doctors again, so all the dumb orthopedic surgeons can sit down. And Kim Harmer's going to talk about sleep and recovery. This to me is a really interesting concept, and it's really, I think, something also that we didn't talk about yesterday in terms of sports specialization. There was a decent paper that said that the biggest indicator for youth sports injury is before sports specialization was sleep, and that's something that I think sleep medicine is fascinating, and whatever Kim will teach us, because she's much smarter than we are. Thanks. All right, so hopefully y'all got some good sleep last night and are well recovered and ready for this. Let's see here. There we go. There's my disclosures. So as you know, sleep plays a really key role in athletic performances. It's important so people can train, so that they can recover, so that they can perform, and just really to general overall wellness and mental health. There's been an increasing recognition in the importance of sleep from all sorts of different organizations. In this 2019 statement from the International Olympic Committee, there's a big section on sleep, and it talks about looking at several different things when you're considering sleep. That the amount of sleep is sufficient, that there's proper circadian alignment, that there's good overall perceived sleep quality, there's an absence of sleep disorders, and it recommends education, proper assessment and screening, as well as treatment. The NCAA also got in on this game. This paper on sleep came out in 2019 as well, and it really focused on the importance of health or sleep to health performance and mental functioning. It identified a lot of barriers to sleep for athletes, including academic time demands for students, athletic time demands, social time demands, and it defines sleep health as having, again, sufficient duration, timing, the overall quality, and the absence of disorders. The NCAA, that paper came up with five different recommendations. One was to conduct a collegiate athlete time demand survey annually. The purpose of that is unclear, because I can tell you, without surveying anybody, that all our athletes are too busy and do too much. To ensure that consumer sleep technology is compliant with privacy laws, particularly in the student-athlete population, we have problems with coaches. Really, it's sort of like, what were you doing last night? Incorporate sleep screening into the pre-participation physical exam, and then providing athletes and coaches with sleep education. And then, of course, that in the professional athletes space, it's been recognized as a key indicator and effector of performance. So the potential functions of sleep include a lot. We actually don't know why we sleep, but it's been proposed that there's a restorative function where the body restores and repairs itself during sleep. There's a clearance function where the brain waste removal system, sometimes called the lymphatic system, removes waste from the brain. And then also brain plasticity and learning. The prevalence of insufficient sleep is really high. When you measure elite athletes, so professional and Olympic athletes, with actigraphs, which are research-grade sleep trackers, there's an average of 6.5 hours a night of documented sleep, which is less than the recommended seven hours. And almost 40% of elite athletes reported insufficient sleep quality by self-report. And when you talk about the prevalence of poor sleep quality, somewhere between 20 and 50 percent, using sort of the gold standard index, which is the Pittsburgh Sleep Quality Index. The prevalence of actual insomnia, which insomnia is defined as an inability to fall asleep at the desired time or to maintain sleep without excessive wakeness, is somewhere between 13 and 70 percent, with an overall rate of about a quarter of an athlete. And so on a team that can really make a difference in terms of overall performance. The demands of elite sport with training volume, anxiety, jet lag, can all precipitate sleep disturbance. The prevalence of obstructive apnea tends to occur more often in sports where people have large neck masses and muscle masses around their neck. And it's estimated to be about 8% in NCAA athletes and 10% of professional hockey athletes. Sleep can have an impact on the risk of concussion. It's really quite profound. Moderate to severe insomnia in NCAA athletes conferred a 3.13 relative risk for a concussion on people who reported that on their preseason surveys. And it's also a reliable predictor of prolonged post-concussion syndrome. So it can really affect both whether you get a concussion and how you recover from it. And adolescents sleeping less than eight hours a night have almost twice the risk of injury that peers do. So it's bad not to sleep. The standard sleep screening questionnaire that's recommended is the athlete's sleep screening questionnaire. It's the only one that's been validated in athletes. This was developed in part by Winnemessa. And there's a difficulty section on it. And it is these five questions. During the recent past, how many actual hours of sleep did you get in a night? Are you satisfied or dissatisfied with the quality of your sleep? During the recent past, how long is it taking you to fall asleep? Do you have trouble staying asleep? And how often have you needed to use medications to help you sleep? And there's a score for each of those answers. And you come up with a scoring key here. And you're either defined as having no sleep difficulty, mild, moderate, or severe. The recommendations for treatment begins really with educating everybody about sleep. And we'll talk a little bit about education. Monitoring with support from your sort of mental health team, your sports psychologist, and then getting into assessments from sports physicians or assessments, more formal assessments with from sleep medicine professionals. So this is the recommendations for sleep hygiene from the NCAA statement. There are things that make a lot of sense and we all know and our athletes should know. Maintaining a regular sleep schedule, seeking out bright light during the day, keeping the bedroom dark, cool, and comfortable, avoiding caffeine, avoiding consuming excessive food and liquids at night so you don't have to get up and go to the bathroom, not staring at the clock when you're having difficulty sleeping. And it generally avoids recommending naps, although we'll talk about that a little bit. And athletes oftentimes that's been shown to be beneficial. And then using beds for sleep and if you can't sleep to get out of bed. When it comes to monitoring sleep the gold standard is polysomnography. This is really hard to do with athletes. You know to get scheduled for the sleep lab, get the athlete there, and it's an artificial environment when you've got all the things stuck on you. But nonetheless it gives you a good idea of both REM and non-REM sleep and is a gold standard. Other ways to monitor sleep include actigraphy, which again is a research grade sleep monitor. But also there's a lot of wearables out there and the wearables are highly used. The problem with the wearables is that all their algorithms to determine sleep are sort of a proprietary. So there's sort of black box and none of them are validated. There's also these nearables which include you know mats that you sleep on or when you put your phone next to the bed and it tracks movement. All of them try to somehow sort of divide your sleep into the four stages of sleep which include REM sleep and then light sleep and deep sleep. And over the course of a night you'll go through several different cycles of these alternating phases. If you look at some of the commercial wearables that are out there this is the output you get and you get a good idea of the time that you're actually asleep. The one on the left is Fitbit, the one on the right is an Aura ring. And you can see the stages and that's probably not as important as really the total time of sleep. These things can be helpful for some people. They give you a sleep score so that people can sort of get a better objective measure about how they're sleeping. But also people can sort of get hyper focused on this and become anxious about it as well. So you have to sort of figure out who you're actually treating when you're using these things as part of your treatment. If you're taking a sleep history you need to make sure that you ask all these different things including sleep schedule, when you wake up, how much you nap, if you're sleeping well, if people are snoring or have other symptoms of a sleep disorder, if they're using medications including recreational drugs or alcohol, how their mental health is doing. Because a lot of times sleep or particularly sleep initiation can really be tied into underlying anxiety or depression and then their environmental conditions. The gold standard treatment for insomnia is cognitive behavioral therapy and this has been shown in many, many, many studies to have a large effect size for treatment. Cognitive behavioral therapy includes avoidance of daytime napping and then usually what you do is you start with us so you can go to bed at 10 and you can sleep till 6 and creating the sleep debt so that you get into a good sleep patterns. The problem with cognitive behavioral therapy in athletes is that a lot of the things that you're trying to do with that particular treatment don't work very well when you have the schedule of an athlete that you're trying to do. And in fact napping has been shown to be useful in many different professional sports in a viable strategy to help sort of make up for some of the traveling debt that people do and and the lack of sleep that they get because of their schedule. Naps in general should be less than 60 minutes and and then there's all the problems with traveling and jet lag which is another talk. So I'm just gonna end or maybe talk a little bit about we talked about education and education and studies has been shown to be effective but mostly short term and so it doesn't work really well and we work closely with our sports psychologists and our mental health professionals to help with relaxation techniques and mindfulness techniques to help people go to sleep at night. But sometimes it just doesn't work and people need to sleep and so I want to talk a little bit about pharmacological treatment. And so when you're treating somebody who can't sleep you need to think about whether they have trouble falling asleep, whether they have trouble staying asleep, or both. There's four classes of medication that are approved to sleep sleep disorders or insomnia. That's a benzodiazepine receptor antagonist which includes both the non-benzodiazepine ones and then the benzodiazepine hypnotics. In general sleep society recommendations don't recommend using the benzodiazepine ones because of addictive potential. The non-benzodiazepine benzodiazepine receptor antagonists have a low addictive potential but it's still present. And then there's other classes including the Doras, Doxepin which is a histamine receptor antagonist and Rameltion which is a melatonin receptor antagonist. So it's very similar to over-the-counter melatonin. And the key here when you're thinking about this is really to look at the half-life over here. And so if you have somebody that has trouble falling asleep you're going to want to use something that has a relatively quick onset. If you have trouble with somebody who's trying to stay asleep then you want to make sure that the half-life lasts long enough so that they can stay asleep. And then you need them to wake up and be alert in the morning. And so this half-life is really sort of the key when you're deciding how you want to treat. Now some things with a 17 to 19 hour half-life an athlete may take it and have no morning time sleepiness and others it'll just they'll just be dead the next morning. But you can make adjustments on your medication based on the half-life. So this I find is a helpful chart when I'm thinking after I take the sleep history what to potentially treat with. Medications should be considered a short-term treatment. All the other things that we talked about the mindfulness, the relaxation techniques, medications are not going to cure sleep disorder and so they should be used sort of as an aid either for short-term sort of situational insomnia or to help somebody understand that they actually can go to sleep and get over some actual sleep anxiety. The other things that I want to talk about is sort of the off-label use of sleep medications. These are not recommended by sleep societies and primarily because there's not a lot of good studies in these particularly for sleep. Trazodone is a common one. It's an older antidepressant that is used in doses that are much much lower than you use for depression and so it shouldn't be thought of as a way to sort of sneak in a depression treatment on somebody who's not thinking. But it doesn't have an addictive potential. It has a relatively short half-life so most people aren't super sleepy in the morning when this take it. And it doesn't have that addictive potential so for some people this can be a really good option. Amitriptyline has a longer half-life and that can, again it's used in doses that are significantly less than you would use in depression if anybody uses this for depression anymore. But oftentimes people can have morning sleepiness with this in a dry mouth. One that people don't think about very much but I actually use quite frequently is cyclobenzaprine which is also the brand name is Flexeril. That is actually a tricyclic antidepressant. It's in terms of its chemical structure. It is one hydroxyl group different than amitriptyline so it's essentially a cousin of amitriptyline. People when they when you give them amitriptyline or Trazodone they go to the internet and they look it up and they're like I'm not taking antidepressant. And when they look up cyclobenzaprine they said that's a muscle relaxant that makes sense to me. And so sometimes you get sort of less resistance in terms of taking this. I like again this because it improves the sleep architecture. It puts people into that deep sleep the stage four sleep and it's non-addictive. Gabapentin can be helpful in some people particularly people that might have addiction issues either a dose of 100 milligrams or 300 milligrams. Again some people have problems with morning sleepiness with this some don't. And then there's antihistamines and melatonin. The thing I think that is probably causing you probably get the most questions about is cannabis. Cannabis has can improve sleep onset however it disrupts sleep architecture and so it's a little bit like alcohol in terms of it can help you go to sleep but then it makes you you don't get good quality sleep and you feel a little tired in the morning which may be why I'm feeling a little tired right now. The other thing that people really you're probably getting a lot of questions about our CBD and so the certainly the internet podcast world is very hot on CBD. The actual research on the use of CBD for sleep is mixed and so the concern is that like cannabis that it improves sort of sleep onset but it can disrupt sleep quality and so I think that the jury is still out on that and so the other thing to think about with cannabis particularly in the NHL is or not cannabis but CBD is that you can't take it across the border and so if your players are using it they need to be aware that that that is illegal to take across the border and may cause a problem. NHL teams can also not supply it even if it's certified. So that's all I've got on sleep and so you should explore sort of the behavioral aspects of it but you know if you need to medication can be helpful. Thanks. Thank you so much Kim. Usually our sleep people would shame us for what we did last night but that's Kim joined the team. So now I have my partner in crime with the Rangers Ryan Linger who's going to talk about infection and thank you Ryan for joining us. All right thanks you know my pleasure to be here. So yeah I guess I do have one disclosure about infectious disease. I hate infectious disease. In team sports I think the best we can do with it is you know to get a par like nobody's coming up to the athletic trainer nobody's come up to the doctor said great job doc you really prevented that infection from spreading into anybody else. It just doesn't happen and and with having you know coaches and managers and a spouse or worse even parents and then maybe a performance doc or performance personnel who has an opinion and maybe ownership you know like I said best we can get as a par and more likely a double bogey. I guess my second disclosure is I'm colorblind and so I can't see a subtle rash real well I can't tell erythema on tonsils too well so you know I don't know what the hell I'm doing up here but after 15 minutes of going through this you might be asking the same thing. So when Anil asked me to do this talk obviously the biggest the hardest thing was going to be to how to focus this talk and so I'm just gonna go pretty high-level overview and these are the things that we talk about that come up every year with us working with the athletes and I'm not these are you know not we're not hitting any of these just a couple that a couple skin things that that are kind of hard to differentiate or a little you know we have to decipher between. So first off tinea versicolor so this is you know anybody's skin if you ever smell the hockey bag you can tell that we all have bacteria and fungus that sit on our skin and that's normal. When these the overgrowth of a fungus in this case Malastasia comes up you get hypopigmented or hyperpigmented macules on the skin and this is not really an infection into the skin but it's a it's just more of an overgrowth and this is to differentiate from pittosporum folliculitis so the same yeast which is the Malastasia if that infects the hair follicles then you get the folliculitis and this is more of a pimples that come up that are pretty uniform in size on upper trunk and shoulders. Now if the sweat glands get clogged just from from sweat this is not from fungus or yeast you can get malaria which is a common infection a heat rash that infects both babies if you remember that and as well as adults and so this is something that comes up when sleeping wake up with from hot in hot conditions or hot sheets but this is not an infection just a common condition that we might see. And the treatment for these things you know the very typical first stuff is just keeping the skin cool dry wear loose more comfortable fitting clothing that promotes airflow trying to perhaps you know change out a workout shirt whether it's in between periods or if they're going from wet to dry you know on ice to off ice that they're changing their clothing can help with that and you could use anti medications like a calamine lotion or cortisone or Benadryl cream. As far as for pittorice's versicolor or tinea versicolor this is something you could use a something basic like selenium sulfide shampoo which is found in selsin blue works very well you could go to a prescription ketoconazole 2% shampoo and if it's more diffuse or just not relenting then you'd go to an oral medication. In contrast to pittorice porum folliculitis you have the follicles that are infected then you want to go to both a topical as well as an oral medication of the fluconazole where you take that fluconazole daily for one to three weeks. If it's not getting better, then you might go to Accutane for treatment, but there can be side effects with that. One thing to note on these things is antibiotics, typically for fungal or viral etiology, if you give antibiotics and they seem to get worse, then you're probably on the wrong track because you're killing off some of the normal flora that's on your skin and you're allowing the fungus to become even more. With the heat rash specifically, gentle exfoliation can be helpful, but emphasis on the gentle and may consider a topical antibiotic. Another common skin issue that comes up in hockey players is just differentiated. These two things are not the same etiology, and you can see the left side, so that's truly inflammatory, and you'll be able to see these, they're not real tender to the touch, they'll have that golf ball type appearance, and they can freely move their elbow. And this you would treat with trying to remove the friction bunga pad. Don't stick a needle in these, especially in a hockey player, because they're going right back into the elbow pad and you could turn what's on the left side to the right side. So the right side was the septic oligonucleotide. It's more diffuse, it's exquisitely tender to the touch, but when you recognize it in the training room, kind of note the difference from that discreet swelling to the more diffuse swelling in erythema. So in the setting of teams and being around each other, viral sore throat and pharyngitis is extremely common, so this can fall into any category of laryngitis, bronchitis, most of these, the viral ages are the most common cause. And the key here is trying to rule out something that's more, perhaps more significant. And from a bacterial standpoint, that'd be like a strep throat. And the treatment with trying to identify why strep throat is to prevent the contagion, to decrease the risk of rheumatic fever. And so oftentimes I'll ask my trainer about these things. So centaur criteria, this is what you can use to help guide whether testing and treatment. And so if somebody has a fever, they have tender lymphadenopathy. If they have a tonsillar exudate, and if they lack cough, and then it's more likely to be strep throat and then you'd either test or presumptively treat with penicillin for 10 days. Other, there are other things that can cause the white spots in the back of the tonsils. So it's not the only thing, but something to pay attention to. Or now is it something more systemic like flu, COVID? So something that we do every year is talk about the flu vaccine and the effectiveness of the flu vaccine and how much does it help? Well, it's not 100% and it fluctuates every year to some degree. And you can see at the bottom of last year's, the flu vaccine was 42% effective at preventing a subsequent positive test for flu. Flu vaccine also lessens the risk of inpatient hospitalization for flu. So even if you get the flu vaccine and you do get the flu later on, it can help decrease your symptoms. And I know nobody wants to hear about it, but do we do a COVID booster or not? So this is put out by the CDC and they looked at people who had, who were either unvaccinated originally or got the Moderna vaccine. And then they compared those two who got an updated dose of the vaccine and how they, if they tested positive. So those who were unvaccinated originally, 36% of those patients tested positive. Patients who got the booster, they tested positive within the first two months, 18% of the time, if they're vaccinated, if they got a booster within four months, 27% of the time they tested positive. So they found that getting a booster vaccine was 58% effective within the first four months, but the vaccine efficacy wanes as time goes on. And keep in mind that with patients, with people's somewhat resistance to vaccination, that some of the lesser known or lesser, less common things are becoming more common. And there's been two recent outbreaks in recent history for mumps. And so typically this is their most contagious a couple of days before they start to develop symptoms. And this can be a big problem. And it's complications, even though rare can be severe. So this could typically keep somebody out for about two weeks. So is this something that we should be testing for? Well, the CDC recommends for things like varicella, hepatitis B and C to test one time as an adult. And they recommend for MMR that it's not needed unless there's an outbreak that's present. But some would advocate for testing and boosting vaccines prior to an outbreak occurring. And this is quite frankly, this is what we do with the rangers. I test anybody that's new on the team and do fine. So we test probably like six people that are new and probably vaccinate off the vaccination doll and probably get three or four every year. Now I'm not saying that's right or wrong, but that's how we handle it. GI illnesses is another frequent call that we get from the trainer. And most of these are viral in etiology, lasting a couple of days. And you may give symptomatic care for them. Most often not typically bacterial in the early setting. If they're traveling overseas, then the bacterial etiology can be prevalent about 80 to 90% of people. Fairly easily treated with antibiotic, but be cautious with traveler's diarrhea. Treatment with azithromycin can prolong the QT interval. If you're also giving somebody Zofran to reduce their nausea, that would also prolong their QT. So you'd wanna go to a different option like rifaxamine, which is macrolide, which may have more of a role. And in this case in Cipro, which is a fluoroquinolone, you wanna, that can have side effects on tendons and generally try to avoid that with athletes. The big question of when to obtain a stool sample, really if you're having any blood at any time in your stools or if you have symptoms that just aren't getting better. So again, being able to recognize when is this common occurring thing, something that could lead to something with bigger consequences. Well, this wouldn't be a talk about hockey and infection unless we talk about STDs. So this is a common call from the trainer that we get that player made a bad decision. And then we're talking to the player about, are you having any symptoms first of off? And is it something, do you wanna be tested or how worried are you? And so after discussion, if you have the concern of chlamydia or you have symptoms, then you should also think about Guyon-Urea and treating them together, trying to treat the partner. Typically, if a guy is worried and he's on his mind, I will throw him a gram of azithromycin for him not to worry about it. If he has any symptoms, then I'm also treating for both. And then sometimes we'll test beforehand, depends on the situation. And yeah, I'll leave that alone. In the team setting, especially in professional sports, doesn't really lend itself to excellent antibiotic stewardship. I think probiotics is a way we can make up for that in some ways. So a lot of guys will be on probiotics regularly as a supplement, and this can help reduce the risk for certain infectious diseases and subsequent need for antibiotics. And these are the strains that do survive the trip through the gut. And if ever I give a guy with two antibiotics, so for the oligonucleotides, the septic oligonucleotides, you should be hitting them with two antibiotics. My favorite or go-to would be Cefadroxyl, which is a third generation cephalosporin for the strep coverage, and then Bactrim for the staph coverage. And I'd hit them both twice a day for 10 days. If I'm ever giving anybody an antibiotic, or two antibiotics, or one antibiotic for a longer period of time, then I'm making sure that they're on a probiotic to try to minimize any risk or side effects. And finally, whenever you give any medication, knowing is it safe to use both in the side effect profile, and then is it also allowable for the rules. So two sources that we look at quite frequently, the NHL puts out the prohibited substance list every year, and they update it. And Global DRO is another excellent source for sports of any sort. You can put in your profession, this country you're in, what sport, and they'll give you whether you can use it or not. So the biggest take home with this, these are challenging. And the biggest challenge is just recognizing when this common thing can be something more serious. Athletes are gonna ask you about, when do we vaccine, and every time a new booster comes out, they're gonna ask you about COVID. So be aware of that, knowing when to consider a stool sample. And we have done that a little bit more frequently. Unfortunately, this year with some of the oversight, even when it's not indicated, but know the true indications when you should get a stool sample. And always be aware of the safety and legality of using supplements and medications. That's it. So, I'm going to invite the panel up, that was an excellent talk, thank you. It just shows you how, you know, there's an old line, it takes a village to raise a child, it takes a village to help a hockey team, and you need a lot of brains from different perspectives. So Darren's up, Ryan, Kim, Eric, so my one disclosure here is that I am, I don't, I mean I do biologics in the OR, I don't do biologics in the clinic, I give all my biologics to Ryan, so I'm certainly no PRP scientist, actually I'm more of a BMAC scientist, but I'm framing this not just about biologics, but it's also about indications. When do we do, because we, you know, I always said to, the difference between Batman and Superman, Superman had magic powers, Batman just had a belt, that's how I train our residents and fellows, and our belt's this, it's conservative, injections, and surgery, that's all, that's the belt that we always talk about, and so all these cases are going to be like how we, you know, whether I'm using the grappling hook, or the little gun he had, or whatever Batman had in that special belt, that's how I want to approach this session. So we're going to do some case-based, so 31-year-old defenseman, degenerative lateral meniscus tear, had persistent effusions, we gave him a cortisone shot early in the season, then we gave him an AHA shot a few months later, has an MRI showing degenerative lateral meniscus tear, midway through the season, I'll just go down the list, Ryan, you know, what are we going to do? Yeah, I think part of it depends on how do you respond to those previous injections, obviously you don't want to overuse cortisone, and repetitive AHA can have some inflammatory response as well. I think PRP is a reasonable option here, in the setting of somebody who's inflamed or irritated, PRP can be an anti-inflammatory, if somebody doesn't have a lot of inflammation, PRP can actually be pro-inflammatory, which may be something that you want in a healing response, but I think in settling down this knee, I think a PRP would be a reasonable option to try, typically we would try a leukocyte-poor PRP in this sort of situation, but it may not be so simple as that. Leukocyte-poor because it's intra-articular versus leukocyte-rich for tendon, that's the only thing I know about PRP. Darren, what's your approach? Just in the fusion, you went two shots, he's midway through the season, he's playing, he's just saying after every game, you've got a big swollen knee. Yeah, I don't think I'd change much. I think the one thing, corticosteroid, I'd try once, I'd probably try AHA more than once, depending on the reaction, especially if there's a chondral lesion, and then sometimes we'll combine the AHA and PRP, maybe on the second injection. Other than that, I wouldn't have a lot. For the meniscal pathology, if we think that is the pain generator, I mean, I would just do an intra-articular. I know there's some papers of actually doing with ultrasound into the actual meniscus, but I wouldn't do that. That would be my approach. Before we get to Eric, Kim, what's your approach here? What do you want to inject, not inject? What's your thoughts? It's the effusion that he's, it's not so much pain, it's the effusion that he doesn't like, the tight knee. Well, I think if the effusion is his primary problem, considering PRP is a great idea, I would go as well with a leukocyte-poor PRP, make sure that I drain the knee if there's an effusion. And then also, in these situations, a lot of times there's just a power to just, a therapeutic power just to doing something versus saying, sorry, dude, there's nothing we can do. So sometimes just doing something can make people feel better. So Eric, he comes to you and he says, so the third shot's going to work, Doc? And when do you bite the bullet and say, you know, it's a small surgery, should we just operate him now so we can get him all ready to go for the playoffs? What's your? I would do everything that's been said, for sure, give it a chance, and he can be the one to say, hey, I'm sick of these injections, is there anything else we can do? And there's some utility to just going in there and flushing out. There's probably some debris, there's probably some little particles, and doing a little flushing out, and it may not even really be the meniscus. And so I think there is some utility in that, and let it calm down, you're midway through the season, you've got time, you can always do injections later if need be, but I would have done everything that everybody else has said. So this was early in our, we did another cortisone shot because we thought it was going to be the most anti-inflammatory, that's something that I'm proud of. And he struggled the whole year, and we scoped him at the end of the year, and he was like perfect in three weeks. So in retrospect, this was one of the ones, we would have tried PRP probably now, which we didn't do it as much, and I don't know the answer, but I probably would have pushed him to an earlier scope. Eric, if you're scoping this need, do you ever add a biologic at the time of a scope, or it's a degenerative, this is not a 25-year-old, this is a 37-year-old at the end of his beat-up knee? So usually not, typically not, and I don't do a cortisone shot. I think you do that, there's a little bit of down of the immune system, a little bit down, higher risk of infection, then you don't know how much the scope helped, so I don't do that. You could always do that later if you need to, cortisone, but then PRP, it would be what I would do if we wanted to do something, and I usually let things settle down, and maybe a week or two later, if even doing that. Yeah, I mean, I think cortisone at the time of surgery is pretty much a dead thing now for all joints, where we all did it at one point, and now no one does that. Dharmesh, Brad, do you ever, Joel, do you ever add a biologic at the time of surgery for a failing knee? It's becoming more and more in vogue. I think we probably do what Eric would do, we'd probably wait four weeks after a scope or six weeks, and as you start advancing his activity, if he pops into fusion again, then we'd probably use HA or PRP. So there is some growing evidence about repetitive PRP, initially it was thought one injection, two injections, it doesn't make a difference. Now some more recent studies seem to suggest that multiple intra-articular PRP injections may be more effective. What's your experience? Well, I think the best evidence for that is in the hip joint, where there is a series that showed that three intra-articular injections for degenerative changes in pain. So I mean, I'd use that same approach. I think, you know, in a lot of the football players more, we'll see the patella articular surface and that's beat up, and I definitely would do that, although I find it doesn't help as much in patellofemoral way. But yeah, I would go to the three PRP approach based on the hip data. The other thing about PRP in a joint, especially a knee joint, big joint, you don't get that a pain effect, where a lot, you know, we could talk about PRP for tendon, PRP hip joint can still cause pain. It's really, you know, PRP in the knee is very forgiving. So that's the one thing, because some, a lot of athletes now say, I don't want PRP, that's the one that hurts, right, Doc? I want the one that makes me feel better, that's all they know. But PRP in the knee to me is a pretty safe thing. Joel, you have a comment? Yeah. I've been around this for a little while and not only, as they say, not only a user, but a patient at the same time, and it's my feeling that, you know, we use cortisone for a long time for a lot of different things. Cortisone really does do a good job when you have an effusion and you want to take that effusion away. It's pretty dramatic. The key though, at least in my experience, is that sometimes I call it drying the joint out. It will dry the joint out and then whatever pathology is there actually hurts more. So it's not uncommon for people to come back and say, my knee hurts more. But then you add, whether it's a HA or PRP, and now things start to turn the corner. If a patient continues to have, or a player continues to have an effusion, that to me is a trigger for arthroscopic intervention, and whether you're washing it out or whether you're just cleaning up debris or whatever you're going to do, but a persistent effusion after a cortisone injection is something that makes me go to the next one. That's exactly what I learned in this case. I wish I outran this guy earlier. Dharmesh? I agree with Joel completely. For these players, these are difficult to treat, and PRP seldom works for these recurrent effusions. So what we do is we aspirate the effusion, inject cortisone, and then one week later chase that with a HA injection. You're right. It dries the joint out, and then the pain starts again from the cartilage pathology. Or you do them both. I mean, actually, it's interesting. In the U.S., there's no combi cortisone HA, but in Canada, there is a, whatever, I don't know, FDA of Canada, what is it? Sengel. Yeah, yeah, yeah, which they're trying to get approved in the U.S., which is just kind of interesting. To get back to your question about one versus three, Brad, I think a lot of the literature that looks at one versus three, particularly in the knee, is looking at ACP. So autologous condition plasma, which is a really, really, like, low platelet count PRP. And so I think you have to be careful when you interpret that because there's so many different variables that make all this biologic research difficult to interpret. But you know, if people don't respond to one, they're probably not going to respond to three. If they respond somewhat to one, but not all the way, then it's probably worth chasing it. And it's also my experience that the hip needs more than one, usually, but that's the lowest level of evidence, which would be anecdotal experience. The one thing I do for all my degenerative knee scopes is I actually now add BMAC, and we have an RCT right now going on in HSS because that to me is time zero. It's a natural. We've injected everything post-operatively into the knee, right? We had cortisone, cortisone, bad infection, marticane, lidocaine, oh, chondrotoxic. Then everyone said Toradol. Toradol is the key, right, right? And then now I think, you know, you can get arrested if you look, if you spell Toradol. So, I've gone to their own biology and there's a lot of data on BMA or BMAC, whether you concentrate or not, and I do it for all my adrenaline scopes down. We have an RCT, but that's, that's, I think it's a, it's a, there's more data to become on that. And you do it at the same time? Yeah. And where do you, and where do you get it from? The iliac crest. Posterior? No, anterior, because they're supine. It's very simple to do. Yes. I haven't done it yet, but I would do it in a heartbeat. Like, you know, I would do, I would do it on this guy. I mean, it doesn't, there's no morbidity. There's no nothing. The data is real. And I say I'm putting stem cells in her knee, and they're all like, yeah. They all love it. They don't complain about? No, there's no donor site pain. No, it's just, it's just, it's like a, it's a 16-gauge needle. It's a small little needle. Yeah, I think that, you know, intra-op is sort of one thing. It seems like most of the randomized controlled studies that are looking at BMAC or MFAT for NeoA show that it doesn't really work that much better than PRP. And I think in some people it actually does. So, picking out the right patient is important, but, and sometimes it's just going to the next best thing, because there's no other options, but just make sure to bring everybody's attention to the fact that that's what the literature in NeoA is sort of saying right now, and that may change over time. And that literature is 10 to 1. There's 10 to 1 PRP studies to BMAC studies for knee and hip OA, but it's emerging. It's another tool, and it's another tool in the armatarium, in the ward chest. So it's like Batman got one more thing on his belt. But I don't, to your point, it's pretty equivalent, and we don't have enough data there. So, okay, right wing FAI label tear, decreases performance. Begin the year we gave him a cortisone shot, which I, you know, I try to wait as long as I can, but we did. He's got early OA. Same thing, affecting his performance. Ryan, start with you. What do you do? I don't think, you know, is the hip, you know, how is the hip different from the knees, is really what we're saying. I don't think, yeah, I agree. I don't think repeating the cortisone at this time, unless you need to in playoffs. I think you could try HA, and PRP, I think, would have a role as well. I think the risk around the hip is with HO. I would be a little bit less concerned about HO intra-articularly, as opposed to extra-articularly. So, I think it's reasonable, but just with appropriate counseling. Darren, you were just saying about PRP in the hip. Yeah, I mean, I wouldn't, I would go with HA, and I mean, you know, clinical exam is so important. You know, when are people having the pain? Is it just a general ache, or is it actually with skating, without skating? But, I would do HA, and honestly, I mean, we could try PRP, but in the end, if this is FAI, it's FAI. So, basically, what I'd be doing with the first hysteria that you've already done, the HA and PRP, is trying to see if kind of the pain from the chondral area is, we can help to get them through the season. Eric, Kim, anything else? Yeah, I would do HA and PRP, same time. You know, give them both You know, there's some literature that suggests that's a good combo, and I would try it. You know, you're really just trying to get through the season, because you're probably, they're going to need something at the end, if they can make it. Yeah, I don't think PRP works very well for labral tears, either in the hip or the shoulder. So, you'd be treating the other pathology that's there, and if I was going to stick something in there, I would probably combine the HA and PRP, and just see if anything worked. Yeah, I mean, my gestalt now is that I don't like PRP in the hip. I don't have a good experience with it. I really like HA in the hip, and I've never seen, like, an HA reaction in the hip. Like, you know, you can't see in the knee. But, since we're a hockey meeting, we gave him another corazon shot. Did not work that well, and we did a hip, we scoped his hip at the end of the season. And actually, here, there is data to show that every hip scope now, we put BMAC in every hip scope, and there's, we have a paper we published, and there's two other papers showing increasing, you know, PROMS. It's not the best science, but we use BMAC. Eric, what's the role of adipose in the professional athlete? Eric, Darren, Kim, everybody. You know, I mean, that's a really good question that we still really don't know, you know, there's not enough data, and I think there may be some. I'm not convinced yet. I'd like to see more. I think I like the idea of the BMAC. Now, let me ask you this, you know, what data do you have on that that's helping the hip scope? I mean, you're getting data? No, no, no, we have, there's Scott Martin published a paper in JB Jess, and we have a paper in Arthroscopy. What's it cost? What? It's, I mean, depending on your thing, but it's like $300. Is that HSS cost, or is it? That's HSS cost. $1,000 for you. We bring in the mobsters to get our prices down. What do you charge? $3,000? $4,000? No, no, no, no, no, I don't, we don't charge the patient. Not HSS cost, either, or charge, no? No, I mean, if anything, adding, sometimes adding a biologic, you know, if you're not talking about the professional athlete, well, can drive your business in volume, because people are like, oh, I'm on the fence of having a procedure, and they want to do it, but that's a different conversation. Anybody else on adipose, Kim? What's your thoughts on that? It is unclear to me what the role of adipose is right now. Anything? Well, you know, is it, I don't even know, is it, what's adipose in Canada? Yeah, so basically, BMAC and adipose, any stem cells, was shut down by Health Canada about three to four years ago, because they felt that, you know, they weren't too concerned about, you know, in the arthritis world, but then there were clinics charging $5,000, $9,000, and then there were people doing IV, saying it would, you know, help strokes and cerebral palsy, so Health Canada doesn't let us do it. We're, we're, my clinic is probably going to be part of a trial that they will allow us for research purposes, but that's been a year and a half of meeting with them, so I don't have the, the personal experience with it. Ryan, anything to add on adipose? I agree the same on the adipose. Just one point on the second injection for anything, you know, especially with the hip, I think if they had a good but temporary response to the first one, just to convince you that you're on the right track, because I think the hip, the sensitivity of an intra-articular hip injection is very high, so patients should, they should have felt some relief, and if they didn't, then be looking for one of the other things around the hip. Yeah, I felt uncomfortable giving this, because I've seen a lot of chondrolysis in the hip, in high-level athletes, professional athletes, who've gotten three injections in a year, so it's something that it, the hip is, you know, you can abuse a knee with cortisone, and, you know, a hip can go down south with too much cortisone, so I would, I'm saying this because, you know, I'm... Also AVN. Yeah, yeah, yeah, yeah, yeah, it's more chondrolysis, but whatever you want to call it, it's something that you should be cautious. The hip's a different animal, and so, although I'm saying we did it here, I would not recommend, I would not recommend it. No, no, no, I will, no, I will say the hip, you're allowed one shot of cortisone, but, but it's in the hip, but it's, it's one shot. It's not, multiple cortisones on the hip is bad. You got, you don't do adipose at all? No, I don't believe in adipose. It's like... HSS could, you know, charge for liposuction too, at the same time. No, and when I got trained on it, I was just like, this seems to be, the guys at Duke do a lot of it, T-Mormon does a lot, a lot of my friends, you know, are believers in it, and high-level athletes, but I have, I've gone to the BMAC over adipose. I think most people that are using the adipose are using it as a filler, so using it in sort of chronic tendinopathy and, and, and places where there's, where you need something to, to, to stick some, some substance into things. So this is a pretty similar case to what Dormer said. So we got a 26-year-old defenseman, grade two MCL tear off the, off the tibia, was out for, you know, about a month. He still, still wore a brace, but he had a recurrent injury. We did nothing from the get-go. Would you, so first of all, Ryan, would we, would you ever do PRP from the get-go? Because it seemed like Dormesh, you did it from the get-go, right? He did early, early PRP for a grade two MCL off the tibia, which is, yeah, yeah, yeah, yeah, yeah, yeah, not like as in failed conservative management. So early, early in the process, would you do PRP? I think there could be a role for PRP on the tibia. Again, being warning signs to about heterotopic ossification, but I think it's a reasonable thing to do in this setting. Dormesh, would you, would you ever do early PRP? Yeah, I, I mean, you know, I would discuss with our, our, our knee surgeon and, you know, typically if there isn't any retraction of, of the tendon, they would, they would actually encourage me to do PRP in that area. So that's, that's how we do it with the distals. And I, you know, definitely see more distal MCLs in, in hockey than, than other sports. Eric, what about you? Would you? Yeah, I do PRP here. It's not a routine, but, but it's always a discussion and sometimes the players ask, sometimes the agents ask and I'm all for it. But I, I don't routinely do it, but I don't have any problem doing it either. You know, now, now this is a different situation. Now you said that the initial, this is four to six weeks later. No, I'm saying both. Four to six weeks later. Early versus late. Four to six weeks later, I think, yeah, for sure, I would do it because you've already tried something. I'm not going to go to surgery for grade two. We need to try something. Now PRP can be very, it can be painful and, and sometimes consider PPP, you know, that may give you some benefit, but without that pain as well. And we've seen some benefit for, for some tendon issues using that, although this is more ligament. Kim, what's your, what's your thoughts? Early, early MCL tibia. I think it's, it's worth a try. You know, there's not a lot of downside to it. I would also like that picture bothers me because there's no ultrasound there. And I think that when ultrasound connected to particularly when you're using a biologic, you know, if you use cortisone, you can just put it in the general vicinity and you'll get, you'll, you'll, there's some forgiveness to it, but with biologics, you need to be pretty accurate. And so I would hesitate to do it without ultrasound. Yeah. Certainly an extra, I mean, I think Bill brought a great point up that, that, you know, we now have transitioned us gray hairs to, you know, much more ultrasound. Ryan does a lot of ultrasound for our team. So I think that's, that's definitely the role. Okay. So it's now four to six weeks later, he had another, another event still has pain. So is this a guaranteed PRP to the tibia, Ryan? So he, he failed now he's going from the acute phase. We didn't treat him to the chronic phase. What do you want to do? Did the PRP help him? What? No, he didn't. We didn't give him PRP. I think there would be a role if he's, if he's still limited. He's playing. He just hurts. I think it could. I would say just a brief point as Eric just mentioned about the PRP being causing more pain. Early in my practice, I feel like you have this PRP, you want to use all the good stuff. And I think I probably caused a lot of people post procedural pain unnecessarily. And then, you know, past several years, less and less get it to the focal spot with ultrasound and literally using, you know, maybe a half a CC, three quarters of a CC at times in certain pathologies of the rotator cuff or MCL. And patients seem to do a lot better with it and with less pain. So that's a good question. Let everyone give me your volume. What's for an extra articular injection of PRP during how much do you, how much volume are you giving? Yeah, I'm probably somewhere around three CCs or so. I mean, I think intraarticular obviously is more. But I think in this case, the other thing I find with PRP is you can get, and probably the therapist can attest to this, is you do get, you can feel in a lot of cases, a lot of scar tissue developing in those areas. And that could be part of the reason this person has pain. So I'd ensure that, you know, at that point in time, I think you said six weeks that the player's playing, if there's any manual therapy or anything we can do in that area before going to injection. So I think that's another thing that I find. I usually find it in the proximal PR or proximal MCL injuries in the distal. But I think that's something to consider. Kim, anything to add? When you put a needle into sort of a defect, you can feel when it's full, right? So it depends sort of how much I use, like when it starts to feel full. And then sometimes because I... It's of your resistance, you're basically... Yeah, and when you start to try and put liquid into a solid thing, and you're having to push, the harder you have to push, the more it hurts the patient. And so sometimes because you also do get to like, oh, I don't want to waste this stuff. So sometimes I'll put some in the defect, and if I have some leftover, I'll kind of put it around. But I was wondering, in NHL teams, there are a lot of people using Shockwave, because we've really been using that a lot, and had a lot of great... Being able to keep people playing and participating with that. Which Shockwave are you using? Radial and focused. Okay. No, we do not, but I know Kevin Wilk, the PT guru, he really believes in it. I don't know if the therapist, T, or Tom, what... Everyone uses ultrasound, but not all ultrasound is create equal ultrasound for Shockwave ultrasound. It's really depending on the voltage. There's low dose, and there's extracorporeal Shockwave therapy that's really... That hurts them. So I'm talking extracorporeal Shockwave therapy. So, I don't know. T, what's your thoughts on ultrasound for tendinopathy, and what spectrum of the voltage are you thinking? Well, my first thought is that we'll use the therapeutic ultrasound for heating up the tissue area. And then, of course, depending on if it's superficially deep, which parameters we decide. And then second of all would be also for any secret sauce that Rammer brings to the table that we want to... Like a Voltaren glygel or something like that, that we'd want to use. So that's sort of my first thought on the ultrasound. So I'd say most training room ultrasound are lower voltage, and you get just that effect. The neovascularization, the revascularization is really based on extracorporeal Shockwave therapy, which is much more higher voltage. They're much more expensive machines. The foot and ankle guys love them. I mean, this is how they're treating a lot of plantar fasciitis, Achilles tendonitis, a lot of... So, I mean, there's a lot more... I mean, we have one with our football team as a modality. But I mean, I think in hockey, I don't know if we see enough of those chronic tendinopathies. And if so, we'd kind of send them to a clinic that has it. But for our football team in Edmonton, we actually have extracorporeal Shockwave. Yeah, and it's used a lot. I've used it for myself and it works, but it definitely hurts. There's no doubt. I mean, it hurts. So we talked about the femur and tibia already once before. So last case, we kind of talked about this. Let's just quickly go down the list. You know, you got a midseason sports tourney guy, Ryan. Are you going to inject and what are you going to inject? This is his first, has not had an injection yet. Yeah, I think as you stated in the slide there, I think cortisone to try to sell it down first to get him to play would be the first option. I'd be much more hesitant and reluctant to do PRP as a few papers come out with significant incidence of HO, of extra articular PRP around the hip. So I'd be cautious on using that. You, do you guys inject cortisone? Yeah. So basically, you know, clinical exam again, I mean, I think in most of these and whether it's the imbalance of the adductor and the rectus and the insertion around the aponeurotic plate, but a lot of them have pubic symphysis pain. So I'll do an image guided. I'll usually do my pubic symphysis under fluoro guidance. So I can see the contrast go in because sometimes the, you know, the articular disc in there is quite big. So you've got to fiddle around a little more. And I find that, you know, in most people that takes away a big chunk of their pain. And then the question is, can we more effectively rehab after that? I still, if we do that and there's persistent, you know, aponeurotic pain, whether it's rectus or adductor, sometimes we'll just go with some fenestration around that area with local anesthetic due to some of the HO risks, but definitely have done PRP, but this would be in a situation, you know, shoot up and the person goes right away in the context of, we're going to shut you down. And, and that's kind of some of the stages we'd go through depending on the clinical scenarios. Yeah, it all depends sort of on the, the pathology that's, that's causing this. And so if it, if it seems like it was pubic symphysis, that's what you go after. If it seems like it's more inguinal pain, I actually do an iliohingual, ilioinguinal, iliohypogastric nerve hydrodissection where, where I think that some of the pain is coming from entrapment of that. And so it's, it's super, super easy to do. You just put your needle between the transversus abdominis and the internal oblique and pull it apart and have had amazing results with that when that seems to be the, the, and I use cortisone for that. Well, cortisone and like a bunch of fluid. Yeah. I would say like about 15 years ago when the ilioinguinal blocks were really in favor, like we would do some ablations. So I've done that in pro hockey players and that seemed to get them through the season with that quasi pain, that change where you couldn't put your finger on it. And that's what Dr. Brunton said. That's Demusha technique. She just does an erectomy, you know, that's, but yeah, no, we've had a lot of, I think really good experience with, I call it a cleft injection, what you're basically what you're describing. And I'd be a little bit, you know, as a hip surgeon who doesn't, who doesn't do sports for neurosurgeons because it's done by a general surgeon, I'd be more proactive than Dr. Brunton saying that I think it works very well. It can calm it down to then doing the rehab. It's something that I could even, maybe I don't mind repeating it because it's not like that tendon is going to, you know, really rip off the bone. It's not like I'm injecting an Achilles, but that being said, very commonly, these guys, you know, when you're doing multiple injections, these guys have most of the times have surgery at the end of the season. Okay. Just a quick question. I wanted to go back and ask Dr. Harmon about, about sleep with regard to, you talked about melatonin, you talked about some of the other drugs. Are there any more homeopathic or natural things that actually have evidence that work? For example, like magnesium, I think is a very common, is very commonly used and seems to induce some good sleep as well as helping people fall asleep. Yeah. Magnesium, especially magnesium, the powdered kind. Yeah. Or, or the one that's like a gel. I mean, not, it can be very helpful. It's easy. It also gives, if you use too much, you'll get diarrhea. And so you need to titrate it to that. So, so that's a good thing to try. And again, like the mindfulness exercise and relaxation exercises, melatonin is worth a try. By the time they get to me, they've all tried that, it seems. And, but, but I, other than that, I, I haven't recommended much. Okay. Well that, I think that's a great session. We're going to end it there. We're going to have 45 minutes for lunch, and then we're going to come back here at one o'clock for the, you know, the, the women's section in, in hockey. Thank you very much, everyone.

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