrant abdominal pain radiating to the left shoulder after completing a game. What is the most appropriate management at this time? And if you remember back to what we just spoke about a few minutes ago with the spleen, left upper quadrant pain, and I mentioned to you the KERS sign, which is that diaphragmatic irritation, which will have that pain radiating to the left shoulder, can be significant for a splenic injury. So A, urgent urinalysis to evaluate for renal injury. B, emergent referral for hemodynamic monitoring and abdominal CT to evaluate for splenic injury or rupture. C, observation and treatment with Kotorilac for pain. D, reassurance that this is normal following a contact sport like rugby and will resolve spontaneously. Or E, an EKG and cardiac workup for suspected myocardial infarction. A little bit tricky, because if you had somebody with chest pain and left shoulder pain and other symptoms and at older ages, you might suspect that. But remember, A, urgent urinalysis to evaluate for renal injury. We talked about kidney injuries, flank pain, and hematuria. Those are your buzzwords for renal injuries. Emergent referral for hemodynamic monitoring and abdominal CT to evaluate for splenic injury or rupture. We just talked about that. That would be the correct answer. Nobody with abdominal trauma that is complaining of these symptoms should ever just be monitored and be given a pain medication. Also, you shouldn't just say, hey, this is just normal. And then we mentioned EKG and cardiac workup would be less likely in this scenario. How about question eight here? A football player presents complaining of testicular pain following a direct blow to the testes. After examination, you're concerned that there may be an injury or torsion to the testes. Which of the following is the most appropriate next step in evaluation? Is it to get a urinalysis? Is it to get a CT of the abdomen and pelvis? Is it to get a pelvic angiogram? Is it to get an MRI of the pelvis or a testicular scrotal ultrasound? And I mentioned to you before that you want to know that you want to get an ultrasound, testicular scrotal ultrasound. OK, just a few minutes here on injections. And I'm just going to highlight some things that may show up on your exam. And these things are probably things that you're much more familiar with. You know that corticosteroids can be effective at sites where inflammation is significant. Obviously, you already know you want to avoid with tendinopathies due to the increased risk of rupture, especially weight-bearing tendons. So as you already know, injecting tendons with corticosteroids on a test is a bad thing to do. Controlled studies suggest that corticosteroid use and sometimes rehab, no additional benefit. I just mentioned all the negative effects on tendons. Reduced cell viability, cell proliferation, collagen synthesis, disorganization, and necrosis has been shown. And mechanical properties of the tendon is reduced. Again, as you already know, don't inject tendons with steroid. How about for adhesive capsulitis? You know the literature as well or better than I do. But obviously, there may be some limited benefit to corticosteroids initially with interarticular steroid injection and for recovering range of motion. And then obviously, what you know about osteoarthritis with some limited pain relief from corticosteroids. There's obviously, as you know, some consideration for articular cartilage destruction and then the increased risk of rate of infection with the subsequent joint replacement and needing to wait after a steroid injection for that procedure. What do you really need to know about corticosteroids? Again, as I mentioned to you with ergogenic AIDS, pay attention to side effects. That's what they want you to know. It's not so much about the application. It's what are you doing to someone or what are the potential negatives if you're going to advise someone. So tendon weakening, tendon rupture, post-injection neuritis, skin atrophy is a very common one. And as you know, skin hypopigmentation is something you need to pay attention to. Increased risk of infection, decreased ligament strength, and certainly ligament rupture. But associated risk of using these modalities are things that you're going to want to pay attention to. Other associated systemic risks that you may not think about when you're just doing a corticosteroid injection are listed here for you. Again, paying attention to these things, especially in a diabetic patient. If they present you with a patient with diabetes, remember, a corticosteroid injection is a bad thing. Because if you cause hyperglycemia, diabetic keto acidosis, and death, that's not good for that athlete. What about local anesthetics? You're familiar with their effects on chondrotoxicity. In general, especially for test-taking purposes, local anesthetics should not be used for an injury that could be made worse by playing, i.e. don't just inject somebody with Marcane, Lidocaine, when they're going to cause further damage to themselves. And obviously, the player and the physician have to understand the risk and benefit of that injection. Visco supplements, not certain if you'll get any questions on these. You know the literature, again, as well or better than I do. Is it effective? Is there effect on OA? But visco supplements are injections that are not commonly used in athletes. But your knowledge based on that would allow you to answer any questions there. I am going to spend a couple of slides on platelet-rich plasma. Because as you know, orthobiologics are becoming more prominent. And there's some things that you could be asked about with orthobiologics. So you know that the premise of PRP is based on the premise that growth factors released from the alpha granules of platelets in super physiologic amounts can augment the body's natural healing response. Platelets also release bioactive proteins that can attract mesenchymal stem cells, and so oftentimes referred to as kind of stem cell attraction. But other cells as well, macrophages and fibroblasts, which can be helpful. Promotes the removal of necrotic tissue and enhanced tissue regeneration and healing. All sounds like good things for sports medicine physicians. So what is platelet-rich plasma? You just need to know the components of platelet-rich plasma. So there's four components. One is the platelet concentration and volume. The normal platelet concentration in plasma is 150,000 to 350,000 platelets for microliter. PRP concentrated is either considered low concentrate or high concentrate, depending on the concentration of those platelets. We don't really know what the ideal platelet concentration is for all the different conditions that PRP is used for. And it could depend on the tissue in the stage of disease or healing. White blood cells are another component that can or cannot be included in PRP. Neutrophils, as you know, cause a pro-inflammatory response. There can be macrophages, monocytes, and lymphocytes. PRP is traditionally defined as plus-minus white blood cells, but it is a component for PRP. Red blood cells also need to be defined for PRP. And so you know that they can have a deleterious effect, but should be reported in PRP. They can cause chondrocyte death and affect the local pH, affecting platelet function. So it's important, obviously, that we know that red blood cell content. And then platelet activation is the fourth component, as you know, for PRP, whether or not the platelets have been activated or not. That can be done with synthetic activators. It can occur naturally. But the clinical efficacy of platelet activation is unproven. What do we know about PRP? What are some things that could show up? Well, PRP for NeoA is probably best understood, as you know. There is evidence from multiple studies and systematic reviews that suggest pain may be improved for PRP when you compare it to placebo and HA. There's mild improvement in activity level and patient satisfaction for that same thing. There may be some increased initial adverse effects for PRP with increased pain and swelling. The duration of the effects is not known. The duration of the effects, as we best know, is probably around six months. And like every treatment for OA, younger patients with less severe disease do better with PRP. For other things in tendinopathies, probably lateral epicondylitis or epicondylosis has the best evidence. There's a multi-centered trial out that showed some evidence of PRP. Not certain that you'd be asked about that. But otherwise, there is decreasing evidence of the benefit and effectiveness for PRP in tendinopathies. Mesenchymal stem cells, as you know, can differentiate into chondrogenic cells. They can come from lots of different areas. Bone marrow, adipose tissue, umbilical cord blood. You know why they work. You know what their benefits are that are here. Usually administered by an intraarticular injection. And there's lots of questions about safety benefits and adverse events for mesenchymal stem cells. So we don't know what is the appropriate use. There's lots of limited evidence. Age of patient, failing, what's the cost, what's the number of injections, long-term outcome, safety. All of these things make it less likely that you'd be asked specifically about these things on your exam. So two questions to finish up here with today. So if you have an athlete that presents to a team physician to discuss the potential of a corticosteroid injection for a recent injury, when discussing the potential side effects of a corticosteroid injection, which of the following is not a common side effect? So tendon rupture, skin atrophy, skin hypopigmentation, hypoglycemia, or vascular injury. Well, we mentioned the difficulty, the issues with tendon, with steroid injection. I mentioned to you skin atrophy and hypopigmentation, which you're aware of. Vascular injury and nerve injury can occur. But hyperglycemia can occur and especially important to know in diabetic patients. And then you may be asked about the components of PRP or something similar to this to know what is the components, which of the following is not a key component of platelet-rich plasma? So platelet concentration, red blood cells, blood type, white blood cells, or platelet activation. And you know that blood type does not play a role in PRP or the harvest of PRP. So I think between Dr. Best and myself, I wanna give an acknowledgement to Dave Bernhardt, who has given this talk in the past. He was nice enough to share some of his slides with me. And so I did take some of his information that he used last year, augmented it. So I wanna acknowledge him with this talk as well. So I think in the last three hours, you've learned hopefully enough about the medical issues in sports medicine to help you get 80 to 90% of the questions that show up on your examination correct. So thanks for having me here and good luck on your exam. Thank you.

sports injuries

head injuries

concussions

dental injuries

eye injuries

abdominal injuries

injections

corticosteroid injections

platelet-rich plasma