and thank you for coming today. I'm guiding the raft today, and we'll go ahead and here's my disclosures, they're on the website. And then we're gonna start out with Melissa Cristino, she's gonna talk to us about the Psychologic Aspects of Injury and Recovery, and she's at Boston's Children's Hospital and the Director for Sports and Mental Skills Research and the Division of Sports Medicine at Boston Children's. Then we're gonna go on, Jackie Brady's gonna talk to us about Return to Sport After Patella Dislocation, and she's at OHSU in Portland, and the Head Team Physician for Portland State University Athletics. And then Captain Leah Brown is going to talk to us about Return to Sport After Pregnancy, and she's in Phoenix at Banner. And then Dr. Koiner is gonna talk to us about Navigating the Aspects of NIL on Team Physicians, and she's at UConn and Team Physicians for the Huskies there. So without ado, we'll get started here with Melissa. Hi, everyone. I'm gonna be speaking about psychological aspects of injury and recovery. I think that this is a particularly important topic when we're talking about caring for the athletes that we do, particularly at higher levels of athletics. These are my disclosures. Whenever we talk about this topic, it's really important to keep in mind the context in which the athlete lives. If we're talking about collegiate athletes, they're not immune to mental health concerns. These well-being surveys that go out by the NCAA consistently report high levels of mental exhaustion and anxiety among athletes. Shockingly, less than 50% of athletes generally feel comfortable seeking mental health support. Why this really matters, this paper came out just in February, is that suicide is now the second leading cause of death among NCAA athletes in the last decade. The rate of suicide-related deaths has actually doubled in the last 10 years compared to the early 2000s. We need to be taking care of our athletes, both from a physical as well as an emotional standpoint. With collegiate athletes, or I see a lot of young athletes with professional collegiate aspirations for sports, these are years of a lot of identity formation. People are deciding who they wanna be, what they wanna become, and sports is really a big part of that. We know that there's a very high societal value placed on sport excellence from both club teams and elite teams to scholarships. Now with NIL deals and professional aspirations, there's really a lot of pressure on athletes to keep up. Student athletes are not only managing their sports, they're managing time with their families, they're managing their studies, they're managing relationships, so it can be a very complicated world that they live in. The reality for many young people is that they may not have experienced a significant setback in their lives so far, and an injury can be a major one. I sort of wonder how many of you in the audience have been inspired in your careers by an injury that you had when you were younger. So injuries, we all know, are part of sports participation, but I don't think any athlete thinks that they're going to get injured. It's important to understand that an emotional response to that is totally normal. The problem is injuries can really take a toll on an athlete's psyche, and we need to be watching out for this. Everyone's also different, and they might deal with these things in different ways, and so it becomes a little bit trickier to just manage people in a cookie-cutter type of way, because responses might not be predictable. And then there's certainly a difference between routine injuries with a projected time course versus more complex injuries or even career-ending injuries. So on the left-hand side of the slide, you'll see some of the emotional responses that are totally normal after injury. It's normal to be sad, frustrated, even lose some sleep over the injury. But where this starts to drift into the pathologic is with persistent or worsening symptoms or really excessive symptoms from the outset. It's also important, especially in young patients, to understand that injuries can either unmask or be a precipitating event for a serious mental health condition such as anxiety, depression, eating disorders, and substance use and abuse. So this is really a landmark paper for me done by Dr. Webster and her group in Australia, and now is part of a large body of literature that really tells us the psychological responses do matter. In return to play, they matter in our surgical outcomes, and we should be taking these into account when we take care of patients. I can do the exact same operation on these two people and have two very different results, right? So who a person is certainly reasonably can be expected to influence how they do after surgery. So for the sake of time, I'm going to just touch on three psychological constructs that I think are particularly relevant in this population. Most of the data I'll share is from the ACL literature, but athletic identity is the degree to which one identifies as an athlete. So somebody with a high athletic identity, sports are everything to them, and it's their life. So injuries can be particularly devastating to this population because they're losing the one thing that they put all their effort into. Whereas someone with a lower athletic identity, it doesn't mean that they're any less of an athlete, but they might have other things in their life going on. So if an injury happens to them, they can fall back on those things and injuries can be less devastating. Britton Brewer has done some important work in this area and found a significant decline in athletic identity in athletes over the two years following ACL reconstruction. Interestingly, with the most substantial decrease between six and 12 months, which is right about the time that we're telling them you're good to go, go back to sports, have fun. And they sort of surmise that maybe this is a self-protective effect. Athletes might say, well, I'm not really a soccer player, in case they were to get back and not perform how they wanted to. So it's interesting. There haven't been too many studies in athletic identity done in young people, but this was a systematic review of patients less than 22 years old. And athletic identity was associated, well, found to be sort of protective of athlete burnout, right? Because these athletes are the ones that are doing it because they love it. But also there's an increased depression risk in injured athletes with high athletic identity. And I think the best way to really illustrate this concept is by what our patients and our families experience. So this was an email I got from a mom of a 14-year-old boy with an ACL tear whose whole life was sports. And she said his physical injury was easy to see on the x-ray and MRI. What was not easy to see was the injury to his identity, his self-confidence, and his overall mental health. In the safety of our home, he would cry the kind of cry that no parent wants to hear. These are very powerful words, and I think words that a lot of our patients identify with, particularly our elite athletes. So this study looked at 24 patients at the time of diagnosis of an ACL tear. And you can see a tremendously high percentage of patients experience symptoms consisting with post-traumatic stress disorder. So this is not just a run-of-the-mill injury. It really has a significant effect on people. Coping skills is another psychological factor that I think is important. This was a study out of Texas Scottish Rite showing that baseline scores, baseline low scores on the athletic coping skills inventory correlated with delayed recovery and clearance for a return to sport. And they defined a threshold value below which took two months longer to get back to sports than those that scored at a higher level. This data is currently pending publication, but we were interested in looking at the relationship between coping skills, athletic identity, and sports specialization. And we found that athletes who had high athletic identity and were highly specialized tended to have better coping skills, right? Sports build character. They give you good coping skills. But these same groups also scored lower in the one dimension on the coping skills inventory that's called freedom from worry. And so while they may have better coping skills overall, they might actually worry more and that might place them at greater risk after injury. And then psychological readiness is the last construct I'll touch on. This assesses an athlete's overall readiness to return to sport and really has been specifically designed and validated in ACL patients. And the ACL RSI is a well-validated measure that's used to measure this. It's been found in multiple studies to be a significant predictor of return to sport. That's both during recovery, but also preoperative levels of psychological readiness actually predict post-op function. And then in regression analysis, you can see some of the factors that have been associated with higher levels of psychological readiness. These were two interesting studies looking at younger patients who went on to re-injure their ACL graft after reconstruction. And they found that in those patients, they tended to score lower in psychological readiness at 12 months compared to those that did not go on to re-injure their graft. And these patients also had smaller changes over time during their recovery and their psychological readiness. So maybe this is something that we might be able to use to kind of get a sense of wherever our patient's at. We can talk a little bit more about that in the discussion. And then there also might be some age and sex-related differences in how patients report both psychological metrics as well as patient-reported outcomes. So in this study, which was a prospective study of ACL patients, we found that pre-adolescent age group tended to report better in all outcomes, including psychological outcomes, compared to adolescents and then adults as well. And then females tended to report lower levels of psychological readiness and higher levels of psychological stress six months after ACL injury. So that is some of the data, sort of tip of the iceberg. But just to give you an idea, I think the point of all of this is to figure out how we can improve our outcomes and help our patients. And so this diagram, I think, does a good job categorizing the things that can be helpful in recovery. So having a high athletic identity, you want to get back to sports, you'll do what it takes. Having realistic expectations, also important. It also kind of mentions some of the things that can be negatively associated with recovery. So depression, unrealistic expectations, and fear. The good thing is that these things can actually be modified with psychological intervention. So if we can identify patients, we can get them the support they need and perhaps improve our outcomes. One really important key is that patients are not just going to walk into your office and tell you that they're having a hard time. You have to ask about it. And there's still a lot of barriers to seeking help. Many athletes are afraid to reveal their symptoms. Particularly at the high level, they're just accustomed to working through any sort of pain. So they might not even realize that they're struggling and need some help. And then some athletes really feel lost and paralyzed when that athletic identity is threatened or they're taken out of their sport. So we know an athlete's performance and recovery relies on a lot of things. My lane is the top left corner. Physical health, fix the knee, that's my job. But I think we do our patients a disservice if we don't think about all the other things that go into their care, particularly with regards to emotional health. And I think if you get one thing from this talk, it's just to ask your patients how they're doing. You'd be very surprised if you just take two minutes in clinic and ask what people will say if you ask them about it. So I think it's pretty clear that athletes are at risk for psychological consequences after injury, particularly in our elite athletes and those with a really high athletic identity. It's important to normalize this, screen our athletes for emotional symptoms, refer to mental health specialists when needed, and then also try to keep athletes engaged with their teams. Thank you. Okay. Thanks so much for having me. We're going to shift gears a little bit and talk about patellar dislocation and return to sport. Little has been known about this for a long time. I think if you look at not terribly old papers, you'll see sort of oh-by-the-bye tag lines at the end of them that say, like, return to sport in four months. And I think thankfully we've gotten away from that. I think we're still extrapolating a lot from the ACL literature. And so here's a little bit about what we know and some data from the Jupiter multicenter study. The Atkin paper in 2000 kind of hinted that at six months post-injury, right, so just post-dislocation, only 70 percent had returned to sport and there was a decrease in sporting hours spent per week. And then Bob Magnuson in 2017, before that, looked up a cohort of patients who had been treated nonoperatively for their first-time dislocation. That's a whole separate talk who should get surgery. But for those who were treated nonoperatively, which is the historical dogma after first-time, only about a quarter of them had returned to their activities without limitations. And of those patients, 87 percent of them said it was because of the knee that they had injured and the dislocation that they had suffered. So we're maybe not doing as well as we think we are with the nonoperative treatment limb. And then the study that I've been quoting to my patients in clinic when they ask me when am I going to get back to sport is the Mayo data that Aaron Critch led in 2018 where they compared MPFL reconstruction to MPFL TTO. So this is like post-operative return to sport. And they had a good return to sport rate overall, 85 percent. And the TTO was significantly slower, like the MPFL TTO versus the MPFL. But if you look at that number, the numerical return to sport in months is pretty similar to what we quote our patients for return after ACL and a bit shorter for MPFL. And so I've been quoting that. And if you look at the, you like dissect it a little bit, they say, you know, the strength deficits persist for at least six months post-op, especially if you've had a TTO. And the strength deficit had a lower, people with a strength deficit had a lower rate of return to sport, which sort of raised my eyebrows. Like, are we not making that a criterion? So those of you who were in the main session just now, Dr. Letterman got the return to play award, the grant to study this, right, and to really determine a return to play analysis that's specific to the patella femoral group, which I think is wonderful. I worked with Liz Dennis and we have a study coming out in 2024. That's just a prospective cohort of MPFL alone. We're trying to redefine failure, right? Like, if you're looking at outcomes of surgery and what is failure, recurrent instability isn't always a great endpoint because the rates are pretty low even with MPFL alone. And so we're sort of dissecting, do you have post-op apprehension? Are you hyperlaxed? Do you have a J sign that we didn't correct? And we found, again, the rate of return to sport is pretty darn high, 89 percent at two years in our group. But lower if you had preoperative knee hyperextension and post-operative apprehension that persisted. And so how do we fix those things? So, raising some questions. I mentioned the Jupiter Study Group. This is our multi-center group. Note, you're nothing without an acronym in our business, and so this is ours. Better if you're Celestial, right? So, Jupiter One was just a prospective cohort. This had been preceded by an attempt at a randomized controlled trial. Anybody who's attempted that, especially in young people, understands how difficult that is. So, we decided quickly we should just do what we would do anyway and study that group. It was 10 to 30 age group. And we looked at recurrent, first-timers, op versus non-op. And then we went to expanding the number of centers, raising the age cutoff to 35 because adult surgeons were like, hey, like 35-year-olds matter, too, and extended the enrollment and follow-up times. And then now we have three and four. So, three is sort of our audit study, which is trying to reduce selection bias. So, anybody who doesn't qualify for four is thrown out of three, hopefully so we can capture all of our patellofemoral surgeries. But four is the one that you've probably heard of that's the AOSSM grant award winner that Dr. Parikh and Dr. Schubenstein received. So, exclusions are jumping J sign, previous surgery, unloadable cartilage defect, habitual dislocation, tibiofemoral instability, developmental delays. And the one that we're working on is the non-English-speaking. I think all of us, as a society, really want to improve that and improve our PROs and our accessibility because we know these things matter. We have over 2,000 patients and counting. The imaging is the limiting step for analysis. As you might imagine, we're trying to standardize who's reading these images and make sure it's a radiologist and one who's very well-versed in this. And the N for the different studies is therefore variable. So, you'll see some differences when the studies start coming out. But we tried to narrow it down to the return-to-play question. You can see there's a preponderance of women, as is typically the case in patellofemoral research. The average age is pretty young, about 16. And it's younger in the MPFL alone group versus MPFL-TTO, which might be some selection bias there based on, like, are you able to violate the hypothesis yet? And then, you know, the injury rates and differences in injury types are interesting. So, 19 percent contact, as you might imagine, more non-contact injuries. And then 55 percent were recurrent. Surgery was indicated for about 40 percent of people if they were first-timers, which I think indicates the fact that we're more aware that the first-timers don't do as well as we thought with non-operative treatments sometimes. So, again, the return-to-sport rate for those who started with playing a sport, injured themselves, want to go back to a sport, is pretty high. Ninety-one percent. Forty percent to the same level, 15 percent to a higher level, 20 percent to a lower level, and 15 percent didn't tell us. But the mean time, look at that mean time is, like, over, it's almost two years, right? And you're sitting there talking to your patients in clinic about this. Notice, though, that our number got pretty low. We had 479 people who told us they played a sport. We're down to 178 at one-year follow-up. We did exclude the few that had trochleoplasty because we just don't have enough to really do a subset analysis yet, so stay tuned on trochleoplasty. A hundred and nine people, 19 people had MPFL alone. Fifty-nine people had MPFL plus TTO. And then the MPFL had a higher rate of return-to-sport, so, versus MPFL plus TTO. So, maybe something in the alignment arena is hurting people or maybe the complications of surgery. It's hard to know these things at this point, but just a bit higher rate. And then the mean time was different but not statistically significant. So, again, note these high numbers. If you look at the far right column, it's a busy slide. The high numbers of months to return to sport across the board, right? The timing was not statistically different, but if you look at that difference of 22 months versus 25 months for an athlete who's trying to get back to a sport that has a season, maybe it's clinically significant. So, we don't know these answers quite yet. So, in summary, we have a high rate of return-to-sport for sporting athletes who have patellar instability and undergo surgery, but it's lower for MPFL versus MPFL TTO versus MPFL alone, and it's much more likely to be a longer process than we previously thought. So, you all will be seeing my patients when I tell them this and they go down the road looking for somebody who's going to go a little faster. So, hopefully, Dr. Letterman will answer some of these questions on how we get them back safely and how that process should go. Thanks so much for your time. All right. Changing the subject a bit. So, thank you for having me here today. I'm honored to talk about a subject that really hasn't gotten a lot of attention, and so, especially when we're talking about return-to-sport and elite athletes, and that's our pregnant athletes or our postpartum athletes. So, today I'm talking about return-to-sport after pregnancy. I have nothing to disclose. So, I want to talk about the current state of postpartum care in elite sports, the role for multi-discipline care, education and training that needs to occur with athletes, the team, and government bodies, and what we can do to help with policy support and institutional support and our vision for the future. So, why is this important? With an increasing need of elite female athletes competing well into their 30s, many of them want to become pregnant and do become pregnant, and most of them often want to return to their sport after childbirth, but there have been questions about whether this is safe, whether they should, and there has not really been a lot of research discussing this. They've really talked about women being able to exercise in a very recreational manner, but not in a high-intensity matter as it relates to being an elite athlete. And so, what we also know is that very few sports and very few organizations have policies to do this or have policies in place because there is a little bit of a difference because pregnancy is not specifically an injury. And so, we also need to try to identify what these barriers are and some of the things that will help people be successful. So, postpartum athletes face unique challenges. So, there's no consistent return-to-sport framework. There's lack of awareness. There's limited research, and we need to really approach each one in an individualized manner. So, there are also cultural and societal factors that really play into the postpartum athlete. It's really about an athlete identity, and now you're adding motherhood as an identity. So, a lot of times, as we were talking about the mental health aspect of athletes, the mother identity has a lot of effect on a person's ability to return to their postpartum sport. So, this is actually not something that's brand new. In 2015, the IOC actually made a big panel, and they put out in 2016 a study or just a goal for women returning to athletics or participating in athletics after they're pregnant. So, they broke this down into five parts. First, they wanted to summarize the common conditions and illnesses that would interfere with strenuous exercise. They wanted to provide recommendations for exercise training during pregnancy and after childbirth for high levels of exercise in elite athletes, and they wanted to identify major gaps in the literature that limit the confidence in which these recommendations can be made. And what they found in the ones that were successful is that they had support in their postpartum recovery time, and there was not a defined time of what that was, and I think that that's the important part of it being individual. They were given time to manage motherhood and their sports demands. The ones that were really successful also had sports organizations that had policies kind of related around pregnancy, while it wasn't necessarily around return to sport, but certainly supportive of them being pregnant. They also were able to combat or break through the certain stereotypes about motherhood and elite sport participation, and they also had increased social support. And some of the other things to consider is, you know, paid maternity leave, and when we talk about job security, in this type of population, a lot of times their ranking is how they get paid through our governing body. So, they don't automatically lose their ranking because they don't qualify or they're out for a period of time, so, you know, having that be part of the governing body's policy that they have at least a year or 18 months to maintain their ranking so they can maintain their benefits, and as well as childcare and accessibility of childcare during sport participation. So, current literature. So, there's not a lot of quantitative metrics at all. So, the qualitative studies really revolves around experiences and interviews that athletes have faced, and there's a total lack of metrics at all. Nothing was defined. It was really just kind of everyone's personal experience, and this is really where I think we should focus our efforts in establishing quantitative metrics to standardize protocols. So, it's not so much that nobody is interested in this, it certainly is a much more researched topic in Europe, and there have been about 16, I'm sorry, about 16 studies in the last three years regarding return to sport after pregnancy, and of those, eight of them only defined postpartum return to play as part of the study at all, and they kind of arbitrarily said at six weeks it was safe for them to gradually return to activity as tolerated. They kind of, they very briefly skimmed over how much exercise they can engage in with about 150 minutes of moderate exercise during pregnancy, and there was absolutely no guideline on what was safe as far as returning to high impact or competitive level activity after pregnancy. So, recent developments in the sporting governing bodies have made this conversation even more necessary, so now you've kind of heard with U.S. Women's National Team, with WNBA, they have policies regarding pregnancy and support programs, and we need to just expand on this from the medical aspect and help them achieve their goal in returning to their previous level. Globally, again, Great Britain has really led the way with this. If you go to Great Britain Sport, or like their equivalent of the U.S. Olympic Committee, they have an entire section regarding female health or women's health, and they have a whole summary process on pregnancy related participation, and this is exactly what we need to assist athletes in decision making so they can decide if they want to get pregnant, when they want to get pregnant, what the risk is, how soon they want to be able to push their bodies, because there are certain other kinds of risks that are implied, including pelvic floor injuries, all kinds of things that would make a difference, and not just kind of thinking about it in a musculoskeletal way. So, Great Britain has really led the way when it comes to this. As far as the United States, yes, I'm sorry. United States engagement has really only been led by high-profile athletes and advocacy. I think a lot of us remember when Serena Williams came back and won a tournament with her daughter in her hand, Alison Felix getting dropped by Nike after she got pregnant and then came back and won a medal, and Alex Morgan out on the soccer field with her daughter. So, this is a really, really big deal because women athletes are staying into their sport longer in their lives, and we really need to continue to encourage that. So, this certainly is a multidiscipline issue, and we should approach it with a multidisciplinary approach. So, certainly obstetricians need to be involved, physical therapists, orthopedic surgeons, sports psychologists, nutritionists, but just as importantly, we need to educate the coaches and the governing bodies, and we need to lead the conversation when it comes to this. So, return to sport timelines should vary and be heavily influenced by the interaction of the woman's individual recovery with her physiology and her musculoskeletal complications that can be associated with pregnancy and childbirth. So, for example, basketball and track may not have the same return to sport protocols, or a high-intensity type sport may be very different than a low-intensity sport. So, we should really develop a progression of care for the postpartum athlete, and the Great Britain policy has kind of put together this return to sport, kind of phased care, progression of care, and it's a three-phase model. Apologies. Oh, this is why they didn't want us to touch this. So, phase one prioritizes medical status and the initial recovery from childbirth, and if no major concerns regarding postpartum healing are present, then they can rehab to sport-specific training, and then that's the progression to phase two, and then as they continue to rehab and get their fitness up, then they can progress to phase three, which is return to their competitive sport. But they really need to understand that transition from phase three to phase two, it can be fluid and they can go back and forth between the two phases. So, standardized metrics will certainly help create a tailored recovery plan. You know, we need to understand what the mother is doing. Is she breastfeeding? Is she, you know, does she have childcare at home? Is her mental health okay as she is returning back? Does she have adequate support? These other metrics, again, are gonna be sport-specific, and we need to continue to monitor them so we can give the good information on this type of subject that we do for ACLs and patellar dislocations. So, we need to continue to advocate for policy changes. We need to advocate for maternity leave and postpartum support through the sports organizations. We certainly need to advocate in our environment for funding for research and for support programs. We need to utilize a comprehensive, multidisciplinary approach, and we really, really need to educate and continue, like, pushing this for us to be successful and getting this done. So, our call to action is we really should encourage sports organizations to adopt an integrated care model, and we need to advocate for more research on postpartum return to sport, including risk stratification. Thank you. First, I just want to thank the forum for the invitation to speak, but also really, you know, thank all of you for coming to this forum session. It's great to see everybody supporting us in these endeavors, but I don't have any disclosures relative to this talk, and really, you know, welcome to the NIL era where athletes become brands. The last three years for me has really provided unique insights into the intersection of sports medicine and the NIL world, and hopefully, I can share some of our challenges and opportunities. You know, what it is to be the NIL for sports is important, and name image likeness is what we're talking about, and it's really revolutionized college sports, and hopefully, I can sort of better explain why it is important to us. You know, it has a significant impact on the medical care of our athletes, and therefore us as team doctors. We definitely need to be aware of new potential conflicts of interest as we care for NIL athletes, and there are definitely ethical considerations as well as legal ramifications surrounding the care of sort of these new era of athletes. We'll try to condense this all in 10 minutes. I'm going to be talking fast because I could probably talk for an hour and a half on this subject, but you know, historically, collegiate athletes have argued for many, many years, and even there's been lawsuits regarding that their contribution to their institutions well surpassed the benefits they receive as a scholarship. This is a EA Sports from 2013, and there was a lawsuit regarding this because the complaint was that third parties like the NCAA, the institutions themselves, EA Sports, and all these other companies were benefiting monetarily from the athlete's name, image, and likeness, and this was without their consent. So due to these legal challenges, this was all changed in 2021, and now this new rule allows students, athletes to profit from their own name, image, and likeness and hire marketing agents. So with NIL, college athletes are no longer really amateurs. These are professional student athletes, and maybe you don't think this applies to you because you don't take care of a college team, but I hate to break it to you. You know, it's reaching high school, and even if you deal with pediatrics, you aren't immune. Really, you know, kids are gearing up for NIL deals before they even hit puberty, so you might not be a college doctor, but these are important. And every NIL experience is very unique, and it's been interesting to watch our athletes sort of go through this journey. It can be very simple that it's a grassroots level, that they're using platforms called Dreamfield and Clean Connect to negotiate their own deals. They reach out to the companies and want something from them and give something in return. And then on the other end of the spectrum, basically athletes partner with big-time agencies very comparable to the professional superstars that we all know. And let's be honest, the NIL brings significant cash flow to these athletes, and it's not just about cars and jewelry and having the opportunity to have unlimited Uber Eats delivered to your dorm room, but now really athletes can afford and are actually encouraged to seek out specialized medical treatments and therapies. This allows for this private sports performance and healthcare options, including some of these athletes have entire teams and specialists surrounding them that I would probably say rival many Power 5 institutions around one athlete. Nutrition is no longer about their ramen noodles that we probably all ate growing up or the cafeteria food. Instead, there are customized nutritional plans that are funded by these NILs, and some of them even have their own chefs. The NIL posse, as I call it, can run deep. These resources are unbelievable, and not only is it just one physical therapist, but they have an early physical therapist, they have a later physical therapist that's the return-to-play person. So honestly, it's really mind-boggling about how many people surround these players. And don't forget the parents. Some are involved, some aren't involved, but you always have to sort of pay attention to that because it becomes very important. And as you can see here, there's plenty of potential benefits and positives, and I played college basketball. I'm not sure if I would have made any money, but there's a lot of benefits here to our athletes. But as they say, mo' money, mo' problems. And by no means is it all negative for team physicians. That's not what I'm here to tell you. But we must stay informed and adapt to sort of the evolving landscape of the game. These NIL earnings can really create disparities in access to medical care among athletes, naturally leading, at least to the perception of preferred treatment. And the team medical staff may intentionally, or more likely unintentionally, divert more of the resources because that's what's demanded of us managing these high-profile athletes. There's definitely a changing of the guard. Historically, collegiate medical staffs, the athletic trainers, physical therapists, strength and conditioning coaches, had sole control and contact of their athletes. And it's really been a learning curve, not only for us as team doctors, but for the entire support staff to have to collaborate with these external teams. And all of these factors can affect team cohesion and morale amongst our own medical staff, amongst the teams, amongst the coaches, are all of these relationships that we're now having to learn to navigate differently. And really my biggest lesson learned in this process, especially in its early stages, that the team doctor must be the coach and uplift everybody around us. We must lean into these changing landscapes and not make it us against them. There's definitely times for us in that respect, but your staff will then, sort of your medical staff at these institutions, will typically then follow your lead. We need to empower our institutional staff and make sure they feel trusted and valued and that we're not replacing them by these NLL posses, right? They're the ones that have the staying power and will be working with you continuously after that NIL athlete moves on. So coordinating with multiple external healthcare providers really requires extensive communication, which can be super time consuming and prone to miscommunication. This is a significant administrative burden. Many of these tasks impact us as team doctors. For example, one of my athletes, I have a 30 to 45 minute meeting bi-monthly with the agency, with our UConn medical staff, with the coaches, as well as myself. And it's important to recognize this burden for all of the people involved. And agencies, they have their own idea as a way to do things. They implement these numerous apps to track athlete's load, whether they have gait asymmetry when they're returning from an ACL, their sleep, their nutrition. And they expect our UConn team not only to fully participate, but almost to herd the cats when a player forgets to put their insoles in, that's an IMU wearable device, to go track them down and make them fill out their nutrition log. So it really adds a lot of burden to us. And some of these agencies and teams that we work with, we have ways in which our athletic trainers and strength and conditioning has always documented the workout and the rehab programs, but now they want an additional documentation in their own systems. So the athletic trainers and strength coaches find themselves having this increased burden that wasn't previously placed. So I think it's really important, and all of these things are not inherently negative, but it's just crucial to remember to advocate, not only for ourselves as doctors, but also for all those around us. And it's not us versus them, as our ultimate goal is the same, and that's to return the athlete back to play. But establishing boundaries as this process is going on is important. And sometimes the posse's need to be reminded that they have one athlete, and athletic trainers have an entire team. And maybe subtly remind them that our staff isn't receiving any additional compensation for taking care of an NIL athlete versus one that does not have an NIL. And at this point, second opinions, third opinions, fourth opinions, what's happening here? And athletes seek care outside of our health system. It can cause some stress when historically we've taken care of all these athletes. And on a positive note, multiple expert opinions can definitely reinforce diagnoses, but just like a chaotic huddle, too many opinions can lead to confusion and indecision for these athletes. Differential diagnosis and treatment plans can create uncertainty and stress for athletes, coaches, agencies, families. So having communication is really important. Consulting multiple specialists take time, and this can be frustrating to both the athletes, and definitely especially the coaches. When they want an answer, they're coming to you, and we're still waiting for those opinions to come back. And then constantly revisiting the same issue with an athlete can be mentally exhausting and really affect the overall well-being and ultimately performance. So when it comes to second opinions, it's important to realize we're all on the same team, and it's about the athlete's health. I'd be lying to say, you know, if it doesn't bother me when an athlete goes elsewhere, but in this day and age, it's going to happen. We can't take care of everybody. Everybody has their own trust systems that are built. So now I just sort of try to frame it differently, instead of feeling, you know, punched in the gut and feeling a lack of trust and, you know, how I'm not good enough, I sort of approach it as an opportunity. I think it's an opportunity to network, to collaborate with other people across the country and all of you that may see these athletes, and come up with more innovative solutions. However, I recognize this is obviously easier said than done, but you should definitely, you know, check your ego at the door. We've got to trust the process, and having other experts weigh in can really validate and reinforce your diagnosis, making your treatment plan even stronger, and, you know, really let your talents earn you the respect that you deserve. The ultimate aim is the athlete's well-being and performance, so keep the communication open and collaboration smooth. Ultimately, you know, if the athlete chooses to go somewhere else, maybe like Taylor Swift says, just shake it off. But if you're not a Swifty, you know, maybe Bob Arciero resonates more with you. He would say, don't be butthurt about it. So I've learned a lot about him through this process, but, you know, I think this is sort of a call to action for all of us, that we need to elevate our communication as a specialty and have better communication with one another. And if you give a second opinion, or if you're asked to see these athletes, you know, call that team physician, because oftentimes on the receiving end of that, it's really hard to not know what's going on, but then yet expect to see this player and rehab them successfully. And when the athletic trainers are calling us as team doctors when they've had surgery elsewhere, it really makes it difficult. So I think when we all have each other's back in the AOSSM and the society, it's going to be better for overall outcomes. And we really have to document, we heard that earlier at the session that you guys attended, that this is going to be really important from a risk stratification as well as taking care of the athlete. There are some financial resources and external advisors that definitely can lead to request of maybe unnecessary treatments and tests, and managing those can be difficult. Athletes might request MRIs for every minor injury or even nontraditional times, like to assess an ACL graft at six months. It's great when it looks good, but those are hard conversations to have, and you can't really fight it. You just got to lean into it, try to make the best of it. Multiple medical opinions and treatments from various providers can lead to fragmented care and inconsistent care, because it makes it challenging for us team doctors, as we mentioned. And I would be totally remissed from our earlier conversation about not bringing up awareness of the mental health impact of these athletes, due to all the reasons seen here, both for the athletes that have the NIL deals, as well as their teammates that don't. And we as physicians, as team doctors, we at least have to be aware that this is going on. And remember, this is the scariest part for me, I guess, that athletes can promote anything. It's not just sneakers and sports drinks. This includes healthcare systems, individual private practices, medical gear, and you might not think it's true, but there's already reports in Long Island where football players in college have signed NIL deals with sports groups. In the Midwest, there's a set of brothers that signed with an individual group, they're in network in Pennsylvania, signed 20 college and high school athletes with NIL deals. So this is somewhat concerning as we move into the next era of this, and it's important to recognize that these companies may push for the use of specific products and treatments that may not align with our evidence-based medical practices. As physicians, we must educate ourselves at a higher level in regards to what they challenge us to think about, and maybe challenges our comfort zone and introduce us to new technologies. Over the past few years, we've experienced this. We've encountered with devices, like I mentioned, that are wearables in the insole to look at gait asymmetry, 3D MRIs to measure muscle volume during return to play, increased focus on load management, injury prevention and analysis, the return to play associated with load management. So these are all very innovative solutions, and it's been really fun to learn about, but it really requires our careful consideration and validation and making sure that it fits into your medical framework. And there's actually even new rules coming out as of August 1st, and that this is that athletes must disclose their NIL deals to their own institutions, and then that the institutions must track this, the transaction as well as the threshold, which becomes important with our... My personal concern after being in the trenches for the past three years, and really we entered this in a truly uncharted waters and flew by our seat of our pants and made do by day to day. And now I believe it's time to be more intentional and potentially have some policy discussions that we can be the leaders for and potentially advocate. We need to define when we have an institution, who's gonna pay for these second opinions, and do they require pre-approval, and not to say that they can't happen, but they need to be on a more equitable standpoint where if you have a high profile athlete and then the institution says, oh, we'll pay for their surgery at X, Y, and Z hospital, that's not associated with your institution, but then you have a non-NIL athlete and they say, oh no, they have to be treated here. So this really needs to be standardized across the board, and we should really have a more formalized process for second opinions, and again, it's not to limit this, but it's to make it sure that our documentation and communication is more appropriate and that this is the expectation. I think also the athletic department must ensure that student athletes disclose NIL deals relative to medical care, equipment, and services in that line of reasoning, and those need to be communicated to us. This has not happened to us, but I can foresee this happening, that it's not until we're getting ready to operate on somebody that we learn of the conflict of interest. And really, potentially, we need to have a conversation that, do we have policies against competing healthcare products or services when you're taking care of athletes like this? We talked about this in the general session, but the risk management aspect is real. We should all review our medical malpractice to make sure that it includes NIL-related liabilities, and there's definitely been some suggestions of signing waivers to include and protect yourself against NIL-type value loss after medical care. But ultimately, we should focus on communication and documentation to minimize all of those legal risks. So in the end, like it or not, the NIL is here to stay, so it's probably time for all of us to get into the game, and these are some of my final recommendations. Really, the NIL offers us a new way to innovate and enhance care, and we can partner with our athletes, our schools, and external providers to really develop comprehensive health plans. We definitely need to keep up with the NIL trends and the regulations to be able to best support our athletes, and ultimately, I challenge you to turn challenges into gains and be willing to transform those extra resources and attention into advancements for our patients and our practice, both student-athlete and then our general population. And ultimately, have fun and enjoy this journey, and I appreciate the opportunity to speak. All right, thank you to our esteemed panel. I think Dr. Coyner has time for just one question before she goes off to her next panel, so if there's a question for her, we could go ahead and start with that if you'd like. I think that is happening. We don't have a, their occupational medicine is the advisors surrounding them. And some of them are very mindful that they are still making their decision. Even our highest profile athletes don't involve other people. When I've had injuries and told them they need surgery, I said, do you wanna call somebody? The answer was no. And they made that decision. So I think it's gonna be very athlete dependent. But they can absolutely go anywhere. There's no question, and they've got those rights. I guess the concern, and you do a great job with this, your relationship with your athletes are outstanding. And that's the threat, is the breakdown of that. Because the financial model that you just put up there is not sustainable. It's not. Our country can't afford it. So I'm just trying to find ways to solve it. I think the strategy you put is to develop that strong relationship when they get there is probably key. Yeah, but it becomes more and more difficult because you can have the best relationship ever, but all of a sudden, when you have millions of dollars at play, relationship doesn't always matter, unfortunately. But that's my approach. That's how I'm going to continue to do it. Yeah, that's my approach as well, yeah. But I thought I heard inside your question, will it be a workman's comp model? And the workman's comp model, the NCAA wrestled with that even as early as the 90s. Our workman's comp is broken in this country. I think we all know that. And unless we pay the athlete, and you might argue that right now we do have athletes that are paid for play, but not all the athletes. But if we do have that model, then I think by default, they might fall under workman's comp. But I think right now, this is my opinion, you might know more right now, but the Big Ten, just got through this whole thrashing. Right now, our protectors are the presidents of our colleges. And they made the decision that there was a carve out that they wanted to make for football. And the SEC is leading the way, not too surprising. Excuse me, any SEC fans. And our college president said, no, our athletes have to be enrolled as students, and they have to be working towards a degree. Now, that could take a wide swath of what that definition is, and it could be for one year, or less than that. But I think that at the moment, this critical turn that we've had, I think our presidents are our protectors. So for you that are involved in universities, I think you need to thank our presidents, whoever he or she may be. But I think the next thing is to make the, I mean, if you could get paid, if you wanna support Gatorade, that's great. But this pay for play, it's really, that's what's infecting college athletics. You shouldn't pay somebody to play for you. And that's what the NIL started off as name, image, and likening, and has turned to, and not at Minnesota, we don't have that kind of money, but has turned to pay for play. But I do think that the workman's comp model is the fear of what we all have. In my state, I cannot, they're in the office, and they've got a little bursitis, I cannot inject them that day. They have to get approval. And sometimes it's two, three weeks. Sometimes it's a workman's comp model. Right, that's my fear of that threat. I think it's on a different respect, but same with workman's comp. You also have the challenge of their desires to come back. Whether they may rush to come back because they feel that they're not making money if they're not playing. They might hide the injuries from us. Or on the other side of that, you know, if you have a high profile player that may be going professional in, say, six months, and they have an injury that they could return for maybe the last two months of the season, they may have external pressures not to return because they are worried about that next contract. So similar motivation to workman's comp patients about being motivated. Okay, I have a couple questions. Oh, did you have one? Oh, I see you, Michele, sorry. No, I was just gonna comment as how it ties into the rest of the panel, is I think that it behooves us as an organization and organizations like us to establish those principles for what everyone else was talking about, which is our return to sport criteria, and not have those be influenced so heavily by those external factors, but rather we lead that way. So I view this as really a call to action on our part to be the leaders of what that means for those athletes. And then let other people follow, because I'm not gonna seek a second opinion from my colleagues here if I know they're gonna say the same thing because they're all using the same standard of care that we have been studying and have proven is effective. Right, and we can do that for everyone's talk today. The mental health return, the patellofemoral return, the postpartum and pregnancy athletes. I mean, it all goes together. It's important. Okay, now I have a couple questions. If there's any other questions for the panel. Kathy, do you need to go? I have a question for Leah, actually. So this is not a one-to-one comparison, but I've been thinking a lot about the sort of education of the pregnant woman about the postpartum period and sort of what to expect in the context of our surgical residents who are not returning to athletics, but I feel like are returning to a similar like sort of trying sort of stretch a thin kind of like put you at risk for failing breastfeeding, like all the things. And so how do you strike the balance between like not calling them weak, not sort of like setting them up to sort of be vulnerable and weak, but like giving them some window into what's coming and how do we put that into the package from the IOC and from these organizations? So I think what's important is the communication. So in one of those strategies from Great Britain, they talked about routine check-ins, because again, pregnancy is not, at least in most in a normal healthy pregnancy, it's not a medical illness, it's a physiologic change. And so you have to treat it a little bit differently unless there then becomes an illness related to pregnancy and then it is an illness and then it follows that type of pattern. But it's the continued check-in and then the establishment of at six weeks, it's the body at least is physiologically recovered enough to do minimal activities. So the expectation to maybe do whatever the expectation is. And then at the six week, at three months, then there is an expectation of this. What are some of the challenges? Are you breastfeeding? Are you meeting your nutritional goals? Like, are you doing all the, are you meeting your mental health goals? Are you, is your identity all right? Are you having the support that you need? But the successful ones have routine check-ins with their governing bodies and they can also, and they're flexible. So they go back and forth. So it's not always a progression that has to be linear. Yeah, that's great. Thank you. In looking at return to athletics postpartum, which is completely unstudied, right? From a research point of view, what do you think the metrics are that you'd wanna have to say, is it return to sport safely? Is it return to sport at the same competition level? What metric would you define? Because we'll have to define that in order to begin to study it. I think that that's up to us to define that. And I think you can have separate ones. I think you can have separate ones, return to activity and then return to competitive sport. I think part of it is developing or understanding what the athlete's goals are. Because some athletes don't have the same goal postpartum. And maybe for the next two years, they don't identify as an athlete anymore. And what about having, like on ECLs, it's the patient expectation, right? So I wanna go back to sport. And then the question is whether they do it or not. And then it also depends on competition level, right? And how much they have at stake. But there's a lot, there's expectation shift. So people will tell you at baseline, sure, I wanna go back to sports. But then they say, maybe I can move on with my life. That's minor. You have a child. Your expectation all of a sudden may shift, right? At the end of that. So how do we, I don't know how to account for it at ECLs, but how do you account for that? How do we look at that and study that and account for that in that process? Because ultimate goal is for the patient to be safe and the mother to be happy, the child to be well. And also if they want the sport to do it in a way that's safe, right? Yeah, exactly. And I think that that's why this has to be done. And I think the communication part of that is, it's the part of the routine check-in. Has your goal changed? You know, and you have, you set certain time periods where you re-engage the athlete. Do you still want to do this? Is this where, is this still the goal? And so it just, it may be kind of like trying to hit a moving target, but I think that that's part of what makes that, what's part of that makes this difficult, but is why it's so important. Because if you have to, if you have to keep checking in with the patient to make sure that they have the same goals, it's, I think you can kind of look at it like ACL. I think it's, you know, we have no one study it. We don't know when someone's ready to jog a mile or put it in numbers. We have to start collecting data to know when people are ready. We can look at the physiology, but every person's physiology is different, right? So it's trying to get information from our pregnant patients or our pregnant students or athletes. You know, someone's got to start collecting stuff, but what do you collect? And so we're trying to put it. That's my, that's what I want. You have to define the metrics. You got to start somewhere. So we, yes, and we're trying to do that. So we're, I've initiated a study to do this, but you, we have very descriptive questionnaires that go out at different phases of their pregnancy and postpartum and kind of just, it's a check-in and it's very, I mean, it's very detailed. The other part that's important is that not every pregnancy is the same. And so you have athletes that have had multiple children whose pregnancies were very, very different and their return to sport was dramatically different after the first pregnancy, after the second pregnancy. So there's a lot of information that we need to gather, period. A lot of variables. Yeah. Anything else? All right. Well, I think we're ending on time. So that's good. You guys can get to the next one if you want. If you have other questions, please approach us if you have more questions. Thanks.

Laura Alberton, MD

Melissa A. Christino, MD

Jacqueline M. Brady, MD

Leah C. Brown, MD

Katherine J. Coyner, MD, MBA

sports medicine

psychological recovery

physical recovery

patellar dislocation

post-pregnancy athletes

NIL deals

mental health

return-to-play metrics

multidisciplinary approach

collegiate athletes