Good evening. Thank you for joining us this evening for this webinar titled Go or No Go, In-Game and Post-Injury Return to Play Decision-Making with Sideline Management. Dr. Michael Banfi is our moderator this evening. He practices at the Curlin-Job Orthopaedic Clinic, specializing in sports medicine, hip arthroscopy, and joint preservation. He is team physician for the Los Angeles Rams and also the Los Angeles Dodgers. He's the director of the Orthopaedic Sports Medicine Fellowship at Curlin-Job and also associate professor of orthopaedic surgery at Cedars-Sinai Curlin-Job Institute. Dr. Banfi, I will turn this over to you to begin the webinar. Well, thank you everyone for joining and I'd like to thank our esteemed faculty for working with us tonight and welcome everyone to the first fellows webinar of 2021 for AOSSM. When we began this fellowship year, we had just ended the last fellowship year and there was a lot of trial and tribulation with regard to the pandemic and obviously, although we've had the vaccines, things have continued and one of the things that I was most worried about was on-field management. Sure, we can get into the lab, we're still doing surgery, but I felt as though the on-field management was the thing that we're going to miss the most. So this webinar is an attempt to start giving you guys some thought processes that we utilize when we're on the field, we have our athletes go down, how we're going to treat them, who we're going to allow to return to play, and who we're going to hold back. So I'd like to start out this evening with Dr. Ben Parker. He's the director of orthopaedic sports medicine as well as shoulder and elbow surgery and the team physician for Appalachian State University. And before you start, Ben, for the fellows, if you have any questions, we want to try to make this as interactive as possible, type them in, I'll be able to give those to whoever is presenting and we'll make sure to answer those for you guys, okay? Take it away, Ben. All right, guys, thank you very much, Dr. Banfield, for having me and all the other speakers tonight. You know, you guys are all mentors to me, and I appreciate you guys having me up here. I'm in a town in Boone, North Carolina, and we have a good football team up here, remarkably. And I'm young in my practice, so hopefully in this panel discussion, you know, my youth in being early in practice and kind of encountering these questions in my mind when I was thrown into the fire, hopefully this can help guide some of the fellows along their way. So you know, my topic, I chose shoulder instability because this is something we deal with commonly. And you can see initially, you know, the AOSSM has been very supportive of me, and I use their resources all the time. But the first thing we see is we keep you in the game. And you know, that's the question, is when do we keep the player-slash-patient in the game? I have no conflicts, and there is patient information and videos on here, but they're all released for educational purposes only. So here's our player, our injury. You're going to see him. He's number seven. He's an inside linebacker, 20-year-old, right-hand dominant male, 225 pounds, he's a junior. And he's going to run out wide here on the field, and then he's going to come down with his arm almost AD-ducted, rather than abducted. Of course, we make the play, but he's down on the field still. And when we brought him in, that's the first decision is, what do you do? So you know, a lot of situations will have your trainer go out to the field and assess everything. When my trainers run out to the field, I start meandering slowly. I think most of us do that. But I don't wait for them to call me. I kind of slowly meander, and if I have to turn around, I will. But you know, this patient, we actually brought him into the tent, and he had a shoulder dislocation anteriorly. And a lot of these guys, there's kind of three different kinds of guys. There's guys that will run off the field with their shoulder dislocated, looking like Napoleon Dynamite and screaming. There's guys that will lay down on the field, and there's guys that will take back to the tent. And this was in the second game of the season, and we reduced him pretty easily. I felt him clunk in. And then the question is, what do we do after that? So was the reduction successful? The answer for this guy was yes, but sometimes it's not, and you have to take him to the emergency department, specifically if they go inferior or get locked. And that's happened to me once. It's very rare for that to happen, but every once in a while, you do have to go to the ER. And then is the athlete in pain? And then what are the exam findings? So the things that I assess immediately are, you know, when you reduce these patients, a lot of the times, they'll feel excellent afterwards, they'll feel great. And we do strength exams. So I specifically test the subscapular, and I test all the rotator cuff muscles. And I see how apprehensive they are immediately on the field. And then we have to assess what the player status is. What is their mentality? Are they begging to play? Are they a resilient player that you know already? Are they going to make bad decisions because they want to play? And is there profound crepitus? Those are kind of the things we need to assess. So my pearls, just from being with this team now for four years, is number one, know your team. And that involves you just being involved constantly. Become a mentor to the players if you can. Be intricately involved with your athletic trainers. You learn more about them through your athletic trainers, their attitudes, the way they act. And then more importantly, you have to balance the clinical scenario and exam findings, and then do what's right for the patient, not the player. And we understand, you know, you guys, some of you guys are going to go into the Division One world, into the high school world, and you're going to be pressured to kind of make decisions based on the player's status and their desires. But you have to remember that these are patients as well. My third rule is don't be a pushover. And that takes time. You know, if you're new out into the field and you're starting to be into practice, there's a level of trust that the coaches and staff build with you. But you have to be resilient in terms of making decisions and showing confidence with those decisions. And then always be a part of the team and don't be a fan. That's hard sometimes. You know, but you have to make decisions based on the betterment of that player. So once the dust settles, let's say the player goes out there and they play great and they have great strength. That has happened several times. Most of the time the player will get pulled because there's too much soreness in the shoulder. They feel anxious about playing. So how do I manage it after that? Well, once the dust settles, I educate them. And I try to talk as simple as possible. I talk immediately about labrum tears and things like that. And specifically, if the family's at the game, I bring them back into the training room. Even if it's a late night game, I'll sit down with them and say, hey, you got your shoulder. It came out through the front. Usually when it comes out, it can sometimes damage some of the labral tissue in the capsule on the front of the shoulder. And this may be something we need to assess. And then I re-examine them later on. I assess the family and the coaching staff and the patient's thoughts fluidly to see how anxious they are. Because sometimes that will drive me to say, hey, let's get an MRI on this patient very quickly to reassure them and to reassure what I've already discussed with them. And then organize a plan. And what I mean by that is you set a plan up where you say, OK, this week we're going to kind of take it easy the next two days, anti-inflammatories, ice, and then start mobility exercises, strengthening exercises, scapular mobility, scapular strengthening, rotator cuff strengthening, re-examine, and then see how they do through the season. And then the plan is, hey, let's see how you're doing by the end of the week and can you go the following week. And it's a fluid situation. If they start having crepitus, if there's profound situations where they feel unstable, it may require us to address it in another way. How have I gotten burned in my first couple of years? And this will lead to the next question that I'll ask the panel as well as all of you guys out there. Glenoid fracture or a large bony bankart. Always get an x-ray on these patients, whether it's Sunday morning after the game, Saturday morning, high school team, or Monday morning, as soon as they can get one. Because you want to look and see if there's a large bony bankart. You want to be able to assess for an engaging Hillsex lesion to give you an idea of how bad this injury could be. A lot of these football players you guys will work with in your lifetime will be strong. They're really strong and they're resilient. And your exam may not be 100% perfect. So getting some objective data is helpful. And then again, just continually assess the rotator cuff involvement. And I say that because there have been situations where there's been large associated subscap tears with these injuries. And combat all these pitfalls that I've addressed with a good clinical exam and get more objective data if you need to do that. Remember this is the engaging Hillsex, assessing diameter, assessing the glenoid track versus the Hillsex defect. And that's the equation. Honestly, I keep that on my desk sometimes because I have to remember 0.83 all the time. So my first question to the panel is, and to everybody else out there is, do you get an MRI right away, no matter what? If you assess the patient and you feel like they're feeling strong, they don't have any profound crepitus, they feel somewhat, you know, they may be early apprehensive because of the swelling in the shoulder, but that resolves over the course of the week. Are you still rushing to get an MRI in the middle of the season? I'll ask Darryl first, Darryl. All right. So we're closing the poll. All right. Can you hear me now? Yeah. Sorry. I got Meredith muted me. I guess she don't want me to talk, but no, great question. I do. I don't get an arthrogram though. You know, I want to get x-rays. I want to get an MRI, get a sense for if the patient has any bony involvement on the glenoid as well. And so I do. Okay. Anybody else want to chime in? Yeah. I similarly will get an MRI. I won't always get a CT scan if the x-rays are normal and the MRI gives me a good sense of the bone. But, but, you know, one, one quick question to counter you is, is how would you treat this collision athlete differently if they were a non-collision athlete? You know, I saw this great talk one time where they had a rugby player, you know, throw their shoulder back in and it just kept going and they got Dwayne Wade dislocated in his shoulder and he gets wheeled off in a wheelchair, you know, so definitely, you know, different athletes. Right. Yeah. You know, and that's changed for me. So first to respond to Daryl's answer, when I first got up here, I was acting like I was in an ivory tower and would assess entirely by clinical exam. And over the course of the last three years, I have gotten more aggressive about getting MRIs off the bat. And again, that's mostly to reassure the patient. I usually tell them, Hey, you're going to have a bank heart tear. It's whether or not it's bony or something like that, that we need to address this sooner rather than later. And that gives them confidence in me because I've already kind of predicted what the injury is and they're like, wow, he can make up MRIs in his brain before seeing them in his mind. But counter to that, Dr. Manfi, yeah, you're right. You know, that also has changed for me. I believe there's a study in the military about long-term outcomes with shoulder instability and first-time dislocators. A lot of the time I will go and get x-rays, but if they're in the community and they're not contact athletes, I will not jump to an MRI right away unless there's red flags on the clinical exam. Dr. Parker, would you like me to share the results? Yeah. I didn't see those. That's pretty interesting. Two thirds or actually one third, 30% are not getting the MRIs right away, which is surprising. I would have thought it would have been more. I find also with the collision athletes versus non-collision, like I had a baseball player at the end of this last season who dislocated his shoulder and he went back out and played and actually did great. I'm less concerned about the non-collision athlete being able to protect themselves as I would be a collision athlete. I'd be more inclined to keep a football player back, personally. Hey, Ben, one thing I will say is when you get these MRIs pretty quickly after the injury, you'll have swelling in there so you don't need an orthogram, so you can take advantage of that really quickly so you don't have to inject with dye. If you're trying to get them back quickly, you still have the option, depending on what the pathology shows. Yep. That's typically what I'll do. I did the same thing, Daryl. I don't routinely get an orthogram, but I do MRI them just to look again for a hack. I'll look at it so I can talk to the patients and say, hey, you can return to play. Let's see how you do this season, or do you need something done surgically quickly? Yeah. All right, well, awesome talk, Ben. Let's keep moving along here. We're going to switch over to the lower extremity. We have Dr. Patrick Smith from Columbia Orthopaedic Group. He's co-director of sports medicine there at University of Missouri-Columbia, as well as a team position of the University of Missouri. Okay, thank you, Mike. So I'd like to, I've got a quick eight-minute talk here on the subject of PCL. This is my disclosure. So real quick on the anatomy, PCL is about 38 millimeters long, 13 millimeters in diameter. Two main components you want to remember, anterolateral posteromedial, AL is twice the cross-sectional area, and twice as stiff as the PM. Also tensioning is important when we talk about double bundle. A PCL surgery, ACL is tight inflection, and the posteromedial bundle is tighter in extension. First of all, you need to know this is not that common. PCL injuries are rare, about 2% to 3% of acute knee injuries. Most common etiology are sports and MVA from dashboard injuries. And often they're going diagnosed. PCL patients don't have the classic pop you might get from an ACL tear patient. Many times the athletes, even their symptoms are vague, diffuse pain and stiffness. So it's a little bit different than the ACL. We talk about football, mechanism of injury, the two most common, as you see it on the left here, fall on a flex knee. Again, this professional athlete on the turf is a good way to tear your PCL, or another way is seen on the right, if you get a direct blow to the anterior tibia. How's our diagnosis made? Number one, posterior drawer test is most sensitive and specific, but you have to remember your starting position. The tibia is anterior about a centimeter to the femur. So you need to know that as the position of reduction. The Godfrey sag sign is seen in this photo showing the right knee sagging at 90 degrees of flexion. Quartersubsactive test, the patient has their foot on the bed, and they contract their quad. You can see the tibia reduce. We grade them by the amount of posterior translation. Grade one is zero to five millimeters laxity, grade two is six to 10, and a grade three is greater than 10. A key diagnostic pearl that Dr. Birkfeld taught us many years ago. If you have an isolated PCL injury, you'll have a positive posterior drawer with the foot in neutral position, but when you internally rotate the foot, the laxity goes away. And that is indicative of an isolated PCL. Now it's really important always to assess posterior lateral coronary with PCL injuries. It's a bit controversial if you can have a true isolated grade three PCL, meaning greater than 10 millimeters of laxity with nothing else injured, is a little bit controversial. Usually have the post lateral coronary in that setting. So here's a patient of mine, this is a college athlete that has isolated PCL, see his posterior drawer neutral position, and when you watch when I internally rotate the foot, you can see how it diminishes. So again, key point of an isolated injury with PCL, internally rotate that tibia and do your posterior drawer. Let's talk a little bit about in-game management. Again, these are not that common, but if I do, I diagnose a PCL tear immediately in the tent after an injury, I do not allow that athlete to play right away. I worry about further injury, they can convert that isolated PCL grade two to a grade three or have other damage to their meniscus or chondral damage. So it's important to recognize the PCL is different than the ACL. The PCL has some innate healing potential. It's extra articular, but it's intracernal as seen in this anatomic diagram at the back of the knee. So this is a great case to share with you. It's one of my patients who injured her PCL mid-substance tear. You can see the injury on this MRI. I treat her conservatively. It was two plus injury, managed it with PT. We braced her, wasn't happy, wanted surgery. Came back to me a year later, we did another MRI and look at her PCL now. It looks normal. And in fact, here's the radiologist report, posterior cruciate ligament is intact. So it's a key point, PCL injuries can heal. And so particularly on MRI, MRI is great for acute PCL injuries, but for chronic injuries, MRI might fool you because of this interval healing. This was actually a bit of a problem. I ended up operating on this young lady and this MRI report caused us a little problem getting insurance coverage down the way. So just keep that in mind about chronic MRI or PCL can show some healing. So non-surgical management for me is these grade one or two PCL injuries we see in football. I treat them conservatively. There's some question, should you mobilize these athletes in extension to see if you can get some healing of the PCL? Probably a better option is the jack brace, which has a hinge, a spring-loaded hinge to reduce the tibia and allow still for range of motion. They're a bit cumbersome to use. I've used it a couple of times, but there are definitely studies in the literature that have shown some healing of the PCL with use of the jack brace. Non-surgically, the other key is rehab and it's focusing on your quadriceps. Here your PCL is going to sag with gravity when you hurt it, the quad is ideally suited to reduce the tibia through the attachment of the teratendon, the tibiotubercle. So we focus on quad strengthening and no hamstrings. Hamstrings are bad for PCL tears. I think with the quad, straight leg raises are a great exercise, particularly early on. Closed chain is also good, but studies have shown there's less strain on the PCL from 30 to 70 degrees of flexion. So with closed chain, like with squats, we try to limit them to about 70 degrees to minimize stress on the PCL. I like functional bracing. Take your ACL brace, reverse the straps and kind of do a little bit with the jack brace does, and the athletes can get back to practice a bit quicker, I think, with that. Return to play. It depends, obviously, but the key for me is no swelling, full range of motion, a good quad. Some of these PCL patients come back pretty quick in even one or two weeks. Some take longer. So this is another pearl about return to play comes from John Bergfeld. This is a long time ago, 1986, but he reported that there was a two to 3% incidence of asymptomatic PCL tears in elite college football players picked up at the combine where these athletes were good enough to go to the combine and there they were diagnosed with a PCL, but they never reported an injury, they never missed any time. So these athletes can fall on the turf, hurt their knee, they don't say anything to the trainer, you never even know about it, and you might pick it up the next year at their physical that they tore their PCL, but they can tolerate it pretty well. So keep that in mind. What's in the literature about conservative treatment for PCL? Not very much. This is the most quoted study. It was from 2017, 46 patients with grade 2, and then they said grade 3 isolated, no other injury. Again, that's a bit controversial. These are rugby and soccer players, but their return to sport at the full competition was generally about four months, which is a long time, definitely a lot quicker than that. They looked at these patients and follow up at two years, 91% were still playing at their same level of sport, and at five years that deteriorated about 70%, but still pretty good outcomes with conservative management, and they did use the jack brace in this study. The big thing you need to realize is with PCL injuries later on, the risk of OA, Sanders showed these patients treated nonoperatively have a higher rate of meniscal tears and arthritis and subsequent need for total knee, and they deteriorate over time. This study showed that the risk of arthritis particularly involves the medial femoral condyle, medial compartment, and the patella femoral articulation, and again, that's from the biomechanics of the PCL laxity. What about surgery? This study by Gwinner showed in 2018, even with surgeries, arthritis, medial compartment, patella femoral, most common again. So do we do surgery? Is it going to help? Rarely. I do it for a grade 2. Sometimes I do in a high-demand athlete. If they fail conservative treatment, what do I know when they fail? They come to me and they're complaining typically of medial joint pain from the biomechanical overload or they have patella femoral symptoms, then I would consider doing a reconstruction. Grade 3, if they have a post-lateral coroner, I think those need to be fixed with the post-lateral coroner and multi-legs for sure. Real quick just on surgery, just to kind of bring the topic to full circle, my approach is I like the Graflink all inside. It's minimally invasive. I typically do single bundle, although I've done some double bundle PCLs. I use Allograft commonly and I intramural brace on my PCLs. Why do I like all inside? I want to re-tension my graft. With suspension fixation, I can cycle the knee and re-tension the femur and tibia to limit any creep on the operating table. Noonan showed us that, the benefit of capturing the laxity that you have with a screw placement. A Better Biology of Socket Healing, we did a canine study a few years back and showed the good healing for porcelain integration, which is how your ligaments attach to bone. We saw that just in all inside sockets versus using a screw in a tunnel, which just led to fibrous integration. Why do I use intramural brace? There are great forces on your PCL graft. In the operating room, when you do a PCL, you're really happy the day of surgery. It's totally tight. You have your fellows jerk on it. There's no poster drawer, but you'll see it later on. I had that a lot in my early years where I've seen a big poster drawer six months out. So I've kind of mitigated that with the intramural brace. It's easy to use. I do it independent. I pass my intramural brace through my suspensory button. My graft goes through my loop. This is what the construct looks like on the back table with an allograft. Why all inside? Well, I think the flip cutter is huge. Nobody wants to ever have this happen to them. Pin through the popliteal artery with the reamer coming that way. There's a lot of danger in the back of the knee. The vaginal all inside with the flip cutters, we drill away from the neurovascular structures. You can see this one of my cases. I've got my guide in place, a contour guide. I'm going to drill my flip cutter in. You got to be well posterior. The PCL attaches well a centimeter below the tibia in the back. This is where you need to be. I use a post-medial cannula, as you can see here, to help me visualize. Here's our flip cutter coming to make our socket, again, drilling away from the neurovascular structures. Here is the popliteus muscle. You got to be right by that extra articular ridge. You can see on my post-op x-rays. Here's the outline of my femoral socket, the tibial socket, rather, well posteriorly located. This is one of the grafts. You don't see the intramural brace because it's typically behind and a PCL. Here's an MRI that I did on one of my post-op PCLs. Here you can see the graft. I think this is our intramural brace, which I fixed independently with an anchor. Again, I think this will really help my PCL outcomes in terms of lessening laxity. Real quick, just talk about single versus double bundle. Been a lot written about it. This was a good study published last year. Looked at 28 single bundle and 36 double bundle PCL. No difference in clinical scores. OA progression was very similar, about 14%, and their 15-year survival rates were about the same. In the literature, single and double are pretty much coming out about the same. Finally, just close with a sobering thought about surgery. This meta-analysis looked at the return to sport after PCL reconstruction, and it was only 44%. So even with surgery, we have some work to do. Here's us going to touchdown again. That's always good. And here's our poll question for the fellows. A little test there for them, making them work a little bit. So, Pat, while we're looking at this, I have a question for you. So this will be a player that has just finished their season. They have a symptomatic medial firmacondyle, you know, full thickness lesion, and you're going to operate on it. So you can't say you're not going to operate on that. They need to have surgery on that, but they also have a grade 2 PCL. Would you, you know, in consideration of your talk and what you thought or talked about, you know, if you're going to do, say, an osteochondralograft, would you do a PCL reconstruction at the same time, or would you just let it go? No, I'd absolutely do the PCL, Mike, because I'd have to assume that the medial firmacondyle came from the overload. The fellows did a good job on the questions there. I would say, yes, I would for sure do the PCL with whatever I did to the condyle. Absolutely. Yeah. I think that's an indication for surgery. You know, I'm an old guy. I've been doing this 35 years on the sideline. But in the old days, I was taught to get a bone scan for our PCL patients every year. And if we saw increased uptake on a bone scan in the medial or patellofemoral compartment, that was one of our indications for surgery. But now, I go more to the MRI, and if you see a dema in that condyle or a condyle lesion as you're speaking about, that's when I would definitely go for the reconstruction. And what about bracing? How long do you like to brace them for? We try to treat these non-operatively. Yeah. It's a great question. You know, and if you guys use the jack brace, it's not the easiest thing in the world to manage. Number one, it's expensive. But number two, it's a little bit of a hassle to keep these guys in it. So typically, I use an E-Mobilizer or an extension brace for at least a week to 10 days. And then I'll let them go with the functional after that. But the jack brace has been hard for my athletes to really tolerate that well. But the people that use a jack brace, use them for several weeks. The Ossur rebound brace is great too, and I use that a lot on our athletes. So I'll put them in that for two weeks. It's really for non-playing, but I'll use that, and then I'll switch them into a PCL brace, the Donjoy PCL. Yeah. Yeah. Our guys like the pad, the back part of the functional ACL braces too, just to push everything forward. Yeah. Yeah. And again, you know, again, the PCL can heal, and the literature does show a lot of these cases will have a, you know, maybe a grade two or a so-called grade three, and then, you know, at four months, six-month follow-up, it's diminished to grade. So I think they do help. Yes. All right. That was great. Let's keep moving along here. I'm going to introduce Dr. Casey Batten, someone very close to me. He's the lead here at Kerlan-Jobe of our Primary Care Sports Medicine Fellowship. He is the head of Primary Care Sports Medicine position for the Los Angeles Rams. He's also the ultrasound extraordinaire here at Kerlan-Jobe. So he's going to talk to us about concussion. Take it away, Casey. There's an orange, orange, no, I can see your face moving. There you go, can you see me now? Yep, you just got it, there you go, perfect. All right, well, thanks for having me. So for the next eight minutes or so, I'm just gonna go over sort of the acute management sideline management of concussion. And so we'll try to do our best in eight minutes, nothing to disclose. So what I'm gonna do here is set the table with two partial case presentations, and then we're gonna review emergency, sorry, evaluation and management pearls, and then come back to these cases to apply the principles that I reviewed. So case number one, you're covering a high school football game for a colleague. There's an 18 year old running back, there's a big hit. This is a frontal helmet to helmet blow. Referee sends the player to the sideline for evaluation. Your initial evaluation shows that that athlete's alert and oriented. They do not appear to be in any acute distress. They're complaining of a mild frontal headache. However, they deny any other concussive symptoms. Further questioning, they deny neck pain or any extremity symptoms. So we'll stop for that case. The second case is you're covering a community college or an away game. There's a 20 year old wide receiver who goes up to high point of reception, lands on their back, whiplash type mechanism of injury. Back of their helmet comes into contact with the hard turf, and they're lying motionless on the field. When you arrive, they have loss of consciousness with sonorous respirations, and they have good pulses. So I'm gonna let you guys kind of ruminate on those two cases. I'm gonna kind of dive in here to some evaluation and management pearls. So what I'm about to talk to you is all based on expert opinion. There's not a lot of evidence-based medicine involved with concussion management. So it's really based on experience and again, expert opinion. I'd be remiss to not mention emergency action plans whenever you're dealing with something like a head or neck injury, because they could devolve into more serious or catastrophic injuries with intracranial bleed, serious or catastrophic cervical spine injury. And so you really should be familiar with each venue's emergency action plan. I'm not gonna go to the details of what these outline, but they do provide protocols that are in place at each designated venue that outlines equipment that's available, what local hospital resources are available to you, and where your patients may be transported to. The two most important things I will say by experience, especially if you're not in a big metropolitan area, make sure you have cell phone service. Even if you have nothing available to you from an EAP standpoint, you wanna make sure you have cell phone service and 911 access. And then obviously before each game, if there is EMS there, especially in football, most states have to have EMS there, make sure you introduce yourself to the EMS paramedics. It's really important should anything need to be addressed on the field and having that relationship prior to the start of the game is really important. Also pre-competition wise, this is kind of more apropos, I guess, if you're not the official team physician, again, maybe you're covering for a colleague, make sure you meet everybody who's on the sideline. They had athletic trainer, any assistants, maybe some coaches, make sure everybody understands who everyone is, what their role is in evaluation, who's making the call, just to avoid any sort of debate should a tense situation arise. Make sure you know what equipment you have for concussion management, are there any baseline screening tools available to you, and what's the follow-up system for any injuries post-game. So immediate on-field evaluation, again, when you have an injured athlete, you don't really know what the diagnosis is, your mind probably needs to go to the worst case scenario, you wanna make sure they don't have an intracranial injury, like a bleed or a C-spine injury, and so you're really focusing mainly on that to rule out those entities. And then obviously you go to your basic life support, pulses, breathing, et cetera. And then you're really initially looking at alertness and orientation. If you do have loss of consciousness or they're not a reliable historian, you have to assume there's a C-spine injury, they need to be packaged and transported. If they don't have loss of consciousness, you deem them to be alert and oriented, and they're a good, reliable historian, you can proceed with a basic history exam, including neurologic and cervical spine. Kind of equipment removals, obviously, beyond the scope of this talk. So sideline evaluation, this is assuming that you've cleared the cervical spine, you're not transporting them from the field, you get them to the sideline. What do you do here? Well, first and foremost, you really need to get the attention of the athlete. If you don't have a relationship with them, even if you do, sometimes this can be very emotional. You really need to get a good history and getting them into a location where you get them to focus, perhaps out of the view of the crowd and coaches, that really will help you get a better history and exam. You see a lot of these sideline tents that have popped up from the NFL level and now at college level, I've even seen high schools with it. If you're at a location that doesn't have a tent, go to the locker room or somewhere out of sight if possible. It can really make your exam more high yield. Obviously, you wanna take a good history. Really, I'm focusing on the medical history of the injury. Do they have any other significant past medical histories, prior injuries? I'm gonna talk a little bit about a physical exam, cognitive exam that should be standardized. But a couple of pearls here is take the time you need. I know there can be a lot of pressure, but as you settle in over time, you'll find that you gotta do what's right for the athlete. Take the time, don't feel the pressure, do what's right for the athlete. Also, probably the most important thing for concussion evaluation is really use your instincts. Utilize your knowledge of the player. If you have pregame knowledge of the player to make your decision. There's a lot of tools and fancy things out there, but really this is a clinical diagnosis and you really need to trust your gut. So sideline physical exam, I'm not gonna go through all the details, but obviously this involves visual inspection, cervical spine, head, ears, eyes, nose, throat, motor strength, coordination, and balance. And the key here, just like with any other exam, is you want to have an algorithm for you, something that you go through all the time that becomes kind of rote memory. Using a tool like the sideline assessment tool or SCAT-5, which you may or may not see, is very, very valuable. It kind of has all the directions, more or less, on how to do a full concussion assessment. What's nice, you can take notes on this. There are apps available on the phone for you to use this. And I really encourage you to look through these things if you are gonna be responsible for evaluating these type of injuries and using a tool like this. A lot of schools will use this as their baseline assessment, so you may be able to compare pre and post, and which can be somewhat helpful. Management and disposition. If you make the diagnosis of the concussion, take their helmet. A lot of players will try to go back and play, take their helmet so they cannot do so. Constant observation. This is actually whether you make the diagnosis or not. Maybe you don't make the diagnosis of a concussion and you return them to play. It's really important to check in with them maybe between series at halftimes and especially post-game. If they are diagnosed with a concussion, you wanna have someone watching them full-time, and you wanna check in with them periodically. Obviously, if they're diagnosed with a concussion, there's absolutely no same-day return to play. And especially if you're at the lower levels, maybe they're not your patient. Maybe they're going home with a friend or a parent or another guardian. Make sure you've arranged follow-up care, observation at home, and if possible, try to provide written materials and instructions on what to do should they have any questions. And what's nice about that SCAT-5 is all of that stuff is built into that document, and you can make copies of that and give that to the family and the patient. Indications for emergency referral. Obviously, suspected cervical spine injury. They're packaged and transported. Focal neurologic findings, worsening symptoms. Loss of consciousness, for me, is about one minute. That's a gray area. Obviously, travel situations may dictate emergency referral for CT scans, et cetera. And maybe you're in an underserved area or a rural area, lack of proper follow-up is an issue. Maybe you want to be a little more conservative and send them for eval. Return to play. Obviously, at some point, someone needs to see them the following day. You want to make sure that's arranged. There is a supervised graduated return to play protocol. This is an example of one. And note, and I tell coaches and players and families all the time, is that this is not cookbook medicine. This is a progression, and the rate at which they go through this is very individualized. Not everybody's going to go through this in seven days or 10 days. It could be two or three weeks, and it's dictated by the situation. And obviously, be aware of state laws and any league policies that govern your return to play protocols. Make sure you're not breaking any laws. So coming back to case one, I'm just going to kind of go through this and apply these protocols. So case one, this is a pretty simple but very common scenario where you're covering a high school football game for a colleague, and the reason why I put a colleague in there is you don't know this athlete. Like I said, it's really important to engage somebody who knows this person, whether it's the athletic trainer, a parent, a teammate. Get their opinion. Ask them if they think they're normal, especially if things are borderline. Really, really important. Utilize any baseline, sideline tools like the SCAT assessment if you have it. Obviously, in this case, this person you've established, they're alert, they're oriented. You've done that by observation. There's things called Maddox questions. In the NFL, we have to ask this. So that's the, you know, what venue are we at? What half is it? Who scored last? Who did we play last game? Did we win or lose? Those have actually been sort of borne out in some of the research to really establish reliably if they're gonna be a good historian. Brief history and exam. Obviously, mechanism of injury. And you're really looking for no-go symptoms. So these things, if any of these are present, they're not going back to return to play whatsoever. So loss of consciousness, confusion, amnesia, any gross motor instability, those are no-go. No matter what they tell you, no matter what your exam is, they're not going back into the game. Obviously, you're going through a C-spine eval for this patient. Very low suspicion. If they have neck pain, you need to go through and go through, dive a little deeper on the cervical spine eval. In this case, obviously, they have no C-spine issues. You go through the rest of your exam, cranial nerves, coordination, balance, all normal. So in this situation, you're stuck with a 18-year-old running back, high school player. Everything's normal. All they have is a mild headache. Nothing else. Exam stone cold normal. So, you know, there's a couple different options in how you handle this. One, obviously, if you're on the borderline and you don't know if this person's right or not, again, ask health. Ask your athletic trainer. Ask a parent. Gauge everybody's comfort level. I would say if you're at a lower level or you don't know the patient, you're going to lean to be conservative and hold them out. Kind of a rule of thumb for me, it's, you know, just a headache doesn't mean you have a concussion. Usually it's a headache and. Has to be something else. Just a headache doesn't necessarily mean you have a concussion. And conversely, if you don't have a headache, doesn't mean you do not have a concussion either. And the third thing for here that I'll throw out here that people don't think about, it doesn't have to be binary. It doesn't have to be diagnosed now or not. It's okay to observe these people. It's okay to say, hey, you know what? You might be okay to go back in, but I'm going to watch you for 10 or 15 minutes. See if this headache goes away. See if this concussion blooms. See if anything else pops up. And then maybe you're going to hold them back. So that's just case one. Case two, obviously this is a more severe situation. This person is lying motionless, lost of consciousness. Here, obviously you're going to assume there's a C-spine injury, and you're going to take control of that cervical spine. You're going to go through your eval as we described. If their loss of consciousness is prolonged, you're going to transport them. If their loss of consciousness is brief, let's say 15, 20 seconds later, they start waking up. It's okay to stay in play a little bit. It's okay to talk to them and see if they wake up. Assess their alertness and their orientation. If they become a reliable historian, it's okay to clear that cervical spine and remove them from the field without transport. If they're not a reliable historian, go ahead and again, assume it's a cervical spine and transport. Let's say in this scenario, you clear the cervical spine, you get into the sideline, you're going to go through the exact same process that I just described with the previous case. Let's say everything's normal, but their symptoms you're left with is a mild headache, they're foggy, they have a little nausea, but they're not throwing up. Obviously, there's a no-go sign here with loss of consciousness and not going back to return to play. But I really want to highlight this scenario is you really need to do serial evaluations. You're in a way game, maybe there's some transport issues. But the big thing for this is not everybody with loss of consciousness needs to go to the hospital, but they do need to be watched very, very closely. This is the NFL protocol. I'm not going to go over it, but everybody talks about the protocol in the NFL. This is it in a nutshell on a one page piece of paper. Even though this is specific to the NFL, everything on here can be sort of dialed back a little bit, or at least the process can be run through at any level from Pee Wee all the way back to the NFL. So key points, know your athletes, prepare and practice your emergency action plans. High suspicion for cervical spine or intracranial injury, need to rule this out. Use some sort of standardized assessment. No same day return to play if you make a diagnosis. There's a graduated return to play protocol that everybody needs to go through that's not cookbook and is individualized. And ultimately, they need to be cleared by a licensed healthcare provider with experience in concussion management. That's it. Thanks, Casey. You know, on that scenario too you presented, you were on an away game. This individual lost consciousness. They had some nausea, it looks like. You have to get on an airplane now, or you have to get on a real long bus ride. Would you have a lower threshold to get some kind of a scan, and what kind of a scan would you get? Yeah, so obviously back in the day, everybody was getting CT scans. There's a lot of, you know, like they have the Ottawa ankle rules for getting x-rayed the ankle. They sort of have these rules for getting CT scans in the emergency departments, which is really cut down on CT scans. I would say in 15 years of doing this, I've maybe gotten five or six CT scans. I would say if the injury occurred very late in the game, maybe you're gonna get on a long flight, maybe you're playing overseas, who knows. I have at times, if I don't feel like I can observe them long enough, I have at times sent them to the hospital, get evaluated and get a scan. That's only a handful of times. So I would say in most instances, I'm not, but, you know, parents are freaked out. I've had parents call and let my kid get on that plane or get on that bus without a CT scan. I usually don't fight that fight. I send them to the ER, but most of the time I'm trying to observe them, and almost never am I getting a CT scan. I got one more scenario for you. So what about that first player? He has his headache. It wasn't you that was on the sideline. Somebody else said he had a concussion, right? He got his bell rung. They come to your office the next day. I remember this happened to me during my first year out in private practice, and they sent me to the orthopedic surgeon to declare him for their concussion. What are my responsibilities? What are my responsibilities? What are my responsibilities at that time point? In terms of- Of clearing them. What do I need to do? What do I need to satisfy? Right, so again, it kind of goes back to that return-to-play protocol, and almost all high schools in private school leagues have policies on this, and so you want to make sure you're following everything that needs to be followed and satisfying all the steps, but typically, in a nutshell, obviously, symptoms trump all, right? You want to do whatever it takes to withhold them from contact activity. We talk about mental rest, physical rest, cognitive rest, and really want to get them to be asymptomatic. Most of these are student athletes, right? They need to return to the classroom before they return to the school, sorry, to the practice or playing field, so usually you're integrating them back into academics, and then you start going through the physical return-to-play protocol, and then they need to have normal examinations, and again, depending on the level you have, is there some sort of baseline neuropsychological examination that they had that you've repeated, and it's at baseline? There's a lot of debate on whether neuropsych are valuable or not. I tend to think they're helpful, but they're just a tool. So that next day, though, they show up, they have no symptoms today. I just had a headache. I actually felt fine. The mom's like, yeah, he was fine all night, and you could clear him and go to practice that day? Well, again, tough decision. I mean, it's a tough decision. I mean, have I done it? Yeah, again, it goes back to just a headache doesn't necessarily mean it's a concussion, but I think if you have a lot of other information on them and knowledge of the athlete, you might be able to get away with some things. I think in most situations, you're gonna be conservative in holding back. Okay, well, thank you. That was great. It's always a tough concept to cover in a short amount of time, because there's so many nuances, but let's move on back up to the upper extremity. I'm gonna introduce Darrell Osbar. He is the Chief of Orthopedic Surgery at the Rothman Orthopedic Institute in Florida. He's worked with USA Baseball, US Soccer, Orthopedic Consultant for the PGA LPGA Tour, as well as the WWE, and Orthopedic Team Physician for Eastern Florida State College and Seminole State College. Darrell, a pleasure to have you here. Take it away. Great, thank you very much. Let me see here. Is it up? Are you seeing it right now? Yep. All right, perfect. All right, so I decided to do a little something different. Obviously, whenever we're on the sideline, it's great when we get some sports medicine injuries, but often we feel like triage doctors on the sideline and have to be able to manage kind of what comes. And so I wanted to present a forearm injury in a professional soccer player. And so some of the injury details, he was a 30-year-old male professional soccer center back. He had a sideline collision. It was very loud with another player in the first half. The impact was loud. It was about the 40th minute in a soccer game. And for those of you that aren't as knowledgeable about soccer, 45 minutes and a half, 90-minute games was some extra time. He grabbed his forearm, but he continued to play. There was no injury stoppage at the time, and there was no medical evaluation at the time. So fortunately, we're close to halftime. And so we really got a first look at him at halftime, and the player said he felt something in his forearm, had some pain, no prior injuries there. He was a guy that's kind of a stalwart a little bit. He just plays on until somebody tells him not to. His physical exam, he had mild ulnar forearm swelling. He was tender and palpational in the ulna. You could say that you could feel something at the ulna with slight supination and pronation by that time. He had some swelling there, and no elbow or wrist pain or deformity. And so often we don't get looks like this in MMA, where you can actually go back and see the video and see that they get that, but very similar to the injury that sometimes MMA people will see. And so from a locker room diagnosis perspective, clearly we were worried about an ulnar fracture. X-rays, unlike the NFL and some other leagues, in Major League Soccer, we don't have X-rays in the locker room. And so we wanted to confirm what the injury was and kind of ask ourselves, what could we use? So fortunately, my primary care sports medicine specialist that I work with had an ultrasound. So we were able to use a mobile ultrasound unit, and this is what we saw. So what you can see here is the ulnar fracture right here. And so we confirmed it on the ultrasound, although obviously we didn't necessarily need the ultrasound. So what are the options for immediate return to play? Or are there any options, I think is the better question. And so here are the list of things. And so I'm just gonna go down the panel real quick, starting with Ben. What would you say for this player? Would you say that he's out, definitely, let the coaches decide, let the player decide, or tell the players and coaches that he can play in the second half and try to push him in that direction? What would you do? Yeah, so there's a lot of things going through my head with that. I deal with a lot of trauma like this all the time. And the question is, is there a rotational instability component? Is it a direct impact component? Is there something else going on down by the wrist or up by the elbow? At this level of athleticism, depending on the game and how important it is and how much of a season's left and like, I would more than likely tell them, hey, you're out for the half. Because if you were to have another or second injury to that side, there could be potential downfall. Now casting obviously, and padding would be an option. And now, you know, depending on their level of pain tolerance and stability, I think that would be one thing to consider. But I'd be more inclined to say no. All right, Pat, real quick, what would you do? Would you let him play or not? Yeah, here's my question, Darrell. How was his skin? Was there any tending of the skin in the area of the fracture? No, there wasn't. Nothing. You know, I think that if he's a pretty stoic guy and you could put a functional brace on him, and he wanted to play, I probably would let him play. How about you, Robin? Yeah, I agree with Pat. I would let him play. Pat him up. If the skin was normal, you know, no elbow, wrist pain, I'd pat him up and let him play. Casey? All right, how about you, Michael? Casey's still stuck on the ultrasound. He was so pleased to see that. Hey, the phone works great. You know, I think that, I don't know the rules with regard to patting or casting in soccer. In football, I think that if they felt that they could play, I probably would put some sort of a brace on him or pat him. It looked like that was a bit of an overlap fracture. If there wasn't a lot of crevices, their form felt stable and they felt okay, I would. At the same time, totally agree with Ben with regard to where it is in the season. Is this game even important? You know, that would definitely be part of the discussion as well. No, that's good. And so this gets into what's at stake with this decision. So a couple of things that I think fellows need to think about when they're starting to cover games. And a couple of these things come to mind, trust, performance issues, further injury risk and informed consent. I think all these things are important whenever you make a decision. And if you don't think that one of them matters, it always does. Because when it comes down to it, all the players in the team are watching. They're looking over to the shoulders. So often I'll get the players off into the training room and the medical room. So I get them away from actually the other players to be able to make a decision. Performance issues, it's real. Whatever injury they have, everybody probably saw Jalen Wada last night in the national championship game. Obviously when players are limping around and not running as fast, certainly you can have performance issues, further injury risk. And like we talked about medical, legal, always need to be thinking about it and making sure that you're telling the player risks and benefits. And so the halftime decision, what to tell the players and coaches. So you're on the clock and soccer especially. So you need to think about your sport. So from my perspective in soccer, you have 20 minutes. And so the evaluation starts on the way off the field. And so often I will hunt the player down and start talking to them on the way off the field to try to buy as much time as we can to get on the same page. And so this is very important. You wanna make your medical decision along with the athletic trainer. And so usually what I'll try to do is make sure the athletic trainer and myself are on the exact same page before assessing with the player or the coaches. Because the last thing you wanna do is have any divisiveness between you and your athletic trainer. You wanna be on the same page with what your goal is gonna be and then make the recommendations. And so this is what then I'll go through. I'll talk to the player with all these things in mind. And so we kinda got the advice of everybody so far in terms of whether they'd be okay with allowing the player to play. So in this case, I was a yes. I told the player we can pad it up. It depends on how he feels. Went through all the trust and informed consent issues and further injury risk stuff. And then came to the coaches. And so sometimes, just as it was mentioned, it depends on where we are in the season. That was mentioned several times by our panelists. And so in this situation, we had two center backs out with injury. He was the third center back and we were actually using one of our, I think it was our left wing at the other center back. And so certainly never wanna make a decision defined just by who you have on the field to play. But certainly that made it necessary that if he was able to play, then everybody wanted him to be able to play. So obviously, even in the world that Casey was talking about, coaches will typically say yes. And it's our job to tell them no beforehand. So, and then the final decision. So at this point, you wanna make sure that while you're doing this, it has to be quick depending upon the sport that you're covering. And so for me, I was telling the athletic trainer to get everything set up for the player to be able to go out and play. I was gonna talk with the coaches and make the final decision. Because last thing I wanted to do was wait to talk to the coaches and then we're trying to get the player ready to play. And so at that point, when the player said he wanted to play, they're getting him ready. I said I was gonna confirm with the coaches and make a final decision and let them know. And the answer was yes. And it's kind of like NASA, right? The go or no go. So we had a go for launch. And so we were gonna play the player. So let me ask the panel, what would be your decision and how would it be different if it was a high school player or a college player? So Robin, let's start off with you. Yeah, I mean, I think it's different, you know, at a high school level. And again, where are you in the season and what are you doing? I certainly make different decisions based on the level of competition. So I'd be less apt to have them play if they're a high school player. And again, collegiate level depends on where they are in their season, what sport we're playing. And so I think it's different. I think it's tough. And it really depends on, again, a lot of circumstances. But like you said, having informed consent and, you know, a high school player you're gonna talk to the parents, you're gonna talk to the coaches, athletic trainers. It's a lot more in-depth conversation. While at the professional level, you have adults who are making decisions for themselves. And then I'll just hit Casey with this one since he got muted before. Are you off mute now? Yeah, yeah. Oh, same question. Yeah, I agree with Robin. I mean, I definitely think all these levels are very different. It's all risk benefit. And, you know, professional players, I mean, their livelihood is dependent on them playing and providing for themselves and their families. Maybe not as much with the college player and almost never for the high school player. And so I think all of the things we're talking about are treated a little bit differently at each one of these levels. And the one thing that I forgot to mention that I think is really important with all of these cases is that we're talking about sort of making some, you know, tough decisions. And we talk about informed consent. From a med legal standpoint, make sure you document this stuff. And if they're not your patient, you know, find a piece of paper, write a note, keep a copy somewhere. You know, I've seen, you know, any of these lawsuits that I've heard of, it's really what gets people in trouble. It's not that they did the wrong thing, it's that they didn't document that they did the right thing. And so I would say my last point is really make sure you document everything you see on the sideline, especially if you're making these types of decisions. Absolutely, great point. So for me, the high school player is a no, college player is yes or no. In this case, you saw what we do with a professional player, but it does depend on the sport. And so for him, this is actually what we put him in, kind of those splints that you get sometimes to wrap around an ankle or something. We patted it over the ulna and wrapped it up. In soccer, you can't have anything hard. People don't like to get hit in the head and cause concussions with anything hard. So we put a bulky pad splint, discussed injection. Sometimes it fracture sites and things like that. You can do a little local block. Elected no, I typically don't do that, but it is an option. And Tylenol for pain control. The player played the entire second half, had a great result. Exactly like Casey just said, informed consent, clinical eval note. So if you're in a locker room and you need to have a mechanism to still dictate a note, especially in situations like this, where you might have a decision that could come back to haunt you. So always err on the side of making sure you have documentation of the discussions that you had. And so what about performance? Did the player perform well? And so this is a video and I'll try to stop it as we go through if I can. Here we go. And so you can see the player coming into the screen right here. So he's right in the center of the screen right here. And we're gonna see from another angle and you'll see he kind of eased off. He went with his foot, but you can see he didn't actually go with his body. And so he just used his foot. So another example of that was a second half conceded a goal and in soccer, whenever you give up one goal, that's sometimes a problem. So certainly performance is one of those things you don't wanna tell the coaches that this guy's gonna be able to go out and perform his best. You wanna make sure that they realize that he's gonna have a wounded wing and he's gonna do the best that he can on the field, but they've kind of bought what they have at that time. So that's always important no matter how hard the player is or how good the player, how hard the player plays or how good the player is. If they are injured, then sometimes they can't play at their highest performance level. And so obviously post-match treatment protocol, what tells players and coaches. So we wanted to go through operative and non-operative. We had this discussion after the game. We actually had this discussion even at the time of halftime. The reason was is because I told him based on his injury and based on early mobilization and getting him back to play that we were probably gonna do a plate and screws, had already talked to my hand specialist who does this all the time for us and was in full agreement that probably the best way to get back was surgically. So even if it did displace a little bit more, probably didn't matter. And so they're theoretically lowering non-union rates with surgery and quicker return to play. So we were ready to plate it no matter what, no matter if it displaced more. So that was obviously a factor that we talked about with the player because you also don't want the player to think he played more, injured it more and that's why he needed surgery. So we had that conversation even starting at halftime. And so from a critical outcome perspective, trust, everybody was happy. We're able to make the decision in a good setting, make sure that everybody was informed of what we were doing and why. Performance, the player only missed one game after surgery. So he only missed 90 minutes of play, was back 10 days after the injury and another padded splints and felt really good. The player did concede that second half goal, but in terms of further injury risk, he did not. And informed consent was well done and we had a clinic note to document everything we had done. So that is it, Michael. That was awesome, Darrell. There are a lot of great points there that really could cover any injury. I actually don't really have any additional questions since you're pimping us so much during that whole thing. So I'm gonna move on to Robin. Introduced to Dr. Robin West. She's the President of Inova Musculoskeletal Service Line, but also Lead Team Physician for the Washington Nationals, Head Team Physician for the Washington Football Team and Associate Professor at both Georgetown and Virginia Commonwealth University School of Medicine. Robin's gonna talk to us about something that is extremely common that you guys are gonna be seeing a lot in your practice, both on the field as well as in the office. Are you guys able to see it? Yep. Can you see it? Yeah, Robin, you can't see it. Yeah, yeah, I have that problem too. What happened to it? How'd you see it? If you go down to the bottom of the screen, sometimes you can see like the slide down there and then I clicked on it. I don't see it, it's okay. Hold on a second. I'm looking for it. Okay, give me one second, guys. Can you see it now still? If you minimize the control panel, that might be another. Yeah, I did that. Can you guys see it? Yeah. Okay, great. So we're talking about a knee injury in an NFL athlete. Save the best for last, I'll make it quick here. So this is a 21 year old rookie left tackle for the Washington football team. He sustained a valgus knee injury when he was pushed to the ground. And on the field, he complained of medial-sided knee pain and he had no prior history of a knee injury. On physical exam, we took him off the field actually and off the field, he had localized medial pain, already had swelling, very localized over the tibial insertion at the MCL. Negative lockman, negative posterior drawer, he had no effusion at that point. And he had two to three plus valgus opening at 30 degrees of flexion. So at that point, we have to decide, can he play? So we braced him at this point and we tried to get him on the sideline to see what kind of function he had. And really, due to significant laxity, he was unable to return to play. So it was an easy decision for me, he just didn't have the function. So I didn't have to make a decision at that point. We placed him into a hinge brace and an MRI was ordered. So I guess asking the panel, we can go back and say, when you have an MCL injury on the sideline, are these guys getting back to return to play? How do you make that decision? I can't see the panel. So how about Daryl, why don't we start with you? Yeah, so for me, if they have any laxity, then usually I'm not returning to play. If they just hurt over the MCL with more of a grade one, then I'll try to see if they can do anything functional. That said, with what you do on the professional level with an NFL team, so certainly we're always trying to get them to play at that level if they can, but that's usually my shtick. Anyone else have a different opinion on that? Do you guys let them return to play? Do you ever give them some Toradol or do anything else? Tape them, brace them and try and get them back to play? I think that if that laxity can be corrected, so very minimal laxity with taping and bracing and whatever pain meds at a professional level, I'd be okay with that. But they really need to be able to protect themselves and just like any other joint. Yeah, I do the same thing. I'll have them taped and braced and maybe we'll give them even a Toradol pill orally and see how they functionally do. And they'll tell you pretty quickly whether they can play or not. Hey Robin, one question, this is a big lineman. Is he have valgus innately? Is he a big guy with valgus? Because I think that's a particular problem, trying to return these guys to linemen to play after MCL. Yeah, he is and that is the problem. I agree. So here's the imaging. Can you guys see this video it's coming through? Yeah. MRI, this is the day after the injury. You can see his MCL here. Pretty significant, proximal and distal MCL. Go to the next slide here, you can see. The next slide. So you can see everything else looks good, but he has a pretty significant medial sided injury with medial retinacular tear, MPFL injury. We'll go into this view here. Robin, I couldn't tell on that first film is the meniscus capsular ligaments, are they all intact on the medial side? Oh, they aren't, I'll go back to it. Maybe I can get it to go. Oh, not again. No, they aren't, you can see. Here, we'll go back through it. Pretty significant injury in a professional athlete. So just to go over the anatomy. So we have the superficial MCL, which we know is a primary stabilizer. That's 25 to 30 degrees of flexion. The deep MCL is a secondary stabilizer, but greatest contributions in full extension. And then the other stabilizers are the posterior oblique ligament, which resists internal rotation and full extension. And the dynamic stabilizers are the five attachments that's in my membranosis. So we look at these MCL options, and this is the most common injury I probably see on the football side. So the non-operative ones to me are these incomplete femoral-sided ones, which you can see on the MRI up here, a mid-substance grade one to two, isolated MCL injury. And these, again, you can see that here. And these are ones that I'll typically treat in a hinge brace for three to six weeks, allow them to return to play when their function's good. And the question is, do you consider PRP? When you look in the literature, there are a lot of case series of using PRP and MCL injuries. There are no prospective randomized trials. There was a control lab study in rabbits back in 2018. LeProd published it, and it was, they looked at grade three MCLs that were simulated in rabbits, and they did three different PRP concentrations, platelet-poor plasma, two times the platelet concentration, and four times the platelet concentration. And the platelet-poor plasma and the two times the PRP at the time of injury did not improve MCL healing. And the four times platelet concentration actually had a negative effect on MCL strength and histological characteristics at six weeks after the injury. So even though we all jumped to it pretty quickly on, again, on the professional side, I'd say that it's not necessarily supported in the literature. I don't know how many of you guys, would you guys consider PRP? If you had an injury like, let's look at this one. You know, if you had an injury, a femoral-sided injury like that, would anyone consider doing PRP or consider surgical intervention? I only do it in the chronic settings where it's just not healing, and we're trying to treat this non-operatively, and maybe we're gonna jumpstart something. But Casey, you can probably talk to this a little bit better. Aren't we a little bit worried about HO sometimes forming with acute PRP? Yeah, I mean, there's some of the studies out there that was worried about HO. I don't know if I've necessarily seen that in practice. I wouldn't say we routinely do PRP for this type of injury. I think kind of rule of thumb and a couple of thoughts is if you think it's gonna be at least a two- or three-week injury, sure, you could consider it. Anything less, I wouldn't even consider PRP. And I probably read that study Robin was talking about, but no one knows what the optimal PRP is. And a lot of people will say that study went up to 4X. A lot of people say you have to be 6 to 9X. And the issue with some of this inflammatory change and the theoretical risk of HO is kind of what's your white cell content. And the higher your platelets you take, you're usually accepting more white cells and more pro-inflammatory. But some of the new devices, you can sort that out. You can decrease the white cells, higher platelet concentration, kind of customize it. Maybe in theory, it's a little bit better. I try to think I'm pretty grounded in these things. We played with it at different levels from time to time. I'm not sure I've seen too many bad outcomes. I'm just not totally convinced it's sped it up. Yeah, I agree with you, Casey, on that. So then we look at the surgical options. So these are the ones that typically I would consider fixing surgically. And these are complete tibial-sided one where you see a stent or lesion like the one down here, or you'll see a femoral-sided significant lesion like this one here where you get MPFL involvement as well as a proximal MCL involvement or a significant, sorry, grade three mid-substance with meniscal extrusion from the meniscal capsular injury. So surgical treatment, early surgery, the main goal is to minimize swelling, maximize quad function prior to surgery, and then fluid extravasation for these very significant capsular injuries. So we perform this diagnostic arthroscopy under the low fluid, sorry, fluid pressure. You can see that typical drive-through sign here. You can see that deep MCL involvement here. This is the player that we were talking about. I did wind up repairing him. Actually, I did a primary repair, put anchors in the tibia, anchors in the femur, and then I also did an augmentation with an internal brace. And again, you can also do a reconstruction. So more for the chronic ones, I'll consider a reconstruction where you can reconstruct the posterior oblique ligament as well as a superficial MCL and use a graft, either graft. Rehabilitation protocol for me on the surgical side is a non-weight-bearing protocol. Again, depending on the size of the player, the in valgus alignment, that non-weight-bearing for three to six weeks, really putting a big focus on patellar mobility and full extension. That's the biggest concern and losing flexion ultimately and limiting that patellar engagement. Put them in a hinge brace to protect them, the repair or the reconstruction for six to eight weeks, again, depending on their size, with a return to play at typically about five months. Do you guys have anything different on that? Mike, how about you on the return to play timeline? What would you say for something like this? Well, I mean, I completely agree with you with regard to range of motion. I think that's why that internal brace is so great. I mean, you can really arrange them right away and you're not worried about them stretching out. You know, one of the other questions I was gonna ask you guys is, you know, some people lock these guys straight for a while after an acute injury. We can save that for another time. I think that as far as return to play, you know, five months is probably about right after a repair like this. Isolated injury, you know, as long as everything's healed, they have good neuromuscular control. I mean, I have probably a little bit early for me. I'm probably more, you know, six to eight months before they're gonna be 100%. But, you know, it all depends upon the individual player. Yeah, you know, it was tricky. He was one of our top draft picks. And so he gets injured, you know, the first game of the preseason game, right? And so everyone's on me. How is he gonna get back for the end of the season? Should we IR him? Should we pop him? What should we do? It's interesting when you have that timeline in your close, say, what if we make playoffs? Could we have him back for that timeline? But at that point, you've missed this whole season already. Hey, Robin, quick question for you. And the rest of the panel, I just did an MCL today with an internal brace, in fact. But what position of knee flexion do you fixate your internal brace in these MCL repairs? I, go ahead, you guys can go first. I was gonna say, I probably put mine in full extension. I just, I worry about losing extension. So I fix them in full extension and I just do a check rein. I don't make them tight. Again, I just give them a little bit of a check rein to protect that way. I go super tight and full extension. Yeah, I always go full extension, but I learned the hard way. One of the first ones I did, I put it in at about 30 degrees of flexion and I couldn't straighten his knee on the operating table. So I pushed really, really hard and boom, it popped out of the swivel lock that I put in the tibia and then I had full extension, I just refixated it. So it kind of taught me a good lesson. You'd rather be full extension, even if it's not perfectly isometric, you don't wanna lose extension. And if you're not isometric and you fix them at all in flexion, they won't get their extension. Yeah, I agree, Pat, that's a concern. So I'd rather have them be- Oh, sorry about that, Robin. Just one comment I had for all the fellows in the line, depending on what level you take care of, you gotta remember that physical therapists and athletic trainers on the pro level are doing therapy every single day. And so often timelines will be affected by the quality of resources that you have available for your athletes. So you need to make sure that you don't over-promise and under-deliver. That's a bad precedent to set being a team position. I agree. Give a longer return to play time. One thing about the surgical technique, I fix in extension too. I've had a run of MCLs in the last three weeks just from ski injuries and a couple of tibial avulsions. And I'm quick to harvest a hamstring, a gracilis or something to add collagen to the repair and then still do the internal brace with the internal brace kind of incorporating an onlay to get some collagen in there. But one thing, the internal brace, I was burned exactly as Pat described as over-tensioning, bringing deflection. Always check before you leave the OR because if you're doing a repair with an internal brace or even a reconstruction with an internal brace, you can often over-tension. It's the same pitfall you can fall into if you're doing a UCL of the elbow or anything like that. So make sure you're double and triple checking that before dunking the anchoring. I have noticed though that you're a little bit safer around the knee with regard to putting it tight in extension. I think that just the length of that internal brace is gonna have a little bit more wiggle room than in the elbow. Whereas I will put a little looser in the elbow. It's just anecdotal, I guess. Well, for the sake of time, guys, that was a fantastic discussion. I think there was a lot of great pearls that we were able to take from every case there and applied them to whatever we're seeing out there on the field. To all the fellows, thank you for joining. Thank you, Meredith, for putting this together. Thank you, AOSSM. Again, this is the first fellows webinar of 2021. They're doing this every second Tuesday of the month, I believe. And hopefully, as we're all saying, 2021 is gonna be better than 2020. We have the vaccine now. We'll be able to apply some of these principles that we've been discussing on the real field in the real life. But I wish you guys a great night and looking forward to the rest of this fellowship year. Thanks for having us. Thanks, guys. Thank you. Thank you to the faculty panelists for this evening's webinar. I'd like to remind the fellows, if you haven't done so already, you may apply online for free for AOSSM candidate membership. You may access that on the membership page at the AOSSM website at sportsmed.org. Please visit the online AOSSM playbook and surgical video library that's found at sportsmed.org playbook. And we'll see you next month, Tuesday, February 9th at 8.30 p.m. Eastern time. Thank you, everyone. Good night. Good to see everybody. Take care. Thanks. Thanks again. Thanks, Mike.

concussions

sideline management

head injuries

emergency action plan

standardized evaluation tools

follow-up care

return to play protocol

knee injuries

forearm injuries

functional testing

individualized treatment