Our first speaker of the morning is Dr. James Borchers from The Ohio State University. We're going to do back-to-back hour lectures on medical topics, and I can tell you as having been at this course a number of years and also taking this test a few times, this is really high-yield stuff, and I think you'll enjoy it. So Dr. Borchers. All right, good morning. Thanks for having me here this morning. I appreciate AOSSM and the planning committee having me back again this year. As Dr. Miller mentioned, this morning I'm going to give two talks on high-yield non-musculoskeletal medicine topics for sports medicine physicians, and these are things that will show up on your exam and certainly if you practice sports medicine, you're aware of. The first talk this morning, we're going to talk about head injuries, concussion, dental injuries, eye, abdominal, and some brief things about injections at the end of the talk. I don't have anything to disclose for this talk. So we'll talk about all of these issues, and as you'll see during the talk, as we go through some of these topics, I'll bring up some questions that will hopefully identify some high-yield areas for you in these different areas. So let's first start by talking about head injury in sports. So the actual number of injuries is unknown because, as you probably know, many of these sorts of injuries are not reported by athletes. So it's very difficult when we talk about concussion, for example, to get a true measure of incidence or prevalence of concussion in athletes. Fortunately, most head injuries in sports are minor, and sports are actually the third leading cause behind motor vehicle accidents and falls as cause of minor head injuries in adolescent athletes. And so in most athletes, sports are not even the most common reason for a minor head injury. But in sport, the most common head injury is a concussion, and so we're going to spend a little bit of time talking about that. Before we talk about concussion, you need to understand, and I think this is pretty basic information, but think about head injury as either focal trauma or diffuse trauma. So focal trauma is the type of blunt trauma that may occur in sport. If someone gets hit in the side of the head, either with a ball or an object, it's usually associated with loss of consciousness and very focal neurologic deficits. And think about things like acute bleeds, arterial bleeds or venous bleeds, things like subdural hematomas, epidural hematomas, contusions, and intracerebral hemorrhages. Those are a different animal than the diffuse injury that we're talking about here. So diffuse head injuries are not associated with focal intracranial injuries, and the severity depends on the amount of anatomic disruption occurs, and that's the type of injury that concussion is. So if you see something on an exam where there's diffuse neurologic deficits, where there's been a diffuse injury, where there's loss of consciousness, significant seizure following that, you want to be thinking more about blunt trauma than diffuse trauma. As I mentioned, concussion is the most common head injury in sport. We've known about it for quite a long time. We still don't quite understand all the pathophysiology about concussion. So the definition of concussion is complex, and if you know anything about the recent Berlin guidelines that came out, this definition has not changed much because there has not been much change in the definition of concussion, even in the most recent guidelines, expert guidelines. So concussion is a complex physiological process affecting the brain induced by traumatic biomechanical forces. I think this next statement's really important, especially when you think about it on the exam. 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 I think one of the biggest misnomers about concussion is that contact has to occur to the head, or it has to involve the head or neck in order for a concussion to occur. And if you've been involved in sports, you've probably seen these injuries where someone takes a hit somewhere else in the body but suffers a concussive injury. So you do not need a blow to the head in order to have a concussion. In concussion, as you probably know, there's a rapid onset of short-lived impairment of neurological function that resolves spontaneously. There can be neuropathological change reflecting a functional disturbance rather than a structural injury. So again, as you'll see in a minute, imaging is oftentimes normal. There's a graded set of clinical syndromes involved in concussion that we'll look at that may or may not involve loss of consciousness. And so if you remember some of the guidelines from back to 20, 25 years ago, loss of consciousness was often used to help us determine severity of concussion. If you're still thinking that way, stop thinking that way. Loss of consciousness has nothing to do with severity of concussion. It's an individual subjective diagnosis that may or may not involve loss of consciousness. And the severity of concussion may or may not be affected by loss of consciousness. It's important to understand the anatomy of the head injury. And you could be asked a question about anatomy of head injury because this is well-accepted information. There's two types of concussions defined by the impact forces to the brain, linear and rotational. In both of them, neurons can be stretched or torn in the central nervous system. You can see here an example of a linear impact, which shows direct impact stopping the head's forward motion. The brain keeps moving. And as you are probably aware, you can get the classic coup-counter-coup injury with the forward motion when the brain strikes the skull and then has the rebound force in the opposite direction. More significant concussions are thought to happen from rotational injuries. If you're involved in caring for anyone who's in any sort of fighting sport, mixed martial arts or boxing, you're aware that these oftentimes can be significant injuries. A lateral impact can spin the brain on its axis, stretching or tearing neurons. And oftentimes, these sorts of injuries are thought to be very significant. This is a laundry list of symptoms that you should look at and review. There are many, many different symptoms and signs that are suggestive of concussion. You can see here there are four different areas here that are highlighted, and these are also highlighted in the new SCAT-5 guidelines. There's cognitive issues such as confusion and amnesia, either anterograde, not remembering what happened before the incident, or retrograde, not remembering what happened after the incident. The presence of amnesia is usually thought to be more suggestive of a significant injury. As I mentioned, loss of consciousness, certainly disorientation, vacant stares, excessive drowsiness. There's somatic symptoms that are associated with concussion, headaches, dizziness. Balanced disruption, and pay attention to balanced disruption. It's one of the key indicators of concussion, especially when we look at how we evaluate concussion. Short-lived nausea or vomiting, visual disturbances, especially photophobia or bright lights or blurred or double vision, and then phonophobia is very common, especially loud noises can aggravate athletes with concussion. Affective signs and symptoms are very common, and these are things that you should be aware of. Emotional lability, someone who all of a sudden is just crying on a sideline or very angry or upset, irritability, significant fatigue, anxiety or sadness, and then certainly sleep disturbances, trouble falling asleep, hypersomnia or difficulty sleeping at all. These are really important. What do all these symptoms, signs, highlight about concussion? It's very difficult to make the diagnosis sometimes right at the time of injury. This is a diagnosis that oftentimes requires repeated evaluation in order to make the diagnosis. So you can't necessarily make the diagnosis just with one exam and say, oh, it's okay to put this athlete back in the game. Oftentimes you want progressive evaluation, and you're going to see that as we move along. So the answer on an exam of something like, oh, I can evaluate this athlete for two seconds and then on the sideline and show him some lights and fingers and ask him a couple Maddox questions and then put them back in the game is no longer accepted as best practice. These are some red flags, and if you're aware of SCAT 5, which was published in 2017 and has now been in use probably at most places for at least six months to a year, red flags are highlighted. These are things you need to be aware of that could signify that there is something more significant than a concussion going on in an athlete. Certainly a significantly worsening headache. An athlete who's very drowsy, can't be easily awakened, doesn't recognize common people or places, significant intractable nausea or vomity, significant bizarre behavior. Certainly seizures. Seizures are never common in concussion, and so if you see seizure, it's a sign of more significant head injury. Certainly don't forget about the cervical spine. I'm not going to talk about cervical spine in this talk, but certainly you want to evaluate that. So weakness, numbness, tingling in the extremities, and then slurred speech or significant unsteadiness of gait. These are reasons to certainly activate emergency action plans, transport athletes, and get a more significant evaluation more than concussion. These are some things that are included in SCAT 3. I've left SCAT 3 up here because SCAT 5 probably has not been around long enough for it to be in your examination, but SCAT 5 really did not change much in the basis of concussion evaluation. This is universally accepted as one of the best tools to help you manage concussion, and it highlights some of the things that should be evaluated when you're going to evaluate a concussed athlete. In the SCAT tools, there is a cognitive assessment, and you can see the MATICS questions, which are only valuable right at the time of injury to try to help lead you to further evaluation. I just want to highlight that none of these pieces by themselves are validated as single objective diagnostic criteria for concussion, and that these tools put together are not by themselves diagnostic of concussion. They're all to help you make the decision of whether or not an athlete's been concussed. So your clinical judgment is still considered gold standard in using these tools. You can see that in the SCAT 3 and in SCAT 5, as well, there's immediate memory that is looked at, and then there'll be some remote memory. There's concentration with digits backward and months backward in order to help you evaluate that, and then a delayed recall. So cognitive function is part of the assessment in SCAT 3. SCAT 3 and SCAT 5 include a very exhaustive symptom scale that you should be evaluating, so symptoms are important to evaluate. It's important to know that symptoms are only accurate for evaluation of concussion for about the first five to seven days after the injury, and then continuing to evaluate symptoms loses its sensitivity for helping you resolve a concussion. But certainly these symptom scales can help us as we move towards evaluating and resolving a concussed athlete. Balance examination is a large part of evaluating a concussed athlete, and it's highlighted very well in SCAT 5 and in SCAT 3. So balance is part of the multimodal assessment for concussion, and you need to realize that it would be included in the evaluation of any concussed athlete. This is a key slide that you need to pay attention to if you're asked questions about a concussed athlete. It is accepted best practices that there is no return to play on the same day of a concussion. So if an athlete's being evaluated for concussion or if concussion is diagnosed, they are not to return to athletic competition on that day. That's been highlighted in the U.S. Team Physician Consensus Statement. It's been accepted by the NCAA since 2010, and now is legislation in all 50 states, starting with the Lysert Law in the state of Washington. So no athlete can return to play on the same day they have suffered what may be a concussion or if they are evaluated for concussion. So any question on any exam where you have an athlete that may be evaluated for concussion cannot return to athletic activity on that day. Fortunately, in sport concussion, over 95% of the time, the symptoms are self-limited in 7 to 10 days. So if we have symptoms that go beyond the 7 to 10 days, that becomes a more complicated picture. And so fortunately, most athletes will recover their symptoms within 7 to 10 days. They oftentimes will have cognitive deficits. I mentioned those, and that's why in the recovery, we oftentimes mention the need for not only physical rest, keeping them out of sport, but initial cognitive rest as well. When we talk about return to play guidelines for concussion, it is accepted as best practice that they have to have normal testing or be at baseline for whatever testing you are using, and your clinical impression is that they are ready to determine to begin a return to play progression. A return to play progression follows a graded set of introduction of athletic activities for the athlete after they've suffered a concussion. It usually is staged in five or six stages, but this is a schematic that will show you what that looks like. So certainly light aerobic exercise, which may be an exercise bike for 10 to 20, 25 minutes with very small increase in heart rate. Then there may be sports-specific exercises, again, with increasing heart rate, going on to non-contact training drills, and then if in a contact sport, full contact training drills, and then the ability to return to full play, practice, or game play. This is widely accepted as best practices if you look at the latest guidelines from Berlin. What has not been shown is the amount of time in between each of these stages, although it is recommended by expert opinion that there should be 24-hour time periods between the stages, but that has not been shown as evidence-based, but it is accepted as best practice that you can't just do all these things in three hours. You can't say, oh, somebody did really well on their exercise challenge, let's ramp things up and have a full practice in the afternoon. So if you were to get asked a question about graded return to exercise, it's 24 hours would be the accepted best practice for return to sport with these activities. I want to mention neuropsychological testing because many people falsely assume that this is an objective way to evaluate and clear someone from concussion. It has been shown to be of value, but oftentimes you need baseline testing or very good normative data in order to use neuropsychological testing. Neuropsychological testing in and of itself is not a standalone evaluation for concussion and does not give you information and allow to return someone to play from concussion. It's only an aid in clinical decision-making. It requires some expertise in being able to evaluate these tests, and so you can't just accept numbers. So just be aware that neuropsychological testing is an aid in return to play, but its use is not a standalone in return to play or evaluation of concussion. As far as neuroimaging, I mentioned to you already that neuroimaging is not necessary in the true evaluation of concussion unless you are concerned that there is a more focal injury. CT scan is the initial study of choice if you do suspect there is a concurrent focal injury. So as you probably know, if you've been seeing an athlete and you send them to an emergency room with a concussion, they're going to get a CT scan to evaluate for a focal injury. If you have suspicion about something later on in the evaluation of concussion, MRI is better for anatomy if you need something more than 48 hours post-injury. There are many other new modalities that are out there. They are not accepted as standard of care, and certainly there's limited normative data in PET scanning, functional MRI scanning. There is some promising data for some of these, but they are not accepted as standard of care and are not established for the use in the evaluation of concussion. You need to at least be aware of some of the complications of concussion. Second impact syndrome is the one that I want to mention here. Second impact syndrome is thought to be one of the most serious risk of premature return to play following concussion. It's thought to be caused by any insult to the head following a premature return and can cause instantaneous collapse and death. The pathophysiology is thought to be due to a loss of auto-regulation of the brain's blood supply, but has not been clearly defined. There is some debate in the medical community and concussion experts about its quote-unquote true existence, but there are documented cases where this has occurred. And you need to be aware that this is one of the reasons why you cannot return an athlete to play without going through a proper evaluation for concussion. I'm not going to mention CTE here. There is a lot of debate around CTE that I doubt you will be asked about, except to say that although there is much research and much data going on around the link between concussion and CTE, there has been no proven link between concussion being the causative factor for CTE. It may be part of a multifactorial issue causing CTE, but there is no conclusive link that concussion or the history of concussion is the sole factor for the cause of CTE. When you talk about prevention of concussion, there are lots of things out there and lots of devices out there. Multiple factors can help with head injury prevention in sport. Equipment modification can certainly help, and if you're aware of the NFL's new data on helmets, you're seeing that firsthand. Certainly rule enforcement and changes as necessary. As an example, the change in kickoffs, moving the kickoff up or changing some of the rules in football in order to eliminate dangerous plays, and then certainly the education of proper sport techniques, things like USA football that help to educate athletes. But there is no clinical evidence that concussion can be eliminated in sport. There's nothing that you can do. There's no piece of equipment that will completely protect a contact athlete from concussion in sport. We try to reduce the exposures and reduce the risk, but there's no one single thing out there that can reduce or eliminate concussion in sport. So let's take a look at a couple questions here and see how this could be asked on your exam. 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. So we're talking about return to play. A, she may return if she is asymptomatic. B, she may return if she is willing to sign a waiver. C, she may return if she passes a sideline graded exercise challenge and is asymptomatic. And D, she should not return to play for this game under any circumstances once diagnosed with a concussion. And as I just mentioned to you, in return to play, once an athlete undergoes evaluation for concussion or is suspected to have a concussion, they are not allowed to return to athletics that day. So although many of these other answers may seem reasonable to you, the correct answer would be D, that she is not allowed to return to sport on that day. Let's take a look at a second question. A high school football player suffers a concussion during a game. Which of the following symptoms suggest a more serious head injury? And I mentioned to you the red flags that you want to be aware of when we think about head injury in sport. Dizziness, a brief episode of vomiting, seizure, blurred vision, or amnesia. And I mentioned to you and highlighted that seizure is never associated with just concussion and should certainly alert you that there's a more significant possible focal head injury in an athlete with a head injury. I'm going to move on to talk about dental injuries. Before I do, I just want to mention there is a lot out there in concussion. The reason that you don't or may not see a lot of questions about it is there is still a lot of debate and not a lot of consensus based on evidence other than some of the things I've mentioned here to you about concussion. So I would not spend a lot of time delving into those things that are still considered to be not accepted as a standard of care for concussed athletes. Dental injuries in sports are almost always secondary to trauma. You need to be aware of the types of dental injuries that can occur. There can be dental avulsions, fractures, luxations, lacerations, and certainly injuries to the temporal mandibular joint, pain, or dislocation or fractures. And contact sports have the highest incidence, and especially those that don't offer facial protection, things like baseball, basketball, or ice hockey, and certainly ice hockey without a face shield or without a full cage. For dental injuries in sport, it's important to be aware of the anatomy of the tooth. You need to be aware of the three levels of the crown, the enamel, the dentin, and the pulp. And I'll highlight that here in a second as it comes to dental emergencies. Dental issues in sport are really all about knowing when someone can continue to participate, when they need to be referred, and what the best way is in order to save the tooth. When we talk about dental fractures, they can involve all three layers that I just mentioned, the enamel, the dentin, or the pulp. They're oftentimes associated with significant pain when exposed to air, cold drinks, or touch. Oftentimes, there's a loose tooth fragment, as you can imagine, and you want to try to save that fragment in case it can be bonded. So you want to place it in milk or a Hank saline solution. So if you can save that fragment, you can save the tooth. So if you can save the fragment, you want to try to do that. If there's a fracture of the tooth and the enamel is the only part of the tooth that is involved, that athlete can go on and continue to play and just needs to see a dentist within 24 hours. Because oftentimes, they're not going to do anything to be able to save that small of a fragment. But if the dentin or the pulp are involved in a tooth fracture, that requires immediate referral to a dentist, and they should not continue to play. So a dental fracture involving the pulp, you can see highlighted here. Oftentimes, you'll be able to identify that with that reddish area of the pulp being able to be seen. It's serious. It requires immediate referral because delayed treatment can be associated with pulpal necrosis and complete loss of the tooth. Oftentimes, there's bleeding from the tooth when this occurs with heightened sensitivity. There's lots of treatment options for this that dentists can use. But again, from your standpoint, you need to get them referred so that you don't lose the tooth. Dental fractures oftentimes involve the root of the tooth, if you remember the anatomy that I just showed you. Oftentimes, there's mobility of the crown when you have a dental fracture, whether it's complete or incomplete. And there's tenderness to percussion of the tooth. So if you have that, if someone has trauma to the mouth or you're suspecting that, you want to think about a root fracture or the potential for root fracture. These can occur in different areas of the root, the apical, middle, or cervical portion of the root, with cervical root fractures having the worst prognosis, which is what I've shown you here. So the illustration here shows a cervical root fracture. And those have the worst prognosis of dental fractures. You need to refer these folks immediately to a dentist as well in order to try to save the tooth and avoid losing the tooth or causing worse injury if this occurs. Dental luxation is a concussion to the tooth. Subluxation is where you have mobility without clinical or radiographic evidence of dislodgement. Extrusion is either a partial avulsion from bone. And you can have an attempt to reposition these and refer to a dentist. But any time you have movement of the tooth, you should refer that patient to a dentist within a short period of time so that they can be treated. Other than dental fractures involving only the enamel, if they give you some significant injury to a tooth, that needs to be referred. And the athlete should not continue to participate. Dental avulsions, you're likely to get a question about this. They like to ask about dental avulsions, a displace completely out of the socket. So you have a tooth that's completely displaced. This is a common injury that's seen in sport. If you get the tooth re-implanted within 15 to 20 minutes, if you can put it back into the socket, there's a 90% chance the tooth will be retained for life. So you need to know that being able to re-implant the tooth is the best way to ensure viability of that tooth once it's been avulsed. If you can't re-implant the tooth, it should be placed in either a Hank's Balance salt solution if you have a tooth recovery kit, cool milk, saline, or in a container with the patient's saliva in order to try to save the tooth, and then urgent dental referral so that the tooth can be re-implanted. Probably the other thing that's important to know about dental injury in sports is prevention. The American Academy of Pediatric Dentistry and the ADA recommend all children and youth wear mouth guards when they're participating in sports, where there is somewhat of a significant risk for dental trauma. So mouth cards are recommended. Mouth cards have been shown to reduce oral facial injuries. They absorb impact and cushioning, and they can be used to prevent oral facial injuries. They absorb impact and cushion between the mandible and maxilla and can prevent tooth injuries. There are many things you're hearing. I'm just going to go back for a second to concussion, about mouth guards and concussion. There is no accepted clinical evidence that there is a mouth guard that can prevent or reduce the incidence of concussion, although that's being studied and certainly being studied at places like the Cleveland Clinic for impacts to the head. But do not think that a mouth guard can reduce incidence of concussion in athletes. The recommendation for mouth guards is that you use custom molded mouth guards per the Academy of Sports Dentistry. So the boil and bite mouth guards, although they're out there, are considered substandard care, although many people still use them. So if you're asked what the recommendation is or what the best practice is, it's to use a custom molded mouth guard for protection of these injuries. Let me provide you with a couple of questions that'll hopefully highlight how you might need to know about dental injuries on your exam. A collegiate rugby player suffers a dental fracture. Which of the following does not require urgent referral to a dentist? And so I've mentioned this to you a number of times. All you need to remember is that if the enamel is the only thing that's involved, they can continue to participate. So a dental fracture involving dentin, pulp, enamel, or any sort of root fracture, middle, or cervical. So you know that a dental fracture involving the enamel only does not require a referral. 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 a 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 the dentist after the game is finished. Discard the tooth that is not viable following avulsion injury. So as I mentioned to you, if we can get the tooth re-implanted within 15 to 20 minutes, we have a 90% viability of the tooth moving forward for life. And if we can't get it re-implanted, we want to make certain that we package it in an appropriate solution and have immediate referral to a dentist to try to save the tooth. So the correct answer here would be B. The rest of those answers don't follow those guidelines. But if you're not aware of the proper treatment, you may think that any of those could be reasonable. I'm going to move on from dental injuries into ocular injuries in sport. One of the things you need to recognize about ocular injuries in sport is there is a suggested risk profile for sports. And so being aware of which sports have a high risk of ocular injury is important. You'll see here that high risk sports include many sports that either use a ball or projectile. So certainly paintball or anything that uses a target where you're shooting at someone without proper ocular protection is a high risk. Basketball is high risk. Baseball and softball. And then ice hockey. And again, ice hockey without the use of a full face shield on the helmet. You can see moderate risk for other sports, such as tennis, which uses a ball. Soccer, where there can be trauma to the head. Volleyball. Football, again, where there can be direct contact. Fishing and golf. Again, a ball involved. And then you see the low risk sports here by category where those risks are much lower. Certainly considered to be eye safe are those things like exercise, jogging, running, walking, aerobics, those sorts of things. Why do you need to know this? Because you need to know what would be reasonable for someone who is either functionally one-eyed or considered to be legally blind to participate in. And certainly it would be those low risk sports. And I'll talk more about those issues here in a minute. With ocular injuries in sport, it's really important that you know about the mechanism of injury that occurs, whether it's blunt trauma or penetrating trauma. With blunt force, so in any sort of ball sport, if they talk to you about racquetball, baseball, tennis, something where a ball hits the eye, think about an orbital blowout fracture. That's what they're getting at is the risk of an orbital blowout fracture. If there's a complaint of foreign body sensation, a perception of decreased visual acuity or double vision, think about something that's either penetrating or caused by trauma to the eye itself. Physical exam is really important. So if you know nothing else about an ocular exam, you need to document visual acuity when you're evaluating an athlete with ocular trauma. So you need to know that that's the most important thing for you to get. Obviously, if you are doing a more advanced exam, you want to look at pupils to look for changes in pupils. You want to look at the confrontational visual fields, the conjunctiva, do a corneal exam. And then, again, in the blowout fractures, you don't want to forget about the surrounding structures, the facial and maxillary structures of the face. Corneal abrasions in sport are very common. They're due to a defect in corneal epithelium. They can be due to trauma. So a finger to the eye very commonly causes a corneal abrasion. Or they can be due to significantly dry eyes. Oftentimes, an athlete complains of sharp pain, excessive tearing, maybe photophobia, and a foreign body sensation. The diagnostic test is considered fluorescein staining. And this is included in most sport eye kits. So fluorescein stain will show you the defect in the cornea with an abrasion. Treatment is topical antibiotics to prevent infection. And then there's a questionable use of cycloplegics. But what is not accepted as best practice is covering the eye or shielding the eye when you have a corneal abrasion. It's important to know that until the corneal abrasion is healed, an athlete should not use contact lenses and should use polycarbonate goggles if they're going to be able to participate in sport. I mentioned orbital wall fractures. This is asked not infrequently on sports medicine examinations. They follow blunt eye trauma. Oftentimes, there's diplopia or double vision with these due to extraocular muscle entrapment from the fracture itself. Oftentimes, there's also numbness on the cheeks. So if they mention that because of infraorbital nerve involvement, you want to be thinking about an inferior orbital floor fracture. It's really important that in the treatment of these, you recommend that people don't blow their nose, not to increase that intraocular pressure and worsen their symptoms. If you suspect this, CT scan is the study of choice. And you need referral for definitive treatment and return to play. Hyphemas, very important to know about. These occur because of shearing forces to vessels of the iris. You'll notice a layering of gross blood in the anterior chamber that's highlighted here. These are an ocular emergency. You need to be able to rest that athlete. They need to have their body in a position where the head of the bed is elevated. And they need cycloplegic drops. If you don't treat these urgently, there's a risk of re-bleeding and acute glaucoma and loss of vision in that eye. And this is considered from sports trauma to be the leading cause of loss of vision in an eye in pediatric patients. So hyphemas are often missed and can then often lead to complications. They need urgent referral to ophthalmology so that they can be treated appropriately. Globe ruptures. Think about racquetball athletes. That ball coming at a high velocity of speed hits the eye directly. There's obviously pain, visual loss, a significant hyphema. Probably the most important thing to know is if they mention or show you a diffuse 360 degree subconjunctival hemorrhage like you see here, that is pathopneumonic for a globe rupture. They need, obviously, prompt referral. They need to have an eye shield. But don't apply pressure to the globe. So a loosely fitting eye shield is what's recommended when you refer these folks to ophthalmology. There's obviously a high risk for infection and blindness. But this 360 degree subconjunctival hemorrhage, be thinking about globe rupture. Retinal trauma or detachment, you need to be aware of this because this is an ocular emergency. And it does occur in sport. It can be due to direct trauma to the orbit or significant head trauma. So they may try to give you a distractor of a football player, for example, who gets hit in the head. And you're thinking about concussion. And what they want you to be thinking about when they give the vignette is something about a retinal detachment. So it doesn't have to be ocular trauma in order for retinal detachment to occur. Think about things like someone complaining about floaters, certainly flashing lights in their vision or a blind spot in the edge of their visual field where they say, hey, I can't see out over to the right side. Laterally over here, I can't see anything. It's dark to me. Think about retinal detachment. And those obviously need an urgent referral to ophthalmology. Not unlike with dental injuries and ocular injuries, we're trying to prevent significant complications. That's what they want you to know. Can you prevent significant issues to the eye? Can you make certain that you manage things appropriately so that blindness or loss of visual acuity does not occur? This is a laundry list of return to play guidelines that you can take a look at. I've talked to you about many of these injuries. As I've mentioned, many of the significant injuries should not return to play and should be evaluated immediately. Things like corneal abrasions, obviously, if you can diagnose them and there's no change in visual acuity, may be able to return to play. But most eye trauma needs to be evaluated, especially if they mention to you that there is a change in visual acuity, loss of visual function. And if there is any sort of what I mentioned before, signs of globe rupture, hyphema, those sorts of things. You need to know about a monocular athlete because it's important to know that you can protect visual acuity when you have a functionally one-eyed athlete. For the athlete who is functionally blind in one eye, polycarbonate goggles to protect the remaining eye should be recommended at the time of the pre-participation exam. And so regardless of participation in sport, they should participate with polycarbonate goggles. A functionally one-eyed athlete or a monocular athlete should not participate in full-contact sports such as boxing and MMA or martial arts. How do we know somebody is functionally one-eyed? And you need to just highlight this so you remember this. Their best corrected functional acuity of no better than 20-40 in the poor seeing eye. So if I'm 20-60 in the poor seeing eye, I am considered to be a monocular athlete or functionally one-eyed and need to be given these precautions when I'm participating in sport. Let me highlight a couple of questions here of how you might be asked about ocular trauma or eye issues in an athlete. You're seeing a 12-year-old male for his PPE prior to the basketball season. His visual acuity screen results are 20-30 right eye and 20-100 left eye. Which of the following is appropriate advice for the upcoming season? And we just talked to you about this, but this is a common type of question about a functionally one-eyed athlete. He may not play basketball because of risk of eye injury, and it's always important to know when you can, when you should and should not, I'm sorry, disqualify someone from sport. He must wear contact lenses in order to play. 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. He does not need to follow up and can play basketball without restrictions. So as I mentioned to you, you need to remember that measurement of worse than 20-40 in the poor seeing eye makes you functionally one-eyed, and that in order to participate in a sport like basketball, he has to be protected, which is wearing polycarbonate goggles, and he should be referred for further evaluation for that decreased acuity. Another question that you might come up on. 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. If you see, as I mentioned to you, loss of visual field, think retinal detachment. He was hit on the right side of the head and immediately had the sensation of seeing flashing lights in his right eye. Again, I've given you some, again, some clues to retinal detachment. In the classic two-step question, which of the following is the most appropriate treatment at this time? Prescribe topical antibiotics and continue play. We do that maybe for a corneal abrasion, but in no other situation. Finish the game and then assess visual acuity. I told you before that anytime you have an ocular injury, you need to assess visual acuity at the time of injury. We don't wait to do that. Place a pressure dressing on the right eye and send to the emergency room. I've mentioned to you that you should never place a pressure dressing on the eye in any situation, and even with a globe rupture, you should place a loose-fitting shield on the eye to not increase intraocular pressure. Monitor on the sideline, and if symptoms improve, allow them to return to the game. Again, I've mentioned to you before, if you suspect retinal detachment, that that's an ocular emergency. So the correct answer is E, emergency transfer and referral to ophthalmologist for evaluation and treatment. I'm gonna move on to the abdomen here and just mention some high-yield issues about abdominal injury in sport. You need to be aware of rectus sheath hematomas, and many of you probably are, bleeding into the rectus sheath, secondary to blunt trauma and potential injury to the epigastric artery. Oftentimes, there's pain in a palpable mass and tenderness in the rectus sheath when this occurs. There can be tenderness in even a mass that occurs after tensing abdominal muscles. It's very rare that it would be associated with signs of shock. There's usually not that much bleeding that occurs. The studies of choice are ultrasound or CT if you need a study to help evaluate that. The treatment for these, most are self-limiting, but oftentimes, they can't return to play. You might need surgical consultation if the patient is unstable. Probably the biggest thing to know is that if you repeatedly aspirate these, you increase risk of infection and certainly, abscess can be a complication of rectus sheath hematomas. I wanna mention splenic rupture, and I'll talk about this a little bit as well in my next talk when we talk about infectious disease, but you need to know that the spleen is the most common abdominal organ injured in sports activity. The liver is second and the pancreas is third. Most splenic injuries that are not associated with infection are due to deceleration injuries, shearing force on the capsule and vessels, usually due to contact. There can be some blunt trauma to the left upper quadrant of the abdomen. You need to be aware of the signs and symptoms, which many of you, I'm certain, are of splenic rupture, so certainly, left upper quadrant abdominal pain that's very sharp and then dull in nature. You need to be aware of Kerr's sign, which is referred pain to the left shoulder due to diaphragmatic irritation from bleeding that is considered at times, and especially on these exams, to be pathopneumonic for splenic injuries. Nonspecific signs include nausea, vomiting, and then signs of shock, tachycardia, and orthostatic hypotension. And then certainly, if they were to show you a picture of someone with associated rib fractures from trauma, you'd want to be aware of the risk of splenic injury if appropriate. If you suspect splenic rupture imaging, ultrasound can be done quickly in the emergency room for evaluation of the spleen, but the CT is a study of choice for splenic patients. Certainly, if they were to present you with an unstable patient with the suggestion of splenic injury, that's immediate referral for surgery and exploration. Management does depend on hemodynamic status. Fortunately, most splenic patients fortunately, most splenic injuries in sports are self-limited and do not require surgical intervention. If they do, angioembolism and splenectomy may be performed. It's really important if you think about it, if they present you with an athlete that's had a splenectomy for whatever reason, that vaccinations are very important, especially strep pneumo is a vaccination. So make certain that you're just aware of that and tuck that in the back of your mind there when you're thinking about an athlete that either has had a splenectomy or a splenic injury as something that may be required for them in the future. Renal trauma is important to pay attention to with athletes. The kidneys are normally well-protected, but a blow to the flank can cause a coup-countercoup injury that can cause a renal contusion, or in some instances, a more significant renal injury or renal fracture. The two most common symptoms for renal injury are flank pain and hematuria. So if they give you an athlete that has hematuria and flank pain, they have a renal injury. And most athletes that have frank hematuria, we're not talking about exercise-associated microhematuria, the most common cause is an injury to the kidney. Certainly, CT scan is the study of choice. Management for most renal injuries is conservative, but they can't go back to sport until the injury is completely resolved and they have complete resolution of their renal symptoms. Testicular trauma, you need to be aware in male athletes of the risk of testicular trauma as well. Testicular trauma can occur in either the form of contusion, torsion, or fracture. The last two, torsion and fractures, being urologic emergencies. The imaging study of choice for any testicular trauma is scrotal ultrasound. There is no other study of choice for the evaluation. Contusion is the most common injury and oftentimes can be treated with rest, ice, and compression. If left untreated, if you have a fracture, rupture, torsion, the risk is obviously loss of testes. We don't want to see that, and so make certain that those are referred. If you do get presented with an athlete who has only one testes, they can participate in any sport, but you have to make recommendations, obviously, for protection, especially in those sports where trauma to the scrotal area could occur. So how about some questions in this area? So you're seeing a rugby player who is complaining of left upper quadrant abdominal pain radiating to the left shoulder after completing a game. So again, I've told you already, and you're probably already aware that left upper quadrant pain, but certainly with that identified KERS sign with pain radiating to the left shoulder should clue you into a splenic injury. And what is the most appropriate management at this time? Urgent urinalysis to evaluate for renal injury. Well, I mentioned to you that the two most common pathognomonic signs of renal injury are flank pain and hematuria, which we're not seeing here. Emergent referral for hemodynamic monitoring and abdominal CT to evaluate for splenic injury or rupture. And as we talked about, we're thinking about a splenic injury, and so that answer looks reasonable. Observation and treatment with Catorhalac for pain. That's not acceptable for any abdominal trauma. Reassurance that this is normal following a contact sport like rugby and will resolve spontaneously. This is how you get your athlete into trouble, and they go from having a stable injury to potentially an unstable or hemodynamically unstable injury. And an EKG and cardiac workup for suspected myocardial infarction. Unlikely in this rugby athlete, so the best answer here is B, emergent referral for hemodynamic monitoring and abdominal CT to evaluate for splenic injury and rupture. A football player presents complaining of testicular pain following a direct blow to the testis. After examination, you are concerned there may be an injury or torsion to the testis. Which of the following is the most appropriate next step in evaluation? The most appropriate next step in the evaluation, and so there'll be obviously distractors here. Your analysis may be very reasonable in any sort of GU trauma, but it's not the most important next test if we think there's an injury to the testis. CT of the abdomen and pelvis, a pelvic angiogram, an MRI of the pelvis, or a testicular or scrotal ultrasound. And as I mentioned to you, in any sort of injury to the testis, testicular or scrotal ultrasound is the study of choice. The answer is E. I've been asked to mention a few things about injections. I'm certain in this room that many of you, when it comes to injections, know all about complications and much about the evidence around injections. So I'll just mention a few things here that may be more medically indicated. As you know, corticosteroid injections are commonly used in sports medicine. They can be effective at sites where inflammation is significant. Obviously, you know to avoid them with tendinopathies due to the increased risk of rupture, and especially around weight-bearing tendons. There are many controlled studies where the use of corticosteroid injections are no better than other rehab modalities. So you need to know that there is very limited evidence for benefit of corticosteroid injection in the treatment of sports injuries. You know about the negative effect on tendons. It reduces cell viability, cell proliferation, and collagen synthesis. Collagen disorganization and necrosis are shown in in vivo studies when these cells, when the tendon is treated with corticosteroid. And the mechanical properties of the tendon are reduced. So as we tell our fellows, steroid and tendon is not a good combination. You're probably well aware of the use of corticosteroids for adhesive capsulitis, and so I won't spend too much time on that, and in osteoarthritis. You know that there's very limited pain relief, potentially for two to four weeks, but maybe only for a couple days. There's the risk of articular cartilage destruction and decreased matrix formation, and you're well aware of the issues, I'm certain, around infection with subsequent joint replacement with the use of corticosteroids in close proximity to that procedure. What you do need to be aware of for testing purposes is the associated risk of corticosteroids when used for injection. So I would pay attention to these next two slides because this is where questions come from. I mentioned tendon weakening and tendon rupture, but post-injection neuritis is not uncommon. Skin changes are very common, so hypopigmentation and not informing a patient about hypopigmentation and skin atrophy. There is a risk of infection, decreased ligament strength, and ligament rupture. There are also other general associated risks with the use of corticosteroids, including anaphylaxis, which may seem counterintuitive, vascular injury with improper technique, sterile abscesses can occur, transient synovitis. We mentioned cartilage damage and arthropathy with repeated steroid injections. But there are, from steroid injections, reports of hyperglycemia, adrenal effects, and psychiatric effects. So as we talk about the use of oral steroids, those effects can occur from injectable steroid as well and have been reported. So you just need to be aware of those for the exam. Local anesthetics, I think you're probably all aware of the risk of chondrotoxicity. They're used commonly in sports medicine but should not be used for any injury that could be made worse by participating, i.e. you don't inject something where you know you're gonna cause further harm. And the player and the physician certainly need to understand the risk and the benefits and you need to have a well-informed consent before you're gonna proceed with any sort of local anesthetic injection. They asked me to mention something about viscose supplements which I am certain many of you in this room are aware of. There are physiological properties of hyaluronic acid. There's still even question about how does it actually work or does it work or is it just placebo effect or is it effective? There may be modest effect on early to moderate OA that peaks at about six to eight weeks after use. But remember that in early to moderate OA, just about everything works to improve symptoms. There is some modest improvement when compared to intra-articular steroids and placebo. They wanted me to talk just briefly about orthobiologics for testing purposes. Platelet-rich plasma is certainly being used more commonly for many sports-related injuries and articular issues in orthopedics and musculoskeletal medicine. PRP therapy is based on the premise that growth factors released from the alpha granules of platelets and superphysiological enzymes and superphysiologic amounts can augment the body's natural healing response. That's just theory. Platelets also release bioactive proteins that can attract mesenchymal stem cells, macrophages and fibroblasts to the area of injection. They can promote the removal of necrotic tissue and can enhance tissue regeneration and healing. It's important to know with PRP therapy what the components of PRP are. Platelets certainly, normal platelet concentration you can see here. PRP is considered either low or high concentration based on the number above that concentration that is present in your injection. We do not know the ideal platelet concentration for PRP for different tissue and injuries in sports medicine. And so the ideal concentration remains unknown and is not well studied. White blood cells can be present in platelet-rich plasma. Certainly you know neutrophils have a pro-inflammatory response. There can also be macrophages and monocytes which may be helpful depending on what you're treating. Lymphocytes are also available and PRP is traditionally defined as either leukocyte-rich or leukocyte-poor plus or minus white blood cells. Red blood cells should not be present in PRP. We know that they can be deleterious to the positive effects theoretically of PRP. They alter the local pH affecting platelet function and can directly cause chondrocyte death. And then certainly platelet activation is the other part of PRP, whether or not the platelets are activated in vivo or prior to being injected by using either thrombin or calcium. They're synthetic activators and the clinical efficacy is uncertain in PRP with activation. Just briefly, conclusions of knee arthritis. Pain is improved for PRP versus placebo on hyaluronic acid. There are some studies out there that show that it is equitable to hyaluronic acid. There's mild improvement in activity levels. If you look at systematic reviews for patient satisfaction for PRP versus those two things, you need to know that it is fairly well accepted that in the short term in seven to 10 days after a PRP injection, there is a higher risk of side effect profile locally with pain and swelling. Younger patients with less severe OA may achieve the most benefit from PRP and with everything else you do for osteoarthritis. And there's significant limitations. There's limited evidence for benefit in tendinopathies with the use of PRP, probably the best evidence in lateral epicondylosis or lateral epicondylitis. Just briefly mentioned mesenchymal stem cells. As you know, they can differentiate into chondrogenic cells or any other cell under proper environments. They can come from bone marrow, adipose tissue, potentially from umbilical cord blood. They have no MHC class II antigens, HLA and DR receptors, thus no T cell response from host. There are lots of benefits that theoretically occur with stem cell use, controlling inflammation, inhibiting apoptosis. They can hone in on damaged tissue, leading to repair and can be obtained from the host. Usually administered by an intraarticular injections, there's certainly a lot of question about not only efficacy but safety and adverse events around stem cell treatment in sports medicine conditions. The biggest thing around these is what's their appropriate use. We have evidence is limited for initial use in OA treatment, which is probably getting worse as the literature continues to show up. We have to look at indications and failed traditional treatment or combination of treatment. And then certainly questions about cost and the numbers of injections and long-term outcomes and data. As you know now, there's many people that suggest the only use of mesenchymal stem cells in these issues should be used in clinical studies and clinical trials. So a couple questions to finish up here. An athlete presents to a team physician to discuss the potential of a corticosteroid injection for a recent injury. When discussing potential side effects of a corticosteroid injection, which of the following is not a common side effect? Well, we mentioned injury to tendons, so tendon rupture. We mentioned the issues with skin, skin atrophy and hypopigmentation. We mentioned that vascular injury could occur. But it is possible to get hyperglycemia from a steroid injection, not hypoglycemia. Question 10, which of the following is not a key component of platelet-rich plasma or PRP? So I mentioned to you that there were four key components to platelet-rich plasma. Platelet concentration, red blood cells, blood type, white blood cells and platelet activation. And you know that the patient's or the subject's blood type is not a key component when we're discussing PRP. There's some references. I wanna acknowledge David Bernhardt, who shared information a couple years ago here at this course and was nice enough to allow me to use some of that information in this talk. So that is the end of this talk with 46 seconds to go in this hour. So we'll take a 46 second break and then I'll move on to my second talk. Thank you.

Dr. James Borchers

head injuries

concussions

evaluation

management

dental injuries

ocular injuries

abdominal injuries

injections