Ladies and gentlemen, please take your seats. Our session is about to begin. Please welcome your moderators, Drs. Ashish Bedi and Peter Indelicato. Thanks everyone for being here. I know it's one of the later sessions between dinner and reception, so we'll try to keep it lively. This is the give it to me straight, what team physicians are really doing session. I'm Ashish Bedi, and pleasure to do this with Pete Indelicato, the longtime team physician with the University of Florida. We have an incredible panel here of experts at both the collegiate and professional level that are going to lend their expertise and insights, and these are some cases that often come up. I introduce the panel. Rob Brophy from Washington University in St. Louis, Lyle Kane in Birmingham, Catherine Koiner at the University of Connecticut, Jason Dragoo right here from Denver, and then unfortunately Jeff Guy and Chris Jones could not be here, but we had a substitution with Mark Safran, who has incredible expertise from Stanford University. So thanks to the panel for lending their expertise. Just moving through, disclosures are in the program as for all the other sessions, and Pete and myself have nothing to disclose related to this talk or presentation. Just to share a little bit about how we're doing this, cases will be presented, but we'll leave it rather fluid. We'll present a case and engage a panelist, maybe two, to give a thought, and then there is some audience polling in this to hopefully keep it interactive. If you have questions, please do feel free to come up to the microphone. We'll also have the audience response system here for some of these questions. So with that, Pete, maybe I'll turn it over to you for our first session. I do want to share this QR code. This is for you to be able to use the mobile app for the audience response, so if you want to take just a moment to take that code down, that's how you'll be able to provide answers. Most of them through the session are yes and no questions. Okay. So let's start off with case one. Case one is an 18-year-old high school senior football wide receiver with a Division I offer, injures his knee in late October. His MRI shows an isolated flap tear of the medial meniscus, and the question is what's the discussion that you feel as a teen physician would be appropriate to have with his parents? That's the AP, and there is the lateral view. So according to our rules, we're going to start with a polling question. Polling question number one for the audience. With the tear that you see here is a big flap tear, would you recommend a partial medial meniscectomy or suture repair? And now's the time to answer the questions as far as the audience poll is concerned. And while that's coming up, let's start off with Lyle. The conversation that you would have with the parents given this information at this point. Well, I think two key points is the time of year. This is October, so it's mid-season. He's a high school senior with a future, and so you have the discussion about the long-term risk of meniscectomy. I think with this particular case, it's not a vascular area, it doesn't look like a good repair. You're going to get a meniscal transplant. Just kidding. This would be a straight partial medial mastectomy, and you talk with the family about the long-term consequences, which are a little bit unknown based on alignment and other things, but I think that discussion's pretty simple at this point. The biggest discussion is about return to play timing, and I think that's individual. So I'd have to tell them there's a wide range of return to play timing, depending on how your response. So wait, Lyle. So what exactly would you recommend? Let's just say you say all that, and so what do you think, doctor? What should we do? Yeah, so I assume that based on that arthroscopic picture especially, the MRI wasn't too impressive, but that large displaced piece, he's probably symptomatic enough that he's not going to be very effective as a player. So if he could play with it and didn't have symptoms, I have no problem with him playing and doing it post-season. My suspicion is his symptoms are enough that you'd have to do it during the season, and then you'd have return to play questions about when can he get back from the coaching staff, the family, and the player. Rob, one question. As you look at this polling response, there's this impressive response of trying to repair this meniscus, suturing this meniscus, and I feel like as I've lost more hair and have grayer hair, there's been this paradigm shift towards this would have been an obvious flap and trimming and more of a approach towards meniscus preservation. Thoughts a little bit about this? Are you more aggressive now with a flap tear in this population, radial tear or root variant tear? Are we shifting more towards giving it a try because our repair techniques are better, or is this one that's doomed to failure and we're just putting this off until months later when it turns into a trimming? Ashish, I agree that there is this trend and an appropriate trend to preserve meniscus as much as possible. That being said, I agree completely that this tear, given its location and in terms of its pattern, the likelihood of this healing in a beneficial way is very low, and particularly if this athlete is going on to play collegiate football in this timeline, putting him through an extended recovery with a high likelihood of having to go back and debride it and then delaying him even further, I don't think it's particularly beneficial. I mean, if the family was, for some reason, more concerned about trying to preserve the knee as much as possible and you had that discussion and you wanted to repair it and you knew there was a high likelihood of going back, I don't think that's a wrong approach, but I think in this case, the optimal approach, and you could discuss both with the family, would be to debride it and let him get back to sport as quickly and as reliably as possible. Yes, there is a slight decrement in terms of long-term health of the knee, but having a repair and an unsuccessful repair would probably be worse. You know, one thing that is a surprisingly popular conversation is, can I play with this? And Mile talked about it a little bit, and I don't know, it would be great to poll the audience as well as all of us, but I have not seen that work really well. These inter-articular, you know, these really significant pain generators, A, we've done a couple times at the collegiate level, and then by the time we got in, there was surgery after a bowl game, just one more game doc, and it has been a real mess, so it hasn't worked well. Those players that have aspirations because of recruiters coming, so I need to get a couple more games, and you look at their film, and that just hasn't been impressive, as Lyle was saying, them playing injured. And I think the big thing that sometimes we miss in the conversation with the families is the whole thing about the pain inhibition reflex, and the chance of, again, of activating that inter-articular pain, leg giving away, and having even a worse injury than that, that can be much more limiting for the future, so do you guys have the same experience of trying to play with these? It just hasn't tended to work. Yeah, I mean, I think it depends on the tear configuration, tear pattern, how unstable that flap is, that's why I said this one particularly on the scope view, the MRI, I could argue maybe could play with it, when you look at the scope view and you see that piece displaced, I think it's unlikely he's going to play with it. Second point is, on the meniscus repair side, I think we've gone so far on the pendulum towards repair, I'm not advocating that we abandon repairing meniscus, but I think we need to think about the psychological effects, the time loss effects, all of the things that happen when you have a failed surgery, so it's easy to say, let's just try to repair it, and if it doesn't work, we'll scope him a second time, that's a lot of change from a psychological standpoint, and some players never get over it. So let's say we go ahead with a meniscectomy, and the parents say, okay, let's take that flap out, doctor, what do you think the chances are of my son developing a problem with that knee 20 years from now, and let's, for the sake of discussion, let's say he has a normal BMI and a normal alignment, what would you say as far as, is my kid going to have a problem with OA? Well, I mean, you tell them that the meniscus is an adapter between the rounded thigh bone and the flatter leg bone, and that you're losing some of that distribution of forces, so that does increase the rate that the knee might, or the increased contact stresses will develop earlier arthritis, but on the inner side of the knee particularly, the knee's more adaptable to being able to tolerate not having that meniscus, but even leaving a meniscus tear there and not taking it out, it's not going to necessarily function normally either, so you want to remove the symptomatic cause of the knee symptoms, and that rate may go up, and certainly there's not much that we have technique-wise at this point in time that will lessen that likelihood. Rob, getting a little granular there, you have a paper in kind of the elite population, in the NFL population of longevity and seasons after a meniscectomy that's a little humbling, how do you see this extrapolating to the high school kid who's got this D1 offer? Is it the same, is it a couple of seasons and maybe not, or how do you extrapolate that data, because it's one of the better papers out there that talks about this. Thanks Ashish, just one thing to follow up I think with Mark is, the injury is what caused this knee to now start the road towards arthritis, I think it's important to emphasize that, once you injure your meniscus, you don't have a normal meniscus, right, and so our treatment, non-operative, operative, whatever we're doing, is just trying to mitigate the damage of that injury as much as possible, and it's not perfect no matter what we do, and I think it's important to tell that to the athlete and their family, because, you know, where they go is not the fault of the treatment, it's the fault of the injury, and then we're doing the best we can to put them in the best place possible going forward, and, you know, that ties into what Ashish was asking about, which we did show with athletes coming into the combine, particularly in the setting of ACL reconstruction and partial meniscectomy, there was definitely a decrement in their durability in the league, so I think there's no doubt going to be an effect somewhere down the road. To your point, this athlete at this level may be a little bit younger than the guys in the league, may not make the league, he still has to go through college, so there probably is an impact, it's probably later down the road, but it can impact them even in college as well, so I think it is something to make sure they're aware of, that it's likely to have some impact on their career, let alone the health of their knee. It's really interesting in the professional, again, review and trades coming in, that we have these players with a significant injury history and significant surgery history at the same time, they're functioning perfectly, and this is now seven years later, so I think having this conversation is what this is all about, hey, this could really affect you and it can affect you soon, this might not really ever shorten your career, we've seen both of those, so just, it's part of the consideration and we want to work with you, we want to see your athlete year after year to make sure that we're not going down the trend of a quick degradation, because it's possible, greater than your neighbor who hasn't had any issue with their knee. Great, maybe for sake of time, we'll shift to different case vignettes, I'll take this one, this is case number two, it's a 22-year-old college senior, pre-season All-American and projected first-round draft pick, just to make the stakes high, he's a running back, and unfortunately is tackled on the first play and we're mid-season, he tells no one, he plays the entire game, but of course comes to the training room afterwards and says his shoulder feels weak, claims that it's his first shoulder injury, his exam isn't too remarkable, but he does have some apprehension in an ABER position. And of course, in the modern era, given who he is, get some imaging studies and it shows your typical isolated Bankart lesion, in this case ruling out kind of bone loss for simplicity of things. And so maybe just starting a little bit here before we get to the audience poll, maybe Catherine, engage you a bit, what are you telling the parents? There's the literature that tells us first time dislocation, fix these, and a number of literature that talks about that, but how about the reality of the conversation with the parents? Is that mandatory or is there room for play there? Well, my disclosure is I take care of UConn football, so I've never seen an All-American in a first-round draft pick, but maybe if this was basketball, no, I was just kidding. No, so I think the conversation is real, right? We would approach this patient and obviously educate them on their redislocation rate and what that would mean. The good news is that if we do try to treat this conservatively, many of them will be able to play, but yet the redislocation rate is real. So counseling him on when it matters most to potentially have surgery, whether it's now and he would miss his senior season or whether it's at the end of the year, it's all about communication and sort of similar to all the advisors that I'm sure this athlete has, roping in everybody from athletic trainers, all of their advisors, parents, and everybody to make the decision is going to be super important. So let me throw this in there then. I mean, a lot of people say, well, we'll give you one shot at trying to play with it again, but if it comes out a second time, then we're talking more seriously about a surgery. And then the parents ask you, well, how more difficult is it repairing if it comes out one more time or more pertinently, is how much less successful or different is the operation going to be? Is it going to be a lot less successful, so significant that I'd be crazy to let my kid go back and play after he has that kind of lesion? Catherine? Yeah, that's a great question. And I think I would answer that in the fact that we don't 100% know, but after a second dislocation, I don't think we've increased or worsened our outcome significantly. I would counsel them that it may change the operation. If you can choose to do this arthroscopically, maybe there's an open bank card conversation because he's a contact athlete, it may cause, we don't know what's going to happen in the future regarding bone loss, and it may change the operation that is required. Lyle, as you're dealing with this in Alabama, for example, one of the other things is timing, and timing of season, and implication for the next season. If it's a high school athlete, implication for being ready for mid-season commit in college, ready for the combine. How does that factor into what you're telling the family, which of those milestones is the most important, in addition to just the natural history of a harder operation or higher failure rate? Yeah, I think seasonality is really the key to this whole question, in that whether you're a high-level college player, or a freshman, or a pre-season All-American college player, or a professional, I think we would all agree that a first-time dislocator is the easiest fix. It's the most likely to be successful arthroscopic labor repair, less likely to cause more damage, bone loss, all those things, but it's individual, right? So if this is in February, March, first-time dislocator, I'm probably going to fix him. If it's August, and we have a chance to win the national championship, and he wants to be an All-American, not a pre-season All-American, there's a risk-benefit analysis for each player. What is the risk of re-injury and worsening surgery, versus what is the benefit to playing that season? And if the athlete determines that it's worth the risk of coming out again, and maybe having a worse outcome, or having a bigger surgery, to have the value that they provide by playing that season, then it may be worth it for that individual player. So it's very individual, but seasonality plays a big part in that, because if you know that you can fix him and have him back before the season, it makes it a really easy discussion. Well, go ahead, Mark. Any comments? I was going to say the seasonality key is a big issue. Certainly we know that when you look at the WOSI scores, the first dislocation, if it doesn't come out again, they're not normal, but they do better than if they had two dislocations and don't come out again, or three, and so forth. But that's your everyday person, and what I try to do with an athlete is, their life is in seasons, and so you talk to them about whether or not, the majority of the trauma is with the first dislocation, not the second, and so if they didn't have really bone loss with the first, I think if they came out a second time, it wouldn't necessarily be significantly worse or change the procedure that I would do, so I ask them about the importance to them of playing out that season or not, but regardless, at the end of the season then, we would fix them so that they don't miss the next season, you know, come out and miss more weeks in that next season. So that would be the discussion that we would have. Great point. Let me just, one more question. So let's say this is now a senior in college, he's a projected first round draft pick, and it's the same situation. He has a one-time dislocation, he has that kind of a bank guard lesion, okay, and now the NFL is starting to talk to him. Is he, I'll ask it this way, is he less or more a higher draft pick, or does his grading drop or go up when he comes to the combine, having repaired that but not played, or not repaired it, as far as draftability is concerned? Robert or Jake? Well, I used to work in that arena, thanks to our lovely owner, but I won't go there. I think that, look, they're both challenging. I think that if, for example, if you had that injury, you played through the fall and had no problems, nothing else had happened, and presented with that sort of, you know, untreated bank guard with one-time dislocation, I think that might be the most positive situation. I think there's still a high likelihood people would think about fixing it before going into the league, but I think that might be the best situation. Certainly having it, and having had surgery, and having an appropriate recovery to date is hopeful, but, you know, still a little bit tentative. So I think the worst case would be if they'd had a season of significant injury and, you know, worse and worse performance, where it just showed that it was clearly an issue and it was untreated. I think that would be the kind of worst case scenario. That's interesting, because either way, it's an intermediate medical grade, right? There's nothing about this athlete that would be a low score, or therefore would be medically not advised to take, but at the same time, with that intermediate score, then there's either a track record of that player playing after their injury, and that's the proof of everything, right? So what I'm trying to say is that if you have an injury and you play, like Rob said, that is a better score and more reassuring than having surgery and not coming back to play because you don't know. It's not a known entity. Or at the same time, if you had the injury and you just stopped playing in rehab for the rest of the season, it's an unknown entity. They never re-engaged within the sport. So that's the slight maybe nuances of otherwise just an intermediate grade between the two. Yeah, great grading is for sure complex, and it depends upon the prognosis and repairability and whether they're planning on taking the player and having them play the first season or allowing them to recover in rehab and having them for another day. I just want to take a moment to engage the audience here. Polling question. For this particular scenario, would you recommend surgery now or possibly wait for a second event? And while the audience is voting, Lyle, I think you were going to make a comment. So yes or no for surgery now or waiting? Yeah, I was just going to say, I've had this scenario multiple times in the last 17 years, really. I think we've had 69 first-round draft choices, pretty crazy run. And what our general philosophy has been, if the player wants to play, we'll let them play as long as they're stable and don't have repeated events. But then as soon as the season's over, usually after the national championship game, we fix them. And then they have the draft in May, so they're at least four months out when the draft comes. And by the time they get to minicamp, they're usually cleared for everything non-contact. So the seasonality part works out well in college football for that to happen. And so I think it's, you know, my fear is always if you let them go into the draft or into the combine without fixing them, then they're going to be downgraded with a labral tear. So we've always fixed them preemptively, even if they did OK through the season. This is interesting data that I think points out what all of you were pointing out, which is there's the literature about the first-time dislocation, and then there's the art and subtleties of timing of seizing and discussion. And there's still a lot of optimism for considering a second event, at least in this case. I'll maybe throw a little bit of a curveball here for the panelists. You know, what if you have this on imaging? So you have the MRI that I showed you, but now you get this, sorry, CT scan, and there's a small but reasonable size, what looks like maybe acute bony Bankart lesion there. And we're getting these more and more, right, with this assessment of track and subacute bone loss or subcritical bone loss. So Jason, does this change your assessment now? Do we wait for the second time, or does it matter if there's a bony Bankart? Have we missed a window? And maybe at a fault, repaired a lot of these at the end of the season with a bony, and so then was that bony worse? Not detectable, et cetera. So this is one thing that might push us a little bit more in the surgery, but it's not absolute. Just because, okay, they have a small fragment, not changing the discussion that we've all had about the timing and all of the different portions of it, just kind of pushes the needle slightly for me. Yeah, no, I don't disagree. I mean, obviously it's, you know, how much is small, right? So I mean, that plays into it, but assuming it's something we would all agree is a small bony Bankart, it doesn't really change the algorithm much. Katherine, you alluded to it earlier a bit about, you know, for contact athletes and collision athletes, open repair and an open Bankart, and despite all the improvements in arthroscopic surgery, you know, in this population can be as high as a 20% failure rate. So is there, in your mind, a situation where you might shift more towards an open repair? Is that still part of the arsenal or are we all arthroscopic all the time for these? I mean, I think it depends. In that first situation where it was just the soft tissue injury, I think arthroscopic would be fine, but I think you could absolutely make a good argument for this if you wanted to do an open Bankart with the skills to do it, that it's going to rival any arthroscopic repair. But I think with, you know, small, you know, it's hard to tell, you don't have a sagittal to see exactly what the percentage is. But if it's approaching, you know, subcritical, then I think in a contact athlete, that would be an absolute reasonable option. We'll get the audience involved again here. Hopefully they can play this video for us with this slide deck, but this is shifting to the other side of the equation a bit for the audience. If they can play this video, what we're showing here is a Hill Sachs lesion, and it's a sizable Hill Sachs lesion. So, you know, does this, in fact, need to be treated with a first-time instability event given all of the discussion at the meeting about being more aggressive to treat these Hill Sachs lesions acutely? I don't have the ability, I think, to click that forward, but can they play that in the back for us if possible? Could you play that video? So again, sizable ill sacks without giving the measurements of on or off track. And audience, based on what you're seeing here, should this get a REM massage at the time of even a first-time surgery? Mark, what do you think about this big shift? I remember hearing, at least when I started, I could ignore most of these ill sacks lesions, so a big change. Yeah, totally a big change. In the old days, people would look at that and say, that's not such a big lesion, but we've been looking more and more at the ill sacks. And clearly, it's a two-sided parts of the coin that need to be addressed. And certainly, I think the data these days is showing, clearly, the outcomes are better if you did include a REM massage along with your Bankart. So I think addressing just one side would increase your risk. Being a contact athlete, and my concern with REM massage is really in your overhead throwing type of athletes. And he's a running back, so that shouldn't be an issue. And so in my mind, that would be part of this equation. You know, Lyle, there's a lot of papers that are justifying this for the off-track lesion, but now even some emerging literature from Albert Lin and others, good work that suggests maybe it doesn't matter, even if it's on track, do it, and do it maybe in this population if there's not a ton of morbidity. Does it factor in whether it's on track or off track for you, or if there's one there, do it? Yeah, I mean, I think the on-track, off-track is a really good thought process to go through to decide about bone procedures like Latter-Jay and others. But for me, it's a bipolar issue, right? So you can either have instability from coming out of the glenoid, you can have instability from catching on the hill sacks. And my thought is, I used to worry a lot about hill sacks doing REM massage, losing motion, but it really hasn't played out that way. And so I've become a lot more aggressive doing REM massage any time there's a significant hill sack. You know, 20% is the number a lot of people use, but even less than that sometimes, if I'm worried about their stability as a contact athlete, I think REM massage is a good additive procedure. Yeah, for sake of time, I'll show what was done in this case, and indeed, that was a sizable hill sack lesion, and that was treated with a REM massage. This does seem to be an emerging trend and something that's happening a lot in the literature, but was discussed a lot here. So with that, maybe, Pete, we shift away from shoulder instability and let you take the next one here. Okay. Case three, we have a 26-year-old soccer player, falls on his left shoulder and comes to the sideline. Exam, you can hardly read it, exam shows some mild tenderness over his AC joint with no obvious deformity. The player and the coach ask you if there's anything that you can do to continue to help him play, and x-rays are not available. What's your answer? Mark. Yeah, so if I felt he wasn't tender necessarily in the clavicle itself, I'm worried that it's the AC joint, and if he's, you know, you feel like the glenohumeral joint is fine as well, I think it's not unreasonable to try to give him an anesthetic around the AC joint itself and then re-examine him, and if you eliminated his pain by just injecting the AC joint in the area just around it, and he's got good motion, no crepitation, I think that's not unreasonable to get him back to play. Catherine, if this is a 16-year-old rather than a 26-year-old, would you wait for x-ray or would you inject him given the same circumstances? So I think seasonality, but not seasonality, the aspect of the game. If it's the state championship, and that is very important, but at that point with a 16-year-old, you're definitely going to get the parents out of the stands, you're going to have a much more thorough conversation. I would tend not to inject that patient unless there was some extenuating circumstances that it's the most important game in their entire life. I think that's the risk-benefit profile of that is very different than a professional player that potentially is making their own decisions and understands that a little bit better. So my question to Mark is this is international football, not American football, and in particular, one, you don't have an opportunity to get this athlete off the field somewhere you can inject him, get him back out there. So I think if you have that exam, it's a little bit of suck it up buttercup, get out there and finish the half. If you're still having an issue at the halftime, then you could consider an injection, but I think unlike American football, you don't really have that opportunity to do that in the middle of the flow of play. If I just can add a comment to Catherine's thing, you know, 16-year-old, very different issue, particularly because more likely to be a fissile injury, you know, that as the distal clavicle fissus closes a little bit on the later side. So it's not really just an AC joint sprain potentially. So I think that, you know, I take more concern about that as well. In response to Rob's comments about international football, you know, my experience with international football is if this guy had a grade one AC separation, he'd probably come off on a stretcher. So you got plenty of time, he's going to writhe around for about 10 minutes, and the stretcher comes out and pulls him off, so you got all kinds of time. Lyle, just one question and follow up before we do the audience poll, you know, as liability around caring for, you know, sports has changed, particularly at the collegiate and professional level, is some of the concern about injecting a local anesthetic without the X-ray about the medical concern, or is it more about the medical legal concern for you? All medical legal. I mean, I think, you know, if your exam, a grade one AC separation is a pretty clear exam typically. You know, occasionally you'll have one that hurts all down the distal clavicle and you feel like you need an X-ray, but most of the time it's pretty obvious. So I think the reason to get an X-ray, the reason to be careful is more medical legal than true medical, honestly. That's interesting that depending on the sport, but if we even put this to football and a little, or semi-contact sports even, it's, we've always felt that it was really beneficial to have a protocol if we're going to be starting to numb up anything, you know, and so for AC joint, and I know it wasn't part of this, but there was no X-ray, but we always do an X-ray because we are taking a risk and the player's taking a risk, and whether it's the parents or the agents, et cetera, that's number one. Number two, do they have strength? Because we don't want to numb up something and then they have a weak upper extremity, send them back into the football game, and number three, can they protect themselves, right? So in the AC joint, just have them fall against a wall kind of in a push-up position and make sure that they can protect themselves, and if they can do those, all three things, then giving the injection, it seems that that's more palatable to whoever you're talking about. I know it's not quite the scenario, but it might be a good thing to think about just having a protocol if you're going to be injecting. Okay, so polling question number four, given those original circumstances, would you offer a local anesthetic without an X-ray? Well, almost split 50-50, half the audience would wait for an X-ray and half would not. You want to go on to the next? No, actually, there's one more situation with this case. What if his right shoulder or right-handed collegiate quarterback showed this X-ray? So it's not a 26-year-old soccer player, but an adult right-handed quarterback that shows obviously a lot more suspected tissue damage on a plain X-ray and this on an MRI. So for the audience, polling question number five. If you do advise surgery because of the situation described, do you add a tendon graft for the acute grade 3AC joint repairs, again, a dominant arm of a quarterback? And while we're waiting for the polling answer to that, let's say, Robert? So assuming that we ended up here and it's a grade 3 that we're fixing acutely, and there's a lot that would go into that decision, I think that might also depend here. With a throwing athlete, I might be less inclined to do a graft if I thought there was good tissue and an actually reasonable repair because I'm obviously concerned about stiffness going in and the more surgery that we do, the more I'd be concerned about that. You know, if it was a lineman or linebacker where we were more worried about stability then I'd probably be more inclined to think about a graft acutely just to make sure this is the last time this has any issues. But I think with a throwing athlete, there might be some serious consideration about just repairing it if you had reasonable tissue and felt like you had a good, strong repair at the end of doing that. What's a timeframe beyond which you would say, I definitely would use some kind of biological graft? I mean, two weeks, three weeks, six weeks? Well, I'll be honest, I don't do a lot of AC joint repairs, reconstructions within weeks. But if for some reason I was ending up there, it would probably be within not more than a few weeks that I'd be thinking about a graft in most cases. You know, Lyle, I know you've dealt with this at Alabama and there's some precedent to treat these types of grade threes non-surgically even in a throwing shoulder and they've performed at the NFL level and there's ones that get surgery. Graft or not, what's factoring into your decision to fix a grade three right in the gray zone? Yeah, it's a really, really tough question. You know, there was a study 15 years ago, maybe it looked at NFL quarterbacks with grade three AC separations, dominant arm, and it was really difficult to tell who would survive non-operative treatment and do okay versus those who'd have late surgery. One thing that came out as one of the factors is early on, if the athlete can externally rotate against resistance, if their clavicle goes posterior to their trap, they did poorly. Just probably a sign of more AP instability more than just superior instability. And so, you know, for me, a quarterback, the last thing you'll do is operate on their shoulder if you can help it. Some grade threes do great, some do poorly. You know, I try to test them initially and if you can kind of see the clavicle, if it looks like it's going back in their trap at the initial exam, then I tell them, look, we can try conservative. I'd rather not operate on your shoulder, but there's a decent likelihood you'll end up with surgery down the road, and they're definitely easier to fix acutely than chronically in my hands. So, as Rob was saying, I think, you know, for me, if I have a less than three or four week acute grade three, sometimes I'll just do a repair with a suspensory device because you've got enough native tissue there to heal back together in the CC ligament area. If it's more than four to six weeks, then I'll usually do a graft, and I think the grafts are tough in overhead athletes. Mark? Ashish, one other thing I use is I have the athlete try to squeeze their hands together in front of them, and I look for four-quarter shortening. If they have four-quarter shortening, then I think that they lose that fulcrum, the benefit of the clavicle, and those are the people I fix. The ones that don't have four-quarter shortening, I think, can do fine, and certainly I actually have had a couple of patients that are NFL quarterbacks that are great, that have great threes, that have been able to have a good career. So I think it's that four-quarter shortening and losing that strut of the clavicle that's important. So that's the key test, or again, the external rotation, looking for the posterior translation are the two things I look for. Maybe we'll keep rolling here with, for sake of time, I'll take this one, 21-year-old, a little bit paradoxical that I'm taking this one, Pete, since you're the expert of this injury. 21-year-old linebacker has a valgus blow to his leg, walks off the field with a slight limp. For sake of, again, brevity, exam shows effectively a grade 2 plus MCL with opening and 30 degrees of flexion, but it's stable in extension. Comes out of the game, gets an MRI at injury clinic the next day, and it looks like that. So maybe, Catherine, your thoughts, this MCL injury, and what's this look like for you versus other MCL injuries? Yeah, so the good news is that it doesn't seem that he appears to open in full extension, but this is distal. And traditional teachings are sort of that these heal less well without surgery. However, I will say that I've had this exact MRI in a collegiate hockey player that I think it's more about exam, and so if you can get their range of motion back, they don't have a ton of swelling, and reexamine them in one or two weeks. And if you think that they're tightening up, sometimes that I wouldn't fix this and let them play. And again, I think, you know, it's to beat a dead horse, but the seasonality of this does matter in regards to where they're at in the season. So I think my first option here would be no surgery. Is there anybody on the panel that would recommend surgery besides guys from Alabama? Yeah. I mean, I think when you have those coronary ligament tears where you have the, you know, the deep MCL between the meniscus and the tibia torn, I think they're less likely to heal because you get synovial fluid extravasation down that superficial area where it's got blood right now in the MRI. So I mean, I'm not saying I'm going to acutely take the guy out and fix his MCL, but there is a discussion because I think this is less likely than your traditional grade two MCL to heal. A question, you alluded to it, Catherine, you know, distal injury historically may be a little less favorable healing from some of the literature. They ask you upstairs for a timeline for this injury. Is this the grade two that's two to four weeks? Is this four to six weeks? You know, any thoughts on, you know, how you prognosticate this in terms of return? Yeah. So I think this would be closer to, I would, you know, I always say that I overestimate and then hopefully you deliver in a shorter fashion because that sets the expectations when you're talking to both athletes as well as coaches. So that's a really important point. So I would probably say four to six and if you got them back a little bit sooner, it looks like a win. Jason, you are an expert in this area. What if the question comes up, which it always does, what about PRP here? You know, Heinz Ward did it and played in the Super Bowl. So, you know, why can't you accelerate that? Yeah. Well, no good data, right, to show that it improves the outcome of this. This is deliberately a tweener case, right? And as Catherine said, these are all over the map from a knee that is severely unstable. And if it is with this kind of pattern, you know, it's tough to see how that MCL could really tighten down. So then doing the more acute surgery, that being said, we've all examined athletes where you have, you know, surprised to see this because their knees are so stable and like the panel said, I wouldn't touch it. But PRP has no known benefit in this that with the data. Sheesh, just one more comment. I think if, you know, this particular tear pattern, this coronary ligament injury, if you do treat it conservatively and they're still loose after a certain period of time, let's say post-season or six, eight weeks, you can fix these late without having to do a reconstruction or anything. You can still go make a little incision, sew down the coronary ligaments with some grip, with some anchors. And so this is one that you don't have to do acutely compared to most collaterals. Let's do a little polling question for the audience. Would you recommend surgery for this distal grade two plus MCL injury, yes or no? To your point, Lyle, a little bit with this particular type of injury, there's a lot of focus at the moment on augmentation, either augmentation with something to protect it, suture type material, augmentation with graft. How does that factor into your equation acutely versus chronically? And what are you considering using to do that for collaterals? Yeah, so for me, it's tissue quality basically. So if this same person's acute, I'm not going to use a graft, a suture, internal bracing, all that stuff. If they're chronic, it depends on what the tissue looks like. Most of the time, I'm still probably not going to use any of that. Now if it's a more proximal tear with kind of amorphous looking tissue, or if it's the distal tear that involves the whole horse tail off the tibia, and that tissue looks poor, then I may add a graft or add suture. But with that particular tear configuration, I typically would not use it. Rob, is there any role for immobilization for MCLs after the initial injury? There's some anecdotal group that say, lock them out for a few days. Others that say early range of motion doesn't matter. Any data, or is that just kind of treating ourselves? Well, I think there's also the risk of some stiffness that takes quite a bit of time to come back. And so I think you're trying to balance getting the ligament to heal and also preventing them from having a prolonged recovery in terms of range of motion. I do think they tend to be a little bit different. I think the proximal injuries tend to be more stiff and more problematic in terms of range of motion, whereas the distal injuries, and again, not always there's variability, but they often get their motion back much quicker, but take longer to heal perhaps. So I would rarely immobilize a proximal injury. I might think about it in somebody with a distal injury who's got great range of motion immediately after injury, which sometimes happens, and then you're more worried about the healing. But definitely not locking them out for a long period of time, if at all. Looks like, Pete, they're reading your paper on healing of MCL injuries the audience went with non-op. Yeah, that was about 40 years ago now. Still an important one. Still works. The method that was written up a long time ago has certainly advanced quite a bit. What was a plaster cast with the knee in 30 degrees of flexion is now basically a knee immobilizer and an ace bandage for the same exact lesion. Okay, so next case is an offensive lineman, hobbles off the field, which with, as best as you can tell, is a relatively minor inversion ankle sprain. This is before the game, pre-game warmup. He's hobbling off the field, but he can bear weight, and I'm not sure he has that amount of discoloration, swelling, acutely. But your exam shows only lateral and anterolateral discomfort. So the polling question to the audience, would you get an x-ray in this situation? Let's just say this is a Division I college game, and would you tape him and let him play and get an injection? I know this is, I don't know how they're going to answer this on this slide, but put the The yes or no for the x-ray. Yeah. Why don't you just say, would you get an x-ray? While that's coming through, Lyle, this happens in Alabama, and he hobbles around. Can you let him tape and play, or are you worried about it? Yeah, I mean, I think a road game SEC x-ray takes a whole quarter at least to get done if it's pre-game. So, I mean, you've got to decide based on your exam, you know, is it possibly has a fibula fracture? Yes or no? If the answer is no, then you tape him and try to let him play. If the answer is he's sore up the tibia, maybe not just on his ATFL, and you're worried about it, then you hold him out and x-ray him and make sure before you put him on the field. From what I've heard, they only take a quarter to get x-rays for the Alabama players. The other teams, they do it much faster. Rob, you think, you know, there's some rules, you know, that are applied in the ER with ankle sprain injuries, right, auto rules and others that can give you some guidelines whether you need x-rays or not. You think that applies to the sideline as well, or too much risk? Well, yeah, I think they're a minimum. And I think generally on the sideline, you're going to be far more careful about it in terms of using imaging and being careful about what you're doing, and as what we talked about before, not doing more harm. So if there's any concern about that, you're going to go much slower. So I think imaging is going to be preferred if at all possible. It would have to be very much based on exam, their ability to bear weight and move. If you were very confident it was an isolated, you know, highly confident it was, you know, an isolated ankle sprain, you could consider being more aggressive. But I think obviously everyone would prefer to get an x-ray if it's possible. She's just one more comment. So to make up for that one-quarter or two-quarter x-ray problem we have in road games, we actually now have a portable x-ray machine in the tent with us on road games that we take with us and x-ray if we have a question, and it gives you a lot of confidence compared to where you were pre-x-ray that you can treat them a little more aggressively. Ashish, if I could, I mean, just, you know, the Ottawa rules are based on general guidelines from Merge's room, as Rob was saying, but, you know, one of the things I have seen, certainly some of these athletes have higher pain tolerance that are playing Division I pro football, and so the inability to bear weight doesn't always apply. For me, it's really the exam about are they tender on the fibula itself is really, that they're not going to hide from you, but they will, you know, be able to bear weight on it, which is, again, one of the criteria with the Ottawa rules. So just to realize that it's a little bit of a different population that it was made for. No question. I certainly would admit to being humbled where sometimes an x-ray line shows up in this type of an exam where I wouldn't have expected it, and it's always a cautious reminder to me that those rules don't maybe apply in this venue. If injecting an ankle, and I guess this is to the audience, excuse me, to the panel, if you're injecting an ankle, where would you inject it? With ultrasound, if we have it? With what anesthetic, and would you add a corticosteroid? Catherine? Well, I guess this isn't going to answer the question, but I think with what we discussed, I probably wouldn't inject this player to get them out to play if they're unable to bear weight, even with a negative x-ray. So maybe I'm a little bit more conservative, and it just, it would be a bigger discussion, but if I were going to do it, you know, we would probably do it with ultrasound, because, again, we don't have portable fluoro. We barely have a tent on the sidelines, but we do have ultrasound. Jason, if a player comes to you and says, you know, I can play, I just need you to help. Jason? That they're not going to play. No, I can play. I want to play, but can you do anything to help me play with less discomfort? Yeah, well, often, right? That's an often conversation, and so a couple of things. Number one, it's the place and time, right? So a spring football game, no, no, and having that conversation that there's going to be other battles. Championship game, that's another story, right? The other thing is interarticular injections of the, we were talking about the AC joint, various other joints of the upper extremity, maybe hands, depending on the sport, but in the lower extremity, interarticular injections lose proprioception, and that could lead to significant injuries. So then I have never been a fan of any interarticular injections to get a player to play of lower extremity weight-bearing joints. So that means then if there would be a big negotiation, but an ultrasound-guided extraarticular injection, again, in the ATFL region, et cetera, but that would be it. So then no corticosteroid, because the corticosteroid wouldn't work, and that's not going to help with the healing. It's not going to help in time to get that athlete back. So it'd just be a purely anesthetic, because injections, I mean, aren't going to help in the near term, right? That's not part of the treatment plan. You can consider PRP, but that's not a sideline decision, right? That's just a treatment decision over time. Lyle, if it's a high ankle that's theoretically stable, thoughts on injections of high ankles? You have Dr. Waldrop there that has done a lot of work in this area, and sometimes treats these relatively, more aggressively surgically. Is there a high ankle that ever warrants an injection, and when do you do it? Yeah, good question. So I was going to say the question would be better if it's high ankle rather than a typical inversion injury, because the high ankles, the initial evaluation, one of the main points of a high ankle is whether they can bear weight or not. If they can bear weight, if they can do a single toe rise on a high ankle, that tells you that most likely it's a stable syndesmosis, and for those, we will inject occasionally. If they can't do a single leg toe rise, that tells you that they probably have diastasis of the fib joint, and they're probably not going to do well even with an injection, so we typically don't inject those. And on the injection for the inversion sprain, I would do it, in my mind, most of the things we do on the field, in the tent, in the locker room during a game are kind of urgent, I guess you'd say. And so we don't use ultrasound, I don't even use the CRM. We go inject the ATFL and sometimes the post-shear fibula with local, no good steroid, but it's all done just by feel of point of maximal tenderness. I think we're right at 530 here, just past it, so we'll stop there and spare the panel our additional cases, but really want to thank Lyle, Mark, Catherine, Jason, and Rob, and everybody for hanging through this one. Thank you very much. Thank you, everyone. Thank you for attending this general session. Join us tomorrow morning at 8.45 a.m. for the Hall of Fame induction and presidential guest speaker, Tiki Barber. Have a safe and enjoyable evening.

Asheesh Bedi, MD

Peter A. Indelicato, MD

Robert H. Brophy, MD

E. Lyle Cain, MD

Katherine J. Coyner, MD, MBA

Jason L. Dragoo, MD

Jeffrey Guy, MD

Kristofer J. Jones, MD

sports medicine

team physicians

injury cases

athlete management

treatment strategies

shoulder dislocation

medial meniscus tear

AC joint injury

MCL tear