Thanks, Tom, for filling in. Our next two lectures are on medical aspects of sports medicine, and they're given by Dr. Jim Borchers from Ohio State University. Hi, Jim. All right. Good morning, and thanks for having me back again. Thanks to Dr. Kading and Dr. Miller. It's my fifth year here at this course. This morning we're going to spend time talking about issues that are probably less familiar to you as an orthopedist, but certainly should be familiar to you as a sports medicine clinician and that are certain to show up. The first talk this morning will have to do with head injuries, concussion, dental injuries, eyes, abdominal, and injections. So we just spent an hour on the elbow, and now we're going to spend an elbow going through all these talks. I don't have anything to disclose for this talk. Here's the things that we're going to cover here this morning. When we think about head injury in sport, the actual number of injuries is unknown because many aren't reported by athletes, and we know that that's a problem with concussion. Most head injuries in sport, fortunately, are very minor, and we know that. And know that sport is really the third leading cause of minor head injuries in general behind motor vehicle accidents and falls. So it's actually more dangerous to ride a bike or a skateboard without a helmet than it is to actually play a helmeted sport. It's also really important to know that in all sport, the most common head injury is concussion. Okay, so it's going to be really important to know that in sport, there's two types of head injury, and you want to be able to distinguish these two. Focal head injuries are those that are caused by blunt trauma. They're usually associated with loss of consciousness and focal neurologic deficits, and then possibly, you know, these lucid intervals and then significant, quick neurologic demise. These are the things you need to be thinking about with bleeds, right, venous or arterial bleeds. So things like subdural hematomas, epidural hematomas, cerebral contusions, or intracerebral hemorrhages. These are rare in sport, but you need to be able to recognize them. Much more common in sport are diffuse head injuries, and this is what we commonly think of when we think about concussion. So these are not associated with focal intracranial injuries. So if you get something that shows up on, you know, your exam with a CT scan with a bleed or some sort of mass on MRI, that's not a concussion. We know that the severity of these injuries depends upon the amount of anatomic disruption occurs. Basically, how much does the brain move inside the skull? How much neuronal or axonal disruption occurs? And again, this is concussion. So this is what you want to be thinking about when you think about concussive injury. Be able to think about differentiating focal versus diffuse head injuries in sport. I mentioned already that concussion is the most common injury in sport. This has been around forever, since the 10th century AD, and was first described as an abnormal physiologic state without gross traumatic lesions of the brain. And as you're going to see here in a minute, we haven't done much better than that with our definition for concussion, even in 2019. Because we still don't completely understand the pathophysiology of concussion. So by definition, concussion is a complex physiological process that affects the brain induced by traumatic biomechanical forces. It's really important to know that concussion can be caused by direct blows, not only to the head, but to the neck, face, body, torso, with that impulsive force that's transmitted to the head. So you can get clinical scenarios that are presented to you where an athlete, for example, is not necessarily classic head-to-head targeting type contact, but where someone's been hit in the chest, for example, and still will suffer a concussion. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. So this is not long-term. Stuff that lasts more than 7 to 14 days gets into other realms. It's either a focal neurologic deficit, post-concussive syndrome, but it's not concussion. There can be neuropathological changes reflecting a functional disturbance rather than a structural injury. We're going to review here in a second a graded set of clinical syndromes that may or may not involve loss of consciousness. For those of you that are out there and have been around for over 20 years, you know there are old concussion dated grading systems that use loss of consciousness as a main definitive factor for concussion. Forget about that. Loss of consciousness has nothing to do with the severity of concussion, and it should not be considered much when you think about how you're going to manage concussion. Concussion is associated with grossly normal neuroimaging studies. They're not of help in making diagnosis. Even the advanced studies you're seeing now with PET scans and all of those sorts of things, there's no imaging study that can make the diagnosis of concussion. So know about the anatomy of the head injury. There's two types of concussive injuries that occur, and this schematic from the CDC does a great job of defining those two types of injury. There's a linear impact. This is the type we think about, for example, in a hockey player, football player, lacrosse player who's a helmeted athlete where there's a direct impact that stops the head's forward motion. You get this cou counter cou injury of the frontal and occipital lobe. The brain keeps moving inside the skull and recoils back and forth to cause injury. Hence the reason why even though now there is some new data, although you will not see this on your test, that in football there are some helmets that seem to perform better in preventing concussive injury. There is no helmet that can stop a concussion. There are some in NASCAR and other things that can diffuse force, but this is why with the brain moving inside the skull, helmets don't stop concussion. And then know about rotational injuries. Think about this in MMA or boxing when you have a lateral blow to the head and you spin the brain on its axis causing axonal damage. And these are thought to be more significant injuries. So somebody who gets hit head on, less significant concussive injury, you get punched to the side of the head, you're more likely to have a more significant injury. This is a table that you should just be familiar with and you probably are if you take care of athletes or see athletes that have concussions. Suffice to say there are a number of clinical signs and symptoms that can be associated with concussion and there is no one clinical sign or symptom that is pathopneumonic. So be familiar with these, the cognitive symptoms such as confusion, anterograde and retrograde amnesia, loss of consciousness, disorientation, vacant stares to somatic, which are the things like headache, dizziness, balance disruption, which you'll see in a second, is included in the multimodal assessment of concussion, nausea, vomiting, and short-term. I just want to highlight that short-term nausea and vomiting. That lasts for a significant amount of time, is not associated with concussion. You need to think about another injury there. Visual disturbances and especially diplopia or double vision or photophobia and phonophobia. So bright lights, loud noises, an athlete who's complaining of irritation from that, probably a concussive injury. More attention being paid to the effective symptoms of concussion, emotional lability, irritability, fatigue, probably falling asleep, sleeping more than usual. But it's a multimodal assessment for concussion. There are multiple symptoms that can be associated with concussion. You need to start this slide just in case this were to come up on a test. You need to be aware of those signs and symptoms that would suggest a more significant injury than a concussive injury. It's difficult to ask a lot of questions on tests about concussion, but being able to differentiate a more significant brain injury from concussion is one area that can be an area of focus. So think about worsening headaches, headaches that get significantly worse over a short period of time. An athlete that's becoming very drowsy or that cannot be aroused. Someone who cannot recognize familiar people or places. I mentioned significant nausea or vomiting. Someone who's behaving very unusually, becomes more confused or significantly irritable. Seizure is the big one. Seizure does not correlate with concussion. So there has to be some sort of intracranial process going on. Just like you think about with mass effect in brain or whatever else, be thinking bleed, be thinking intracranial hemorrhage, something going on. Very often if an athlete presents with seizure, it is not a concussive injury. Anything that has to do with weakness or numbness in the arms or legs, and again, I'm sure you're spending some time in your spine talking about cervical spine injury. Always want to assess the cervical spine in a concussed athlete and be thinking about cervical spine injury. And then significant slurred speech or unsteadiness of gait. Some updates on concussion. Know that there are tools out there to assess for concussion and the most commonly used tool on the sideline is the standard concussion assessment tool. There's a fifth version out now. Know that SCAT-5 is for age 13 and older and that you need to use the pediatric or child SCAT-5 for those that are 12 or younger. SCAT-5 and appropriate assessment cannot be performed in under 10 minutes. Okay, so the reason I put this up here is you cannot assess somebody for concussion on the sideline in like a two minute evaluation. You can get in a sense whether maybe you should assess them for concussion, but appropriate assessment for concussion takes time. So the idea that you look at somebody on the sideline, wave a pen around, ask them a couple questions and say they're good to go is not something that's appropriate that comes up on a test. The other thing to know is that concussion symptoms evolve over time and so it's possible that someone can initially present and say, hey, I didn't really feel anything until one, two, three hours later. So making certain that you monitor these athletes is really important. There are some things in the SCAT-5 and you don't need to obviously know all the particulars of the SCAT-5, but it's probably good to be familiar with the idea that the first thing you want to do is assess for red flags, then look for observable signs of concussion or significant head injury. The MADEX questions, which are the questions, the five questions that most of us think about, where are you, what day is it, what's the score, who are we playing, you know, those sorts of things can be immediately used to assess for further evaluation of concussion and then you want to make certain you do your examination. Know that the only validated scale for evaluation in head injury is the Glasgow Coma Scale and also know that you have to do a cervical spine assessment when you're assessing an athlete. So any answer on a downed athlete on the field or if you're worried about a head injury and you're moving them before you assess a cervical spine is going to be incorrect. Know that in the SCAT-5 also now they've defined the off-field assessment, so this is different than the SCAT-3 and SCAT-4. There's now an on-field and off-field assessment and this is, the off-field assessment obviously is more significant, but this is where you're doing a lot of the testing that is significant for concussion, the symptom evaluations, all the cognitive screening, neurological screening and balance testing, looking at delayed recall and then finally making a decision whether or not you're diagnosing the athlete with a concussion. So this should just highlight for you the fact that you cannot diagnose an athlete with a concussion, like I said, in a short period of time. It's a multimodal assessment that takes time to make the diagnosis. There's some new recovery pearls that I just want to put out there for you about concussion because there's some things that you should know that have kind of come forward in the last one to two years that may be a little different than what you're normally used to thinking about. Relative rest is preferred over complete rest. You do not put an athlete with a concussion in a dark room and leave them sit there. You don't let them, you know, completely rest. Relative rest, so getting an athlete back to doing their normal activities as quickly as possible and their daily routine is accepted standard of care. So first steps in recovery is trying to get the athlete back to their normal daily activities. Visual oculomotor screening, testing, and rehab. There is no validated visual oculomotor test for the diagnosis of concussion. They can be used as part of multimodal assessment, but there is no standalone visual oculomotor test that can be used to make the diagnosis of concussion. But visual oculomotor training and rehab can be very effective in the rehabilitation and recovery from concussion. I think this is probably, number four is probably the one that stands out the most. For a long time people were keeping athletes completely at rest from any sort of physical activity until their symptoms had completely resolved. We know now that there's research, especially even in younger athletes, of getting athletes back to earlier light aerobic exercise while their symptoms are improving. If their symptoms, if you're exercising them below symptom threshold can actually improve their recovery and is beneficial for the recovery from concussion. So early light aerobic exercise is considered standard of care from concussion. Supplements, there's lots of things out there. There's lots of teams and athletic groups that provide omega-3 fatty acids because of anti-inflammatory effect. There is no evidence that they provide recovery from concussion. Same with ketogenic diets, so just be aware that although lots of theory out there and anecdotal data, no evidence that that is the case. Part of a concussion recovery program is instituting a return to learn or return to school program. It's mandated in concussion recovery protocols by the NCAA and it is part of, considered part of a total recovery or treatment program for concussions. So if you see that, it's likely included in a correct answer. I think the other thing to know is that concussion requires a multimodal, multidisciplinary approach. Just know on any test question, there is no one singular test, no one singular treatment, no, I'm sorry, no one singular test that can diagnose concussion and there is no singular treatment that allows for the recovery from concussion. So it truly is a multimodal problem. Some things to talk about with return to play. You'll be asked this on your test, I would almost guarantee it. No athlete, there is no situation where an athlete diagnosed with a concussion can return to play on the same day where they've been diagnosed for a concussion. Even if a physician on that day determines that they may not have had a concussion, they need to sit out. That's true of the U.S. team physician consensus statement. The NCAA made that statement in 2010. There's legislation now in all 50 states that states athletes have to sit out, beginning with the Lystat law in Washington. So if you get questions about an athlete that's had a concussion, they have to sit out. There is no situation where an athlete diagnosed with a concussion is allowed to return to play on the same day. Duration of symptoms of concussion is 7 to 10 days. There's been multiple studies that have shown that by multimodal assessment and evaluating cognitive deficits, that 7 to 10 days is the average time period for someone over the age of 13 to have symptoms of a concussion. If you start to see people with symptoms or they're giving you questions about somebody with symptoms that are lagging, going on and on, it's no longer concussion, okay? For pediatric patients, it's 28 days or four weeks. So kids will have symptoms that last longer, but if they get a month out, two months out, three months out, be thinking of something else in the diagnosis. Return to play, obviously normal testing at baseline and clinical impression to determine beginning of return to play progression. The gold standard for making a decision to return an athlete to play is a clinician's impression of that athlete returning to baseline. There is no, I know I've said this a number of times, but with everything that's out there, there is no test that can make that decision for you. There's interpretation of tests that can aid the clinician, but the gold standard is a clinician's impression of that athlete being ready to return to play. There's no set time period for completion, but just know that the accepted standard is that between the stages of return to play activity is 24 hours. This is a schematic that shows the most recent updated and familiar return to play guidelines for concussion. Stage one is symptom limited activity, and that really should be occurring during that active phase of recovery while an athlete is becoming asymptomatic. Stage two is that light aerobic exercise, and usually those are activities that increase heart rate and obviously want to make certain those are below symptom. Stage three is getting to sport specific exercise, and that's mostly aerobic exercise. Stage four is non-contact training drills that involve increased coordination and thinking, and progressive introduction of resistance training. So it's important to know that really in the recovery of concussion, you don't reintroduce resistance training or lifting until you're almost halfway through the return to play protocol. Stage five is full contact practice, and then stage six is return to sport. It's important to know that almost every guideline out there requires a physician or a physician's designee to make a written declaration of return to sport, okay? So if you're asked about that, just know that a physician or a physician's designee needs to make a written declaration for return to sport in almost all guidelines. I want to mention neuropsychological testing. It's prevalent. It's been around for a long time. It's been shown to be of value when evaluating concussion. It is still recommended to use baseline testing. There is no standard of how often you should baseline test an athlete, and unfortunately there are lots of confounding variables that can affect baseline testing. Know that neuropsychological tests can be used without baseline testing. There are normative data out there that you can compare this to. Neuropsychological testing of itself is an aid to clinical decision making. Again, impact testing, COGSport, those sorts of things out there, it's never the correct answer that that makes a decision when to return an athlete to play, and it needs to be interpreted by an experienced clinician. You can't just hand it to the people at Dick's Sporting Goods, and they look at the computer and look at the sheet and say, yes, you're ready to go back to play. Neuroimaging, as I mentioned to you, is not necessary in the diagnosis of concussion, and it's usually normal. CT scan is the initial study of choice if concurrent focal injury is present. MRI is better for anatomy, and if imaging is needed, 48 hours or more post-injury. So if you need an immediate study, you know, you've got an athlete that's been hit by a baseball or something in the side of the head, you're worried about an epidural, a hematoma, and they ask you about study of choice, obviously CT scan, you've got a concussed athlete who now has symptoms for 28 days, MRI is the study of choice. Newer modalities, there's lots of them out there, functional MRs, PET scans, all those things, exciting research tools, but still not indicated in the care of concussion. We know about some of the significant issues about concussion, second impact syndrome, whether you believe it exists or not, there are documented cases about athletes dying with second impact after a concussion. It's considered the most serious risk of premature return to play following a concussion, hence the reason why an athlete cannot go back to play within the first 24 hours after being diagnosed. It's thought to be due to loss of auto-regulation of the brain's blood supply, and researchers have questioned its existence. It's rare, but you need to know that it's a complication of concussion. For concussion, prevention is key. Know that there's multiple factors that can help with head injury prevention in sport. We mentioned equipment modification. There is new data out there. I doubt, like I said, you'd be asked about it with some of the NFL data on football helmets, with better performing helmets for concussion risk than others. Most importantly, rule enforcement and changes as necessary have been shown to affect the incidence and prevalence of concussion. So just think in your head, if you change the kickoff in football, if you limit the amount of contact in practice, you can affect the prevalence and incidence of concussion. That makes sense. And then education of proper sport-specific techniques, so proper tackling techniques, for example, have been shown to improve the incidence and prevalence of concussion. But there's no evidence that we can completely eliminate concussion in sport, right, unless you just stop playing sport. So it's all about risk-benefit. So let's take a look at a couple questions here that may be similar to some things you could see with concussion. 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? 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. D. She should not return to play for this game under any circumstances once diagnosed with a concussion. So they're going to put all kinds of disclaimers out there for you, but the correct answer, like I said earlier, is if you think an athlete has a head injury or concussion, they are out. Question number two. A high school football player suffers a concussion during a game. Which of the following symptoms suggest a more serious head injury? Dizziness, brief episode of vomiting, seizure, blurred vision, or amnesia. And you know from what I just told you that seizure is the most common issue that comes up to distinguish a focal head injury versus a diffuse head injury. So any athlete with seizure does not have concussion. All right. Head injury and concussion. Hard to ask a lot of specific questions because there's a lot of data out there that is still not conclusive, but you will get questions about concussion management on your exam. Let's move on and talk a little bit about dental injuries. Dental injuries in sport are secondary to trauma. There's lots of different types of dental injuries. There's avulsions, fractures, luxations where the tooth moves, lacerations, and then temporal mandibular joint issues, pain, dislocations. Just know that contact sports, as you would expect, have the highest incidence of dental injuries. So baseball, basketball, and ice hockey have the highest incidence. Notice football, wrestling, rugby are not listed on there. And those sports, they tend to wear mouthpieces more often than these other sports. It's important for you to become familiar with this schematic. It'll help you answer a lot of questions about dental trauma. It's just basic dental anatomy. Know that you have the crown and the root, the two major portions of the tooth, and then just be able to distinguish mostly between enamel, dentin, and the pulp, the three areas there that make up the crown because when you have dental fractures, it's going to be important that you can distinguish which dental fractures need to be emergently referred and which don't. So the real key with dental emergencies is what do you do with a tooth if it comes out, when do I need to refer, and when can somebody keep doing what they're, you know, what they are doing in sport. So dental fractures can involve all three of those layers that I just mentioned, or enamel alone or subsequent deeper layers of the tooth. Dental fractures are associated with pain when it's exposed to air, cold drinks, or Obviously, you need to look for the loose tooth fragment, and if you can find it, you need to save it. So one of the pearls with dental injury is never throw something out, okay? So I know that, you know, I've been doing sports medicine with a lot of orthopedists, you know, you take stuff out of the joint, sometimes you get rid of it. For dental stuff, don't. Save it. Put it in the appropriate stuff and save it, okay? That's the answer on the test. If you have fracture that only involves the enamel, okay, so if you don't see any bleeding in the tooth, then that's safe for that athlete to continue to participate and see a dentist afterwards, okay? You want them to be seen within 24 hours. But if a fracture only involves enamel, it's safe for them to continue to participate. If it involves the pulp, and that's, you'll get a picture that kind of looks like this, and I've tried to highlight this. If you see bleeding or that red pulp in a fracture, that's considered a dental emergency and needs immediate referral. And the reason is if you delay treatment, you can get pulpal necrosis and lose the tooth completely, okay? And that happens fairly quickly. So you'll see bleeding with heightened sensitivity. You don't need to worry about the treatment options because the most important thing is to refer to a dentist and make certain that they see these athletes. Dental fractures involving the root, okay? So these oftentimes are more difficult to see without x-ray, but just know that if you have or presented with a tooth that has crown mobility, so you can move the tooth around with pain, it may have a root fracture. There's three types of those root fractures. There's apical, middle, and cervical. And just know that those cervical root fractures having the worst prognosis. So the closer to the crown, the worse the fracture for a dental fracture. And those all need immediate dental referral, so they cannot continue to play. Dental luxation or a concussion to the tooth, okay? Oftentimes with dental luxation, the tooth may move a little bit. But remember, it's going to be difficult for you to determine whether or not there's a root fracture, so those need to be referred. Subluxation is that same mobility without evidence of dislodgement. Abulsion, which can be partial abulsion from bone. So when you have somebody who gets hit in the mouth, you know, and the tooth is moving and it looks like it's partially coming out of the bone, you want to try to replace that tooth in a normal position, okay? That's the right thing to do. And then get them to a dentist. If you have lateral luxation or intrusion injuries where the tooth is driven down into the socket, those are dental emergencies. You're going to likely lose the tooth if you delay treatment on that. Dental abulsions, when the tooth comes completely out of the socket, makes up about 20% of all dental and 10% of all sport dental injuries, so getting a tooth that completely comes out. You want to try to get that tooth reimplanted within 15 to 20 minutes. So if you can put it back in place safely and transport the athlete, putting it back is the right thing to do. The most important thing for you to know is when you're handling the tooth, only handle the crown and the enamel. Don't be grabbing the root and trying to, you know, you just want to handle the crown and the enamel of the tooth or you're likely going to damage the tooth and it may not be able to excuse me to be saved. This is important if you're unable to re-implant the tooth don't throw it out. Don't say well I couldn't get it back in there it's probably not worth anything. You want to place it in either Hanks balanced salt solution which comes with most dental recovery kits. If not cool milk, saline, or even saliva. Okay try to save the tooth so that the your dentist can put it back and then emergent dental referral. Prevention of injuries is important when you think about dental injuries in sport. The American Academy of Pediatric Dentistry and the American Dental Association recommend that all children and youth wear mouth guards. Mouth guard is always the right answer for prevention of dental injury. Okay mouth guard is not the right answer for concussion prevention. So mouth guards and I highlight this here lots of mouth guard companies out there say that they you know decrease the incidence of concussion. Not true. There are some studies out there looking at the use of mouth guards to measure impacts and head impacts. But there is no mouth guard that can decrease incidence of concussion. But they can and do reduce oral facial injuries by absorbing impact and cushioning the teeth. Custom molded mouth guards are considered the best type of mouth guard if you were to get asked a question about that. All right so let's take a look at some questions that might remind you of some things we talked about with dental. So you have a collegiate rugby player that suffers a dental fracture. So dental fracture immediately should just signify to you enamel play anything else can't play. Which of the following does not require urgent referral to a dentist? Dental fracture involving the dentin which is the second layer of the tooth. The pulp which I just mentioned to you is when you'll see bleeding and sensitivity. The enamel the root middle or the root cervical. So I just mentioned again if you have a fracture that involves only enamel then the athlete can continue to play. Question four a collegiate women's hockey player suffers a tooth abulsion. Which of the following is appropriate management regarding this condition? So A have the athletic trainer pack the tooth in ice and follow up with the dentist in 24 hours. B attempt to re-implant the tooth if not successful place the tooth and Hank's basic salt solution and immediately refer to a dentist. C re-implant the tooth and allow immediate return to play. Follow up with a dentist after the game is finished. Or D discard the tooth that is not viable following an abulsion injury. So you know because we just talked about it A is not correct you don't ever want to put a tooth on ice and you want to re-implant it as quickly as possible. C you don't you do want to try to re-implant the tooth but then you can't let the athlete go back to play it's a dental emergency and we never want to discard the tooth. So we know we want to re-implant the tooth that we can and if not put it in the appropriate solution with emergent dental referral. All right let's go on to eye or ocular injury in sport. This table here highlights high-risk sports so it's important for you to be familiar of which sports are at highest risk for eye injuries. Certainly paintball or anything that involves a projectile object without a goggle is at a high risk but basketball and baseball are extremely high risk sports softball and ice hockey. More moderate risk tennis again you think about orbital injuries with the tennis ball, soccer, volleyball, football, fishing and golf and racquetball would be in there and then lower risk obviously things like swimming, snow skiing, water skiing, bicycle, snowboarding and then ice safe which is important to know is jogging, running, walking and aerobics. But just be familiar with high-risk sports and when eye injuries occur. For eye in general it's really important to know the mechanism of injury. Okay you want to know what happened did they get poked in the eye was there some sort of pressure applied to the globe you know think about what the mechanism of injury is. So is it a high-velocity penetrating object or that blunt force? Do they have a foreign body sensation? Do they have a perception of decreased visual acuity or do they have double vision? What is it about the ocular exam that's unique to them? Every physical exam for an eye injury needs visual acuity. You always do visual acuity so there's no physical exam or no evaluation when you're evaluating an eye injury that doesn't include visual visual visual acuity. You want to look at confrontational visual fields. Obviously pupil examination will be important. You want to look at the conjunctiva and we'll talk about that here in a second in the cornea exam and then you want to do exam of the facial and maxillary bones for concomitant injuries that can be significant for ocular injury. So let's talk about a few of these injuries. Common injury corneal abrasions it's a defect in the corneal epithelium. These happen all the time people get poked in the eye. It can be worse with dry eyes. Oftentimes they get pain, lots of initial tearing. They complain mostly of photophobia and a foreign body sensation. So when there's an injury to the cornea think about bright lights bothering the eye and complaining of something's in the eye when you can't see anything there. The diagnosis is made with a fluorescein stain. So you stain the eye and you see the defect in the cornea. The treatment for this is topical antibiotics and then there's questionable use of topical cycloplegics but topical antibiotics. Not shielding the eye, not patching the eye, not using shades, not using goggles. It's topical antibiotics. The other thing that's important to know is that if someone has a corneal abrasion they can't use contact lenses until the corneal abrasion is completely healed. So you have to make a recommendation obviously that they use eyeglasses and then if they do need that to be able to play their sport, if they're considered one eye blind or that they don't have significant vision to play their sport then they need the polycarbonate goggles. Obviously these obviously don't need referral unless things are getting worse and that usually signifies usually worsening infection. Orbital wall fractures. This is that blunt force or blowout fracture that you need to be thinking about. So think about this in the clinical scenario of a racquetball player not wearing goggles gets hit in the eye with a ball or someone who gets hit in the face with a baseball. The common thing that's seen here is diplopleia. So double vision due to extraocular muscle entrapment and think about the inferior rectus is the most common muscle that gets entrapped in these. Examine the cheek because you'll oftentimes see numbness in the cheek with this so that can oftentimes be the presenting symptom if you're not doing a good exam and that's due to the damage to the infraorbital nerve. It's important that you tell these folks even though they may feel increased pressure not to blow their nose they can increase pressure in the globe and cause more damage. CT scan is the study of choice and you need referral for definitive treatment and return to play. Hyphema. You need to be aware of hyphema. This is a traumatic injury due to shearing forces in vessels of the iris. This is considered a ophthalmologic emergency. What you'll see here is a picture very similar to this where you get layering of gross blood in the anterior chamber. It's important that these athletes rest. They elevate their head of bed to 30 degrees and we use psychoplegic drops. There's a significant risk of re-bleeding if this is not identified and then acute glaucoma and loss of vision and so this is common in pediatrics and one of the most common reasons in sports for an athlete to lose vision and they need urgent referral to ophthalmology. Globe ruptures. We talked about this racquetball. Think about this. This is not conjunctivitis, okay? So that global bleeding around the entire conjunctiva, abnormal pupil, pain, visual loss, diffuse subconjunctival hemorrhage, prompt referral with an eye shield. Don't apply pressure to the globe. So not an eye patch. You just shield the eye. So you don't want to put any extra pressure on the eye. So lots of people want to co-band these things on and tape them real very light shield to the eye and then emergent referral. Obviously there's high risk for serious infection and blindness. Retinal detachments. Need to think about retinal detachments. These are common especially in helmeted or high-collision or contact sports due to direct trauma to the orbit or significant head trauma. So it's important to know and again sometimes there's these distractors there. You may get a concussion-like question and what they really want you to focus on in your exam is that there could be a retinal detachment, right? So something wrong with vision doesn't necessarily mean just concussion. We don't want to lose sight of the fact that there could be an orbital injury or an ocular injury at the same time. So if they describe an athlete seeing floaters, complaining of flashing lights or a blind spot on their visual field, think about a detached retina and that needs to be urgently referred to ophthalmology. That's an ophthalmologic emergency. Lots of things here for return to play guidelines. So anything that involves the cornea you can return them to play. Everything else should see an ophthalmologist. Last about eye. You need to know about monocular athletes. This gets asked a lot. You need to know for the athlete who is functionally blind in one eye that it's recommended that they have polycarbonate goggles to protect the remaining eye at the time of the PPE. So you may get a question about the pre-participation exam and a functionally one-eyed athlete and what the recommendation is for polycarbonate goggles. They cannot be involved in full contact sport such as boxing or martial arts, okay, even with goggles. So it's a absolute contraindication for MMA, boxing, judo, karate, any of those sports for a monocular athlete. What does it mean to be functionally one-eyed? It means that the best corrected functional acuity of no better than 2040 in the poor seeing eye. So you just need to know that number. So if it shows up you can identify because they're not going to tell you that the athlete is a monocular athlete or functionally blind in one eye. They're just going to give you the visual acuity for both eyes. So they're going to say they're 2030 in one eye and 2100 in the other eye. And you're going to have to know, okay, this is a functionally one-eyed athlete. What do I have to do or what are the restrictions for that athlete? Alright, so with that, let's try a question and see what that looks like. So you're seeing a 12 year old male for his PPE prior to basketball season. His visual acuity screen results are 2030 right eye and 2100 left eye. Which of the following is appropriate advice for the upcoming season? He may not play basketball because of a risk of eye injury. 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 any follow-up and he can play basketball without restrictions. So just as I just highlighted, you would know because this is a functionally one-eyed athlete. If he's going to participate, he has to use polycarbonate goggles. You need to document that and that he needs to follow up for his visual acuity deficit and why that is. Another question. A football player presents to you acutely on the sideline and complains with complaints of loss of vision in the lateral visual field of his right eye. He was hit on the right side of his head and immediately had the sensation of seeing flashing lights in his right eye. Which of the following is the most appropriate treatment at this time? And so I've already given this one away but you would know that by looking at this you would suspect that he might have a retinal detachment. So you then you got to know what the treatment is. So do you prescribe topical antibiotics and continue to play? Well you do that if it was a corneal abrasion but we know for corneal abrasions they don't get these symptoms, right? We talked about photophobia and a foreign sensation in the eye. Finish the game and then assess visual acuity. Ah, you can still see. Just go ahead and keep playing. Never the right answer. Place a pressure dressing on the right eye and send to the emergency room. We've already talked about it's never appropriate to put a pressure dressing on the eye. Monitor on the sideline and if symptoms improve allow him to return to the game. Not appropriate either. You need to recognize that this is a possible retinal detachment and emergent transfer and referral to an ophthalmologist for evaluation and treatment. Some of you probably haven't heard some of this stuff since medical school so I'm sure this is captivating. Let's let's talk a little bit about let's talk a little bit about the abdomen and some of the things or some of the pearls you need to know about abdominal injury in sport. Rectus sheath hematomas are common. It's due to bleeding into the rectus sheath, secondary to blunt trauma, and injury to the epigastric artery. So this is an arterial bleed. It's oftentimes a pain in a palpable mass with tenderness and can be associated with signs of shock. So remember just arterial bleed. You just want to think about arterial bleed with a rectus sheath hematoma. You need to get an ultrasound or CT scan and then treatment. Fortunately most of these are self-limiting but obviously if the patient's unstable or it's continuing to cause significant pain they're going to need surgical consultation. Splenic rupture. The spleen is the most common abdominal organ injured in sports activity. The liver second and the pancreas is third. So just know spleen, liver, pancreas. But the spleen far outpaces the other two for injured abdominal organs. It's most often due to a deceleration injury because you get shearing forces on the capsule and on the vessels. So it's not usually due to significant blunt trauma like somebody getting you know hit, right? Remember the spleen is protected fairly well by the rib cage so unless you have significant trauma due to you know rib fracture it's usually due more to the deceleration part of that injury than the actual blunt force. Symptoms of splenic rupture. Left upper quadrant pain, sharp and then dull. So these can be delayed, right? If they present you with a clinical scenario where a rugby player comes in and says I got hit in the ribs and I had some sharp pain I thought it was you know they thought it was a rib contusion but I'm still now having dull discomfort and especially then if they just if they describe Kerr's sign which is radiating a referred pain to the left shoulder because of that irritation of the diaphragm you want to be thinking about something going on with the spleen. Non-specific signs, nausea, vomiting, tachycardia or orthostatic hypotension and then obviously if they showed you an x-ray with associated rib fractures you would be thinking about splenic injury. Splenic rupture imaging. Ultrasound is the initial study of choice if the athlete is stable. A focused abdominal ultrasound if you have availability if not our CT scan is obviously used as well. Management depends on hemodynamic status. Most of the time these can be managed conservatively sometimes by angioembolism. Unfortunately there are rare times with splenic fracture significant splenic injury you have to have splenectomy and what you want to remember about splenectomy that they may ask you they don't care that you know about splenectomy in general except as a sports clinician you should know that that athlete now is going to require vaccination for strep pneumonia and that's the one that they most commonly like to ask so it's what are we doing with that athlete when they report back to you. We'll talk a little bit more about splenic rupture in the next lecture when we talk about infectious disease and Epstein-Barr virus or infectious mononucleosis. Renal trauma. Fortunately the kidneys are fairly well protected from in sport but a blow to the flank causes a oftentimes a coup counter coup injury which can cause bleeding. The most common symptoms for kidney injury you get a clinical scenario that says someone's got flank pain and hematuria they have an injury to their kidney okay if you see that in clinical practice they have a renal injury until proven otherwise okay athletes with hematuria most often have some sort of renal injury they're not peeing blood for some other reason okay. Fortunately renal injuries and contusions are the most common there's four types of renal fractures you don't need to know those but if if they do have a renal fracture you need to make certain that they're monitored appropriately. CT scan is this imaging study of choice. Management is often conservative with rest and observation and appropriate environment with volume and fluid management and looking for the resolution of hematuria but make certain that if that you don't allow athletes to continue or choose something where an athlete would be able to continue if they have flank pain and hematuria. Testicular trauma. You need to know about testicular trauma. This is an emergency in many athletes. Contusions are common that's not an emergency but torsions or fractures are GU emergencies. The imaging study of choice is ultrasound. So testicular ultrasound is always the correct answer when you want to evaluate for testicular injury. If they have a contusion it's conservative management rest ice and compression but it's important to know that the other two injuries that I mentioned need an urgent referral and the reason is is that with any delay you have loss of loss of the testis. All right let's take a look at a couple additional questions here. You're seeing a rugby players complaining of left upper quadrant abdominal pain rating to left shoulder after completing a game. This is how they're going to present this question to you. What is the most appropriate management at this time? So you need to recognize that this is Kersh sign and it most likely is significant for an injury to the spleen. So do you want to do an urgent urinalysis for to evaluate for renal injury? Well I've already told you the two buzz things that you need to look for there are flank pain and hematuria. Emergent referral for hemodynamic monitoring and abdominal CT to evaluate for splenic injury or rupture. That answer sounds pretty good. Observation and treatment with catoral act for pain. Abdominal injuries, testicular injuries, renal injuries do not get pain medication. Okay we don't give them shots of Toradol and see if they calm down and then go back to play. So no pain management and abdominal trauma. Reassurance that this is normal following a contact sport like rugby and will resolve spontaneously. The rugby coach may like to think that but you don't want to think that. And then how about an EKG or cardiac workup for suspected myocardial infarction? And obviously referred pain to the left shoulder can be cardiac in nature but in a contact athlete with this being more common the answer we're going to choose is emergent B. Emergent referral for hemodynamic monitoring and abdominal CT to evaluate for splenic injury or rupture. Alright question number eight. 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. Okay which of the following is the most appropriate next step in evaluation? Urinalysis, CT of the abdomen and pelvis, pelvic angiogram, MRI pelvis or testicular or scrotal ultrasound. And just remember for any injury to the testis ultrasound is the correct answer. Okay. Injections. You guys know about injections and do injections so this should be more should be familiar to you and I'll just try to review a few things that have already been covered and just highlight some things that you're probably already aware of. Corticosteroids and we know that they can be effective at sites where inflammation is significant. You were told in the last lecture and it shows up on sport medicine exams everywhere to avoid them with tendinopathies due to the increased risk of rupture especially weight-bearing tendons. And controlled studies suggest that in general corticosteroid injections for sport injury is no better than rehabilitation. Probably the most important thing to know is what the negative effect on the tendon can be if you were to inject it. So they may figure that you know that it can cause tendon rupture but what are the effects? So reduce cell viability, cell proliferation and collagen synthesis, collagen disorganization and necrosis and reducing the mechanical properties of the tendon. You know that corticosteroids have been shown with some effectiveness in some studies for adhesive capsulitis. I'm not going to spend time talking about that here. For osteoarthritis you know that it's very limited pain relief and that there is suggestion there could be articular cartilage destruction and then you know about the risk of infection with total joint replacement. There are other associated risks that we need to think about and this is probably the most important thing to know about corticosteroid injection from my standpoint. The things that people come in and complain about often don't have anything to do with the reason you gave them the injection themselves. They can get post-injection neuritis, skin atrophy and hypopigmentation are two big common issues. Infection is common, decreased ligament strength and obviously ligament rupture. But there are other associated risks and you'll understand most of these here until we get to the last bullet point. Even with intra-articular or other steroid injections in athletes they can develop hyperglycemia, they can have adrenal effects, they can even develop psychological effects if they're done frequently. So all of the things you might think about with using an anabolic steroid which we're going to talk about in the next lecture, you want to think about with corticosteroid injections because it's been shown that those can occur with frequent use. Local anesthetics, you know about the risk of chondrotoxicity and do not be used for an injury that could be worse by playing and obviously these need to be used with player and physician when they understand the risk and benefits. I don't know that you'll get much question about that other than probably not a great idea to be injecting most things and putting an athlete back to play on a test. Visco supplements, again the physiological properties of hyaluronic acid, people still debate how do they actually work or do they actually even work at all. Are they even effective? Is there a moderate effect on early to moderate OA? As most treatments we know have moderate effects on early to moderate OA. Peaks at about six to eight weeks. Moderate improvement compared to interarticular steroids and placebo but not widespread use in sports medicine at least in acute sports injuries. PRP was mentioned earlier and I'll spend a couple minutes talking about platelet-rich plasma or PRP. Remember that PRP therapy is based on the premise that growth factors released from the alpha granules of platelets and super physiologic amounts can augment the body's natural healing response. So think about medicinal signaling for PRP. Platelets also release bioactive proteins that can attract mesenchymal stem cells, macrophages, and fibroblasts which can be helpful and promote the removal of necrotic tissue and enhance tissue regeneration and healing. When you think about PRP, think about platelet concentrations and volumes. So the normal platelet concentration you can see there PRP has been classically defined as either low concentrate or high concentrate based on the number or the amount of times concentrated the PRP is. And it's important to know that we don't know what the ideal platelet concentration for PRP is for most of the things we use PRP for. It's important to know that PRP has not just platelets as part of its component but usually white cells and even in leukocyte poor PRP there can be white cells. We need to know obviously that there's different types of white cells that can be there and so probably just classifying PRP as plus-minus white blood cell isn't adequate because these white blood cells all function differently. We need to know that red blood cells are part of PRP so we want to know what the red blood cell count is and obviously we don't want any there because there is deleterious effects from the red blood cell to the positive effects of PRP and then we want to know whether or not the platelets are activated. So think about for PRP if they ask about the components of PRP it's PLAR. Platelets, leukocytes or leukocytes, okay, activation and red blood cell. Those are the components we need to be thinking about when we think about PRP. Conclusions of knee OA. So just and again not certain that this would be on the exam but pain is improved for PRP versus placebo and HA. There's mild improvement in activity levels. Adverse effects are possibly greater in the first seven days for those with PRP. Duration of effects is six to twelve months but six months is safe and younger patients with less severe OA achieve the most benefit from PRP. Not surprising as they achieve the most benefit from any treatment we do for osteoarthritis. It was mentioned in the last lecture about the limited evidence for benefit in tendinopathies and probably the most evidence in lateral epicondylitis or lateral epicondylosis. Mesenchymal stem cells. In general for test-taking purposes you need to know that you should not be using mesenchymal stem cells to treat anything. They should only be used in clinical trials. There's lots of things here that we know about mesenchymal stem cells but it's now thought that mesenchymal stem cells really are not doing nothing more than just medicinal signaling. Their benefits include as you can see there and so then we have to ask ourselves what's the appropriate use and evidence is limited for OA but I would agree with Dr. Gill that if you get an answer on the test that includes PRP or mesenchymal stem cells as a treatment that's probably not the correct answer. All right a couple final questions here to finish up this session. So an athlete presents to a team physician to discuss the potential of 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? So tendon rupture, skin atrophy, skin hypopigmentation, hypoglycemia or vascular injury. And just again especially when you think about those common side effects we know that tendon rupture is, skin atrophy, skin hypopigmentation but it's hyperglycemia that is a risk with the use of corticosteroids and even corticosteroid injections. And then question number 10 I mentioned here which of the following is not a key component of platelet-rich plasma? I gave you that mnemonic to think about that PLAR so platelet concentration, red blood cells, blood type, white blood cells or platelet activation. And with PRP it does not matter what the patient's blood type is that does not affect the components of PRP. Some references and this is really good every year I get a little better at this and I'm four minutes early so keeping us on time. Thanks a lot.

sports medicine

head injuries

concussions

dental injuries

eye injuries

abdominal injuries

injections

Standard Concussion Assessment Tool

medical aspects