So, we're going to just start getting our panel up here. So, Anil, Dren, is Ryan around, Dharmesh? So, you know, I know it's been a long day and, but I actually think this is the part of the meeting that is kind of the most interesting and helpful. It's probably the part of the meeting that nobody wants recorded, because it's sort of what, it's kind of what we do, you know, sometimes to keep our athletes on the ice. And I'm not sure any of it would be the answer to your medical boards. I'd lose your medical license. Right. So, we have two panels tonight. The first one is kind of the role of injections, not like injections for tendinopathy, or this is like a little bit more keeping your athlete in the game injections. And then, we're going to bring up some experienced athletic trainers, and they're going to give some tips on, you know, how to keep the athletes on the ice. So, there are my disclosures, nothing there. All right. So, here's our first case, and these are pretty typical cases. I'm sure we've all seen these before. This is an NHL defenseman. He's hit with a puck in the long finger. You know, he comes into the training room. It's swollen. He's got a small subungual hematoma. So, we're just going to go down the panel here. You know, that night in the training room, are you going to stick a needle in that nail bed and drain the hematoma, Anil? Yes. I mean, if it's big, there's no reason to do that. And sometimes, when it's really big, I've taken, not here, but in the ER, I've taken nail beds, the whole nail off. So, it all depends on how much blood there is. How do you do it? How do you drain that thing? Do you do that hot needle trick, or? Yeah. 18 gauge, you know, just heat it up. No, but I actually do a digital nerve block with it. Ryan, how about you? Yeah. Well, first, I would make sure I'd get, obviously, imaging first. We have the x-ray. I think if I were to drain the hematoma, if it was bothering someone, that's TD's favorite thing to do. So, we have the little, you know, prefabbed ones where he puts. The cautery thing. The cautery thing. And then, I would put the, because it's an open fracture, to some extent at that point, I would put someone on antibiotics, because they're going back in the dirty glove. Dharmesh, you drain them? Yeah, I drain them. I drain them with the hot needle. I always tell them that if they get a closed fracture, they get an open fracture. So, there's a smaller conception. I work with guys like that. I started. I've heard so much, but I'm just trying to go ahead and do it, and we drain them all the time. Ryan? Yeah, I drain it, and I've learned it now that I've trained about the hot needle, and I had one of these myself a couple years ago, and I just took an 18-gauge without. And I was ready to heat it up, and I just swiveled it a couple times, and it actually released, and it was painless, largely. So, I don't know that you need a hot needle or. So, you got the blood out of his hematoma, and now you've got to make a decision. Are you going to send him back that night? What are you thinking, Neil? If it can grip, then yes. You know, it also depends where you are in the season and all that stuff, you know. But certainly, if it's a playoff environment, doing a digital nerve block. I mean, we had one defenseman that I did a digital nerve block every playoff game for three weeks in a row. So. You use marketing in the playoffs, really? No. So, I think the other component is if we can get our equipment managers to, you know, alter the glove or internally put something in the glove that does protect it a little bit. But I think with the, yeah, I agree, depending on the time of season and the blocks are very helpful. So, we're going to be very specific here, because not everybody on this conference is so experienced. Like, how do you do this block? What do you, what medicine are you going to draw up? Ryan? So, with a digital nerve block, I would use probably two cc's of Lidocaine and two or three cc's of Marcane. And I'd use a 25 gauge needle and I would go into like the radial dorsal aspect. And then you just, you can inject one spot there. You can travel the needle over to the dorsal side on the other side. And then you can go more proximally. So, not, you don't want to put too much in because of the pressure. And everybody probably needs a total of two to three cc's of fluid. Do you guys worry about adding a little epi with one of your local anesthetics to make it last a little longer? Does it worry you about the concern about necrosing his finger? I would not do that in a digit myself. Agree. And I would do it always at, I want to do it at the level of the joint. I would do it at the PIP joint. Yeah. I'll go a joint above, just let it, and maybe put a little extra sauce in there. Yeah, I usually block them at the MCP joint, way, way. I used to do it there and then he got mad at me because it took so long to last, that I went more distal for the next one. Like if it's more, if it's more proximal, like if it's a metacarpal fracture, non-displaced, do you think you can block those? What do you think, Dharmesh? Yeah, I actually had one this year. I blocked him for all 82 games because it just didn't go on to heal. I mean, I think I had surgery at the end of the season. All 82, he made me travel to games I wasn't even supposed to go, just because he was like, I'm not letting anybody else inject this. Yeah, again, we're not, well, we are recording. Well, that's, that's impressive. Any, any questions from the audience? I mean, I think for the team docs, to be honest, this is a reasonably safe thing to do. I think when, with these tough fractures, you know, they're super painful. I mean, you know, hockey players are really tough. This is one of those injuries where it, it bugs them and, and you can make their finger go numb with a block. I think it's a reasonable thing to do. Any other comments? I use, for these guys, I just use Marcane for these guys. Yeah, I don't even put the Lido anymore because it lasts for almost the whole game. So, yeah. We, a few years ago in the playoffs, we had one that it was actually a middle fracture. We actually started using, you know, the liposomal. Yeah, it was probably not very cost effective, but yeah. All right, so on to our next super common injury. So this is one of our college forwards hit into the boards. He's got swelling and just slight deformity at his AC joint. Comes into the training room. You know, you have the good fortune of having some imaging so you don't see a fracture. Is this an injury that you would inject that day? Grade two AC joint? Yeah. So I was a baseball doctor for 15 years before I did hockey, and we would never inject this in baseball. I remember one time I had, you know, I had an athlete and showed you how cool hockey culture is. And Les Besson from the Sabres was like, inject him. He'll be better like in a week or maybe that same day. And ever since then, we've injected them, and I think it's really good. Anybody else? I mean, I think so first, depending on, you know, what time of the year it is, you know, I may have done something like this in the playoffs this year. But, you know, I think from a local anesthetic perspective, first of all, I would use local anesthetic. I probably wouldn't use corticosteroid right away because my sense is you do need some time for it to absorb. And, you know, I do a day a week of fluoroguided injections, a lot of spine, but also peripheral joints. And the AC joint sometimes is a little bit tricky in the sense of it's a minimal deformity and there's lots of swelling. So we do have a point of care ultrasound. I would probably just use that once to see the margins and make sure, you know, it's just not a funny shaped clavicle or someone had, you know, previous injuries. But I would have no issues, you know, in an important game doing local anesthetic injection. How many times would you inject this? You know, this is the difference between, you know, football and hockey, right? Football players play, you know, once a week. And, you know, if we're in the playoffs or even in a regular season, you might be doing this three times a week. Is that okay? Yeah, I've done it several times a week. I wouldn't inject them on game day because their cuff is just shut down immediately and they can't really protect themselves even if you inject them. Give them two to three days of rehab and then the game after that. Once his cuff starts functioning, I'll inject it with local. Maybe at about two weeks if they're still struggling with the type 2, then I'll put a little bit of cortisone in it. Yeah. Ryan, any thoughts? I think if they're going to have full strength, full range of motion, then I think it's safe to inject them game day. But I don't think the injection is going to get them that strength back if they don't have it already. That's what I think. I think if they've got full motion, full strength and they hurt, the injection is going to help. If they can't get their arm above their head, I don't think the injection is going to help. I think my philosophy is you can numb them up game day and then I usually give them a few days. And if their joint is super sore, I actually have found that a cortisone injection seems to shorten the course of the really sore AC joint a little bit. I don't use ultrasound because I don't know how. It'd be probably helpful. Yeah, no, I don't use ultrasound, but I actually always use cortisone. I mean, one time. You don't do multiple cortisone. And that was Les' whole point, is that you do cortisone early on, it will decrease their time or increase their time to return. And realize this, the end stage history of the AC joint, like the end stage history of the prostate, the prostate, every male dies with prostate cancer. They don't die from prostate cancer. And everyone dies with a bad AC joint. So it's a joint that you don't have to worry too much about. No, yeah, I agree. I just think, you know, this is probably, again, another one of those injuries where as a team doc, you can help out in a safe way. Kim, question? If you inject these things frequently, do you end up with osteolysis and having to fix them at the end of the season? Yeah, I would say there's a chance. You know, if they have a bad AC, a grade 3, and, you know, their clavicle's up to their ear, it's going to take them a long time to get better. But they're probably not going to need anything done. I think the ones and twos are the ones that sometimes it bugs them, whether you inject them or not. And those are the ones that sometimes need a distal clavicle excision, because they're they're a little bit gnarly at the end of the year. Would you agree, Dharmesh? Yes. Yeah, absolutely. If it stays in close approximation, that joint gets really synovitic and really inflamed, and then you got to go in there and open it up. But the type 3 and 5s, they're sitting so far away from the acromion that it never bothers them. And distal clavicle osteolysis, the weightlifting phenomenon, it's not an injection. Now, maybe 11 cortisone shots, different story. But that's one shot of cortisone in the distal clavicle will not induce distal clavicle osteolysis. It's a different pathological phenomenon. And I don't know if the injections change the natural history or not. I just would say that, you know, when I see a grade 2 that stays symptomatic and we're doing some injections, I worry that at the end of the year we might need to do something because that joint is, it gets beat up and like you mentioned, you know, it's synovitic, it looks a little bit angry. Now I would say a distal clavicle excision at the end of the season is a fairly quick recovery and, you know, we can, I think of a case, you know, tomorrow, I run around our town telling, you know, people who take care of hockey players, you should never operate on a bad AC joint. If you have a bad grade 3 or a 5 and you want to do a CC ligament reconstruction, you will operate on them again with probably a broken coracoid or clavicle. But this is not that surgery. This is a distal clavicle excision, which is a pretty quick recovery. I think Ken brings up good points, though, that we need to recognize that both the analgesics and steroids all have a chondrotoxic effect and lidocaine being, you know, robust evidence about lidocaine being the worst of them all. So let me ask you this question. Because of sort of some of the new litigation that's been an issue, you know, what are you guys doing for consent for injections? I mean, do you just kind of throw a note in their chart? Do you make them sign something? Are you doing a formal consent process, Anil? That's why I have Dr. Linger, because he's my official consent. He's very... No. We don't. But actually, our hospital is slowly instituting that for just doing injections in our hospital. But right now, we don't consent players for injections on the professional level. We document verbal consent and have the conversation. Yeah, we document. I mean, I think sometimes in my office, reading the consent form is longer than it takes to actually do the injection. But I mean, I would just document, discuss with player in the chart. So, Dharmesh, you're probably living this in your world right now? Yeah. Do you do a written consent for injections? We do not do a written consent for the injection. You know, I've always been a believer that the real consent comes between what you and your player, the relationship that you have. And the rest is just paperwork that they can throw out in the court system. So I really just talk to them and tell them what the risk of this injection is going to be. And then I document in the AHMS system that we discussed it, and I gave them these reasons. Any questions about AC joint injury? Any other comments from the audience? You guys do something different? I think that's a good point. The one hint I would give is if you're doing an AC joint and you want to get them back on game day because it's playoff or whatever, I really think that they herd along their periosteum and muscle. So I inject the AC joint and then I just fill their entire distal clavicle and everywhere with lidocaine, marcaine, and that seems to be a little better than just dropping it in the joint. Perfect. All right. Get on to a little bit more controversial. So this is an NHL defenseman, he blocks a shot. This is a little hard to see. I don't know if I, so it's, yeah, right, so it's right there on his navicular, right there. You guys can see that thing? So his plane radiographs look normal, his MRI scan, he's got a minimally displaced navicular fracture. You know, he's able to kind of walk around reasonably well, but it hurts and you inject this? A navicular is a hard bone, it's a different bone. We had our captain, defenseman, block shot playoffs against Tom, Tom beat us again as you know, they usually do, but, and we injected his first ray, it worked for the first three games until he chronically displaced it and we watch it displaced during the playoffs. But a navicular is a bone, I'm not saying I wouldn't inject it, but it's a different bone in the body. It'd be like injecting a scaphoid. I'd agree, I mean, this is one where, you know, are we in the Stanley Cup final? We were. Yeah, we were. And so how many games do you have left? Do you have 80 games left or two games left? And I, this would be, this would be a difficult one to treat like the last two. Because we, I mean, we see, Dermesh, I don't know what you feel, we see these all the time on the foot, right? They're either medial or you get a cuneiform on the other side or you get like a fifth metatarsal shaft that's minimally displaced. It's hard to do it like a block, but do you think like just injecting the fracture site helps? Yeah, I think injecting the fracture site definitely helps. I don't even get MRIs on these anymore, I just get a CT and if there's no fracture, then I'm assuming it's a bone bruise and I'm going to inject him. If there's a fracture line, if it's a playoffs, I'll inject him for sure. But if it's a regular season, I'm going to give him about two to three weeks and then inject him for when he comes back after that two or three weeks has passed. Brian, any thoughts? This one makes me uncomfortable as far as injecting. And I think, as Heather said, if it's playoffs, deep in the playoffs, but I'd be consulted with our foot and ankle colleagues about that. My concern is injecting this and does it create a stress riser that creates a bigger fracture and becomes more problematic? So, outside of just having it where they're competing and playing and displacing chronically, is there a risk of that? Well, that's the point. So, we can inject a lot of fractures and they can get displaced. Like the first Ray, he got really displaced over Eastern Conference Finals. He didn't play Game 7. We lost Game 7. But it healed uneventfully with two months of the off-season. This displaces. This doesn't heal when it's not displaced. So if it does displace, you definitely need surgery and it still may not heal. So that's, it's opening up a can of worms. That's why it's a special bone in the body. I think the point here and the reason I chose this case is there are some fractures where, you know, pain may be a good indicator of the thing starting to heal and you feel a little bit more comfortable with the situation. And like maybe you shouldn't take away the pain, you know, because you don't necessarily want them to stomp on it and displace it or have it go on to a non-union. And like you said, Anil, I mean, you know, if you have a great toe shaft fracture or a fifth shaft fracture that you're kind of like, okay, if it doesn't heal, we can fix it at the end of the season without much sequelae. I don't know if, you know, you'd do that necessarily here. I mean, again, I think it's situation dependent. But I think it's important as a team physician to kind of figure out, like if I do something to make this player be able to stay on the ice, am I going to potentially worsen his, you know, situation for his career? I think that's where all of us get a little bit nervous. You know, it's great to have a guy make, you know, play the next seven games, you know, but if you hurt him for the long term, that's not great. The one other comment I would make for our next session, Ramer, who's going to be on the next, taught me one golden rule is that also hockey players don't like hardware in their feet. So you really, you really, you really, you know, they could, you could put three plates on their clavicle, you can, but hardware in their feet should try to always be avoided. I would agree with that. So again, we'll just keep going to more controversial ones. So this is an NHL player with chest injury, checked into the boards. He's got, you can barely see this thing, right? He's got two. So you can see. You have a minor fracture. So what, what are your guys' thoughts about blocking rib fractures, Ryan? We do them. And we, we, we've had, how do you do ultrasound guidance, a hundred percent on this sort of thing. There's no reason to mess around with, without doing ultrasound guidance. We had one of these this year, we injected them and again, to my point about the counter toxic effects of lidocaine, we used this, like a two seasons of lidocaine and a six or eight of marcaine. And I probably in retrospect, thinking about this, you know, the healing of this probably would rather leave the lidocaine out because it could, that impair healing. But yes, we injected it about 30 minutes before game time under ultrasound guidance. Dharmesh? Again, it depends on where you are in the season. If this is a regular season early, I let him give this a couple of weeks before I start injecting it. Playoffs, I'll inject it and I don't use ultrasound for this. I just kind of have him lay on the side. I figure out where it's close by, where it's at and just sort of inject a regional area. Yeah, I would agree with that approach. I mean, I think in hockey players, the body type we have, we don't have 300 pound linemen. It's as easy to feel. If I had the real luxury, I would actually, and I could see it easily, I would probably block them maybe even in the floral suite, have my office and then landmark as to where that was and the effectiveness of it. But again, I mean, I would not, during the regular season, it's a no for this. Yeah. I mean, the one thing I would just add, we always do this blind. I was taught to do this blind by a famous doctor in Pittsburgh. And then after the San Diego incident with their quarterback, who was not 300 pounds, he was their quarterback, which was really helpful for the backup quarterback. He got, I think, $300 million. I mean, Ryan, with his ultrasound, does a great job at this. It worked really well this year. So there's certain times where I'm like, I don't need ultrasound. And this is one where 100% I think you should use ultrasound. So I mean, I think what Eniel's talking about, the risk here is you drop the player's lung, right? So you know, when I was in the Army, the special ops guys had this little program where they were learning how to block each other's ribs because rib fractures are pretty common from blast injuries and just had a huge rash of pneumothoraces. So it's not a totally benign injection and this is one where I really think it's situation dependent. I mean, you better be in the playoffs probably and you know, the player's gotta, like you said Tony, maybe gotta beg for it to be done because the downside is if you do drop his lung, he's gonna be out for a while. Now to add, if you're doing it palpation guided, if you're having an inch and a half needle, that needle, depending on your angle, it shouldn't be more than halfway in because the rib is about one and a half to two centimeters deep and you stay out of that area and you can see that in ultrasound pretty easily. But as long as your needle's not buried, then you're, in only halfway, you're probably okay. So one more. So this is a college defenseman, twists his ankle going into the boards. He's unable to finish the game. Radiographs are normal. His MRI scan's there. It shows a syndesmosis injury. You know, I think there's a fair amount of controversy here. Do you guys inject syndesmotic injuries? And let me start by saying this. Do you inject them, you know, relatively early after the injury to accelerate their healing? Any? I don't think injecting cortisone here accelerates healing at all. Cortisone never accelerates healing. Cortisone accelerates mitigation of pain and inflammatory markers. So I think there's no role for early injection of cortisone. Have we injected this injury in the playoffs? Yes. And it's cortisone once and then just anesthetic after that. But the role of PRP here, I don't know the answer. That's gonna be discussed tomorrow. Not that smart, but definitely one shot of cortisone. And I do a little bit in the joint and a little bit in the syndesmosis. And then he gets anesthetic for playoffs. Acute injury, let him ride. Yeah, I mean, I would say I approach this, whether the pain is diffuse, if it's, you know, that six centimeters up, I find that a little bit more difficult for it to be. But if we're talking about an AITFL injury off the fibula, I would do PRP and I would do local anesthetic. You know, if you have a joint diffusion because of maybe a PTFL and AITFL injury, I think there might be a role of corticosteroid into the talocrural joint to take away that effusion and let them have their range back. But if it's diffuse pain, it's like, what am I blocking? But if it's pinpoint pain of the AITFL off the fibula, then I'll definitely use local anesthetic. I'll tell you what, this is an injury that makes me really nervous, like anytime I see it. So I'm reluctant to inject in the early phase into this joint or anywhere near this. With AITFL off the fibula, I will inject PRP and I keep a very small amount. With PRP, I feel that less is more, more is not more. It's more is too much. And I used to inject this all the time until there's a famous football player from Pittsburgh who had a syndesmosis injected and then just got a whole bunch of HO there. And after that, I was like, uh-uh, I'm not going into syndesmosis. I'll inject at the AITFL small amount. So this injury makes me nervous to just let them ride it out. I think this is one where you want to let them rest, let them heal it up, and then when they feel healed up, take one week beyond that. I'd agree with the others. I don't think there's a big role for cortisone acutely unless it was truly a playoff situation and you're talking about the risks with that. Have injected it with PRP in the same way, I agree. It's been said about a smaller volume with PRP is better. It's kind of interesting because I think in the NFL, it is common practice to inject a syndesmosis a day or two after the injury with cortisone. I mean, I've talked to Les Bisson. He does it with the bills. I mean, Joel's not here, but he's the one that kind of convinced me that it's a good idea. It's like injecting a hamstring with cortisone. It makes no biologic sense, but the level five evidence of the team physicians is that they recover a little faster if you mitigate some of their inflammatory response. Again, I did a literature search on this a year or so ago. There really is not much in the literature. There, I think, is one study on PRP in like Israeli military that did show that they recovered faster with a PRP injection. And so for those NFL players, is there whence the return to play that they're shooting for on that? Like three weeks or one week? Quicker, right? So the thing about an NFL player is they tolerate syndesmosis injuries better than hockey players. Hockey players, this is way longer than you think. And if you're talking to your coach or your GM, I'd shoot for longer, not shorter, with a syndesmosis injury. The one thing is that the classic hamstring paper from Bergfeld that shows three weeks faster, but that's a muscle, it's a muscle tendon. It's straining it and putting, this is bone-to-bone. And dormesh, just like in the pelvis, in the pubic symphysis, if you inject PRP for adductors, rectus, whatever, that can turn. So a small joint bone-to-bone versus a big muscle tendon, they're completely different biological environments. And bone can be formed. And we don't know who makes bone and who doesn't. So I think they're a little bit different biological entities for PRP. Yep. Well, that's all I got. I think those are pretty typical things that we have to deal with. So our next section, we're going to bring up our athletic trainers, and Duran's going to walk us through some things that they can help us with. CD you want to join too Yeah Is Jim on do we know? Yeah. Yeah. Yeah here. I'll just introduce because there's a couple people new So Jim Ramsey is the director of sport medicine performance and the head AT for the Montreal Canadiens Western Canadian from Winnipeg originally worked with the Jets for five years the Rangers for 29 years Won three gold medals with Team Canada at the Olympics and hockey 2002 2010 and 2014 so we're glad that Rammer can join us and I just wonder how his French is these days And And then we have Jeff Winslow who's the head athletic trainer at the University of Minnesota And also the assistant athletic director and and he's in his 15th season Providing medical care with the men's hockey team. So thanks To both of you for joining So I've got four four cases here and very similar to the doc style So case one is is basically this player who's in the white jersey Has a valgus directed force to his knee by the opposing player Right away feels a medial knee stretching and a sharp sensation didn't really feel a pop at all You diagnosed a grade 1 MCL So the question is is how can we get this player through the playoffs safely? What are some of the things that you guys will do as athletic therapists and trainers Sure, obviously we've had this scenario Probably one of the playing wise one of the things we do is Limit their ice time, you know in between games. You don't want to exacerbate the symptoms when you don't need to But when it comes to actual gameplay we brace them one thing we found is if you take the one of the Don Joy Hinged braces and you pull those metal stays out like a lot of the players They don't like the feeling of that extra neoprene the thickness So we'll put pull the middle the metal stay out and just tape that on so you have that That metal stay given a little resistance to that valgus stress as well as taping that to reinforce it Yeah, I'll agree with The bracing option that he brought up. I will say that I do get pushed back on putting braces on hockey players They don't like the feel of it underneath their shin pads and knee pads and if the grade one and I'm not getting any laxity on exam and they're not, you know reporting looseness with With their striding and their skating You know, I think I can at least talk them into doing some sort of neoprene sleeve for compression and just comfort But ideally if I could get them in a hinge brace, I would I agree. I'm I'm a big taper I'm old-school that way. I I've got my techniques today that I'll provide support to the athlete and make sure that they they feel comfortable What I find with bracing for you know, mild MCL is that players really if they're not used to wearing a brace They they won't wear the brace so I'd rather like apply a tape job like Tommy said maybe add in a you know medial stabilization bar and We also will basically use Some kind of magic potions that we've developed over the years in terms of compounding That may have a little Voltaren in there a little lidocaine some heat and Basically kind of take the edge off the MCL as long as they're functional and try and reduce the pain Increase their function as a hockey player I Wouldn't say I really do anything differently. I think if it's distal it can be a little bit more of a an issue It's a little bit more complaints of soreness that you have to manage with you know Modalities or nsads or however you want to manage it, but I would say that the the distal ones are a little bit more Bothersome Anyone else any other comments So that's a good good Good case, so we'll go to the second case And this is you know a situation where you may be working a high school playoff game There's no physicians covering the game except in Minnesota Where you have 15,000 people the high school hockey games And and you know the player which for whatever reason suffers a facial laceration in the eyebrow area Is bleeding and bleeding and bleeding? Exam is otherwise normal you're not worried about a head injury anything to do with the eye So I mean I know you guys sometimes deal with this the elite level of hockey College and pros, but you know maybe Jeff. I'll start with you on this one I Think it's funny you go to me first because my players all wear cages compared to these guys But no, I think I try to avoid hemostatic agents if I can If they're going to get sutured up afterwards that can be a little bit of a bugger That's got to get picked out in order for it to you know. He'll heal the best So I'm just using gauze trying to keep pressure on it to get the bleeding to stop If I can get it to stop in a short amount of time And I'm trying to get the player through the period without pulling them off Then I'll just use like some skin lube which is a more viscous Vaseline sort of Substance that you can smear on to just cover up the area keeps it from continuing to bleed if that becomes a problem where You know it's bleeding through or I have to continue to reapply then I'll pull the player off the bench and you know do a Little bit more work with with steri-strips or something. That's a little bit more permanent Something that I feel works nice is if you guys know what leuco tape is it's kind of a brown thick really really sticky tape If you put you know a small piece of non-adherent pad onto that and kind of create your own band-aid you can slap that Over the the laceration and that tends to stay on even with their sweating Again as Tommy and TD and myself know magic potion Rammer Yes, we have magic potions The the new the new breed of athletic trainers and athletic therapists in the NHL are now incorporating TXA into like a skin lube or a Vaseline base to stop bleeding almost immediately I haven't gone that far yet. We're still researching it in the Montreal Canadiens medical team We have basically a cut cream that anyone can make and blend up it's basically neosynephrine which is a vasoconstrictor a little bit of vaseline and if you're lucky enough you can get hold of some lidocaine and you put a little of that in there and It stops bleeding almost immediately When you have a bad bleed, obviously, you know It's pressure and gauze and nothing drives me more crazy than when a trainer uses a towel out on the ice Stop bleeding, but that's a personal preference and We basically use the cut cream and then a little matisol Stick them and some steri strips and off they go No epinephrine the the well, you can for the vasoconstrictive, but we just basically it's Our guys just put the lidocaine in But that's a good thought Ramerton turned me on to his cut cream about 20 years ago. So we still use it occasionally We do use surge a cell for our purposes not Inexpensive, so probably tough to do cheers Rammer Yeah, thank you tough to do, you know, maybe at the high school level You know, obviously our Plastics dog he's okay with picking out the the surgery cell once he needs to get to suturing Another product is the QR powder. I believe it's called wound seal now That's another one that we've used as well This is a balsam product so I am I'm safe and it's almost 8 o'clock here in New York right now, so It's Friday, so, you know, obviously players are sweating And you know if you're in a situation where you don't have all these magic potions Like you guys do How do you get things like steroid strips to stay on? with all the sweating That that occurs are there things that trainers that maybe don't have the same resources that you guys do. What would you do? We've used mastisol, I think that's fairly inexpensive Compared to some of the other products that that works great to just create that adhesive property Other than that, I mean just really trying to dry the area before you apply it a Real common product that many high school athletic trainer would have to is tough skin and they could spray that on You know a gauze pad or something and just kind of wipe it above and below Good protect the eye make sure their eyes closed. Okay, we'll go on to the next case So another block shot, so this is in the case of an NHL player Blocks a point shot on the outside of the skate. So really at the lateral Outside of the skate at the end of the second period This is an important game goes down for about 30 seconds hobbles off the ice During the intermission points to the right lateral foot around the fifth metatarsus So I just want to get an approach Maybe we'll start Brammer with you How do you approach this? You know, there's x-rays. There's taking the skate off And then pain analgesic icing a lot of things can help this but how do you know when this is really bad? The the funny thing is is and that was one of my former athletes that the pitcher was there and That guy probably blocked 20,000 shots during his entire playing career and probably missed zero games because of them That's one thing that I think was pointed out earlier in the conference is knowing your athlete Understanding their level of pain tolerance and as many of the veteran Physicians in that room and and online here know today The athlete is a lot different than he was when Dan Girardi played the game And it's important for us to realize Pain tolerances of the athlete. So for me Dan Girardi isn't not even a question It's basically are you okay Dan and he's like, yeah, I can put my weight on it. I think I'm okay So knowing your athlete number one number two is What I'll do is a brief check on the bench when they get back. One of my rules is is You'll see a player and they're always when they're injured. They bend over on the bench like they're trying to collect their thoughts I always stand behind them and wait until they raise back up when I that's my Signal to me that that athlete is ready to to converse with me and talk about what just happened and if they're okay That's that's one of my talking points when dealing with young athletic therapists Don't be in the athletes face and and then I'll have them wait there I'll try and you know do some toe raises and things like that if they feel they're okay then I'll let them go a shift, I'll tell the coach, look, you know, I think he's okay, I think he's gonna be okay, I'm going to give him a shift, he's going to be honest with us, when he gets back to the bench, we'll reassess. And then if there's no choice, and I have to remove the athlete, and Neil and Ryan can can attest for it, we've we've actually x-rayed guys through their boot, trying to prevent them from taking their boot off. Sometimes it works, sometimes it doesn't. And sometimes you just make the decision like this guy's not going back. So but those that's my initial list spent of the athlete. Rammer pretty much nailed our thought process to great point about giving the player some time. I know, whether it's even this injury or any injury, when they come back, and you immediately lean over and try to talk to them, the last thing they want to do is have a conversation. So giving them a few seconds, minutes to kind of compose themselves, let their initial pain hopefully subside a little bit is key, as Rammer said. When it comes to playing, though, I think it's pain tolerance and function. If before you actually do the imaging, if they are in significant pain, and you know, then you bring it back. And like Rammer said, we also have done imaging through a skate. However, like most people in here probably know, plain film of foot and ankle are fairly useless, unless it's a pretty distinct fracture. Been multiple, multiple times where nothing shows up on plain film and then next morning CT or MRI or both, you'll find something in there. So again, it comes down to their pain tolerance and their functional level. And you know, as Rammer said, if you give give the player a shift, and they're hobbling around, chances are they're not going to make it and they probably do have something more significant. Yeah, not a whole lot to add up. But I will say that I had an instant where I had a player, you know, block a shot, come to the bench, give him his time to kind of, you know, test it out, told me he was okay. His body language was good. And he was, you know, putting pressure on it on the bench. So I did the, you know, let's go out and try a shift and we'll see how it goes. He ended up displacing a first metatarsal fracture. So it can bite you a little bit. You know, sometimes the player, either the adrenaline is going or they just want to stay in and they'll tell you what you want to hear. So I try to put more emphasis on body language and, you know, how their weight bearing how they're moving around. But even so sometimes it still gets you. So kind of on the same theme. Maybe can can you guys talk about, you know, the uptake with shot, you know, shot blockers or the buildup of the skates? Who wears them D versus forwards? Maybe talk about that a little bit. Tom, do you want to maybe start? Sure. I mean, obviously, there's a lot of different options out there. Some of the equipment managers around the leagues are great with, you know, using kydex products or foam underneath the kydex or some of the skate manufacturers are making some built in. Obviously, it helps if you can try to get your players to wear them, that's most beneficial. But even with them, we've had fractures with with shot blockers on, you know, as far as who wears them, I typically say, I guess, if you went through the league, your D are going to be your most popular, along with your, you know, penalty killers, penalty killing forwards. Typically, your skilled guys aren't wearing them. Ramer, what about complaints of the weight of them, or decreased mobility? Um, I that is a logical complaint. Players, you know, every ounce counts. And, you know, you'll have your players that give you pushback. Another aspect of things is the players, even if the the kydex or is like a eighth of an inch thick, they feel like it's in as their skates start getting low on their blade. Like after a lot of sharpening, you have players that want to a smaller, less tall or thick blade, and they're making a turn in that little bit of kydex just nicks the ice. It drives them crazy. They the sensation, sometimes they make it feel like they're falling. They'll complain about that. So you really have to put on a sell job with the equipment manager and the medical team to say, you know, this is one method of of wearing good protective equipment that's going to help you like the cutproof apparel that we see now. So it is a tough sell. I know some teams tried to make it mandatory. I don't believe that the PA allows for that to happen any longer. But you do have players that are logical and and will take the extra step to have it on. What? One thing that always kind of made me chuckle is we mandated our AHL club foot, shot blockers, then we'd have a player get recalled. And the first thing he would do is toss the shot blockers and never can understand that I'm like, you're doing something right. You just get called up to the AHL. I get obviously it's not hurting your game. You know, actually, I was gonna be my next question, the mandatory component, it is very difficult in the NHL to mandate things. And it takes a long time, Jeff, what do you find in the NCAA? What are you able to do? Are you able to do everything, anything differently with things like shot blockers? Yeah, I mean, it's a lot easier for us to, you know, quote, unquote, control our players, you know, our coach can tell the team, it's mandatory, and it's mandatory, and he'll kick them out of practice if they're not wearing them. And I guess that's kind of gone up and down in terms of, if randomly, we have a rash of foot fractures, then also in the coach will mandate it for practice for a year and a half, and then doesn't seem to care anymore. And, you know, I would say for, if you don't have somebody, and this is more for maybe somebody that's working with high school teams, if you don't have somebody that can help you with custom shot blockers, those ones that you get over the counter, aren't very well formed to the boot. And you know, as Jim said, they can clip the ice when you're when you're taking corners. And I've seen guys, you know, tried wearing some of those over the counter type stuff, and it knocks their, their, you know, skates right out from underneath them and flying into the boards and hitting other players, and it's kind of nasty out there. Awesome. Okay, we'll go to our last case here. So this is a 17 year old elite hockey player, her foot has been very sore, and the pain is approaching a 10 out of 10 points to the dorsum of the ankle. And you can see the area of redness there in the picture. So how can we help this athlete get through the rest of the season? Jeff, do you want to start start with this one? What's going on? Yeah, sure. So, you know, lace bite is kind of a poor catch all term, like shin splints, where it could, you know, mean a number of different things. So I think it's important first to get the right diagnosis and see if it's a tendinopathy, the anterior tip tendon, or a tendosynovitis, or maybe just some other irritation of another structure. So figuring that out first. And then, you know, you want to look at ways that you can reduce that friction that's happening during skating. So the first thing I'll look at is the tongue of the skate. Is it, you know, a really old tongue? Is it a brand new tongue? Do they flop when they skate, meaning that the tongue is outside of the shin pad? That can lead to, you know, a crease kind of forming in the tongue and increasing friction on the front of the ankle there. And then, you know, if it's not a tongue issue, maybe you can look at some padding. There's some decent over-the-counter options with, you know, bunga pads, which is sort of a gel pad. They have these other pads that have a channel cut out of them that you line up so the anterior tip tendon kind of runs through that channel. Those are okay. It's very player, I guess, dependent on whether or not they're willing to have something in their boot like that. You also have to be careful if you're adding, you know, more padding into the area, you could be increasing the pressure. And so it's a little bit of a catch-22. The first thing I'd try even before pads, and it works from time to time, is like a cover roll strip on top of their sock, cover roll being like if you see the football players with the elbow covers, it's just sort of a thin, sticky, I don't know, covering. And then like heel and lace pads with a bunch of skin lube, and you throw that on top of it. And the fact that that lubes it up enough that it takes the friction away from the anterior ankle, and it's minimal extra material in their boot. Yeah, a lot of the same thoughts with that. You know, one thing that we'll do, especially if we're pretty certain it's sort of an anterior tip issue, is, you know, treat it anti-inflammatory, Voltaren on there, Iontophoresis, actually treat the injury versus just masking it, you know, with whatever protection in the skate. But to get them by in the skate, everything from bungas to heel and lace pads. Typically, we tend to see it when the tongues are starting to break down. So whether the player ends up getting a new skate or our equipment managers change out the tongue, that usually can make a difference as well. We've tried, you know, obviously many different types of padding and, you know, but the one thing that I will say is the thicker is not always better. As Jeff said, that typically tends to make it worse. So if any type of thinner protection you can get is truly the most beneficial. Ramer, I'm gonna modify it a bit. I know you're gonna have a special sauce for it. But, but, you know, so do you see this? Two questions. Do you see this in newer skates when people are breaking in skates? Why do people go for a long period of time and then all of a sudden get this? And then typically, how long does it take to recover? I the the time and and Tommy Jeff can, you know, agree or disagree. But the biggest time that I noticed lace bite hitting my athletes is when they come into training camp, or when they're first starting to really get involved on the ice, usually in August. It's because these guys have been walking around in their flip flops all summer long, and basically no support, no nothing. And then they're basically asking their foot to be jammed into the skate, that, you know, the way skates are made today, they're not the old CCM tack leather skates that I grew up with. So I noticed a lot of it happening then. And it can depend like, the the tongue that the athlete chooses to put in their boot. She might like, you know, a stiffer boot with a thin tongue on them. And and these elite athletes today, they can pick and choose exactly how they want their skate designed. So a thin tongue breaks down quick, boom, they have lace bite, a thick tongue that's older increases and and folds over, boom, lace bite. So there is really no, you know, algorithm to predict when an athlete is going to get it. I the time that I noticed that, like I said, is either a skates really breaking down, or early in the season when they're coming out of their flip flops and time on the beach and time on the golf course. And now it's time to go to work and they're putting their foot back where I think it belongs in a hockey skate. So I actually have players that send me pictures of them sitting on the beach and their hockey skates just to show that they're not wearing their flip flops all the time. So they're just being smart asses is what they're doing. But the only thing that I would add to Tom and and is is just a lacing technique. There's different lacing techniques that you can use to avoid an added amount of pressure over the point over the, you know, the tendons, where you can, if it's lower or higher, they can adjust the way that they lace or skate to avoid either skipping out islet or there is actually a different way that, you know, you double double loop through the islets and then come across. So you can do that anywhere on the boot to avoid, you know, if we do have an ankle or, you know, a contusion on the on the top of the foot, or a lace bite, you can use the laces to your advantage as well.

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