subject about game day injections. Just a quick show of hands, how many team physicians out there routinely do game day injections pre-game on their players? Maybe half? I'm on that side. So in full disclosure, I grew up as an Alabama fan. So I was an Alabama fan as a kid under the Bear Bryant years. You know, back in those days if we lost a game I was despondent for the whole next week until the next Saturday came. We didn't lose many games, so it's kind of fun. But then I lived through the lean years. When I was in college we had Bill Curry. When I was in first to practice we had Mike DuBose, three and eight, a couple years. We had Dennis Franchoni when I first started taking care of the team in 2001, who left us for Tex A&M and then got fired and ended up at a small school. We had Mike Price for three months. He got caught at a strip club. And then we got Mike Shula. He's a great guy, but we had kind of a bad team back in those days. So I learned a lot, but I really learned how to be a team physician when this guy showed up in 2007, because he demands a lot out of the medical staff and the medical team and athletic training staff. So I really learned kind of how to manage players, how to manage the coaches, and how to manage expectations. Most of this discussion is really just from personal experience, and not only as a team physician, but as a father of two boys who played high school football and are now in college. And there's very little in the literature. So if you try to look this up, when I did a literature search, there's really not a lot of information on what you can inject and how in sports games. I've had some great mentors. I had two Hall of Fame mentors and Jim Andrews and Bill Clancy, and I've worked with a bunch of Hall of Fame athletic trainers. R.T. Floyd, Bill McDonald, Brad Montgomery, Jim Skidmore, and then currently Jeff Allen in Alabama. So this is my 22nd year of the Crimson Tide. As you can see, I'm excited when we score a touchdown. That's me in the red in the background. Devante Smith scoring in the SEC Championship game to beat one of Kevin Farmer's team. And one of the questions I get from patients and fans and people all the time is, what happens in the tent? So Jeff Allen, our trainer in Alabama, actually invented the tent, patented it. He has a company with the university that sells these tents to the NFL and colleges. And the question is, what happens in the tent? Well, it's really kind of a doctor's office on the field. We do injury evaluation and treatment, as you can imagine. We do imaging. We actually have a mobile C-arm in ours that we've been using for a couple years. Great for like ankles and fingers and stuff. A lot of informed consent discussions. Here's what you have. Here are the options. You know, which way do you want to go, which is a pretty quick issue in a tent. Sometimes it's better to do in the locker room. And occasionally we'll do local injections or do IV fluids in the tent. And we do a lot of modification of equipment, bracing, casting, that kind of stuff. But if you ask the players what we do in the tent, they think of it as an outdoor urinal. So there's a lot of empty Gatorade bottles laying around the tent. So in terms of team physician philosophy, remember we're here for the player. We're not there for the team or the coach or the management or anybody involved. First, do no harm. I think a personal connection with the player, as Walt mentioned, is really important. It's really critical for informed consent because players, if they don't trust you, they're not going to open up about their injuries very much. Only consider injections that won't be hurt further by masking the pain. I think that's the take-home message of this talk. But, you know, sometimes it's hard figuring out what those injuries are. And also think about the psychosocial aspect. Some players are scared to death of needles. Now, they may have a hundred tattoos, but the thought of a 25-gauge needle in their hand makes them pass out. So be careful about those kind of players. In high school sports, it's kind of a no-no, you know, unless there's a really good consultation with the parents because the high school athletes obviously can't give consent. So what is safe to inject? Well, I would argue AC joints, especially grade 1, maybe grade 2, are probably the most common indication in college football. Fingers and toes that are stable injuries, maybe sprains or other things that limit function. I think a hip pointer is a great indicator, early atricrass contusion. And then maybe a stable high or lateral ankle sprain is an indicator. Contusions, sometimes, but beware of local neural anatomy. We'll talk about in just a minute. And then grade 1 MCLs, I know a lot of people inject those. I haven't done a lot of that, but I think it's, you know, if it's truly grade 1, maybe there's no risk. The sternum and lower ribs, sternocostal injuries, I think this is probably why I'm up here today is Stephen Brockermeyer and I talked about when his athletes last year had this problem, and I think those are important to be done under ultrasound or CT guidance. When should you inject it? Well, it depends on what kind of local you're using, right? So 1% lidocaine has a quick onset, but a pretty short life of activity, duration. You add epi, it gives you a little bit more duration, but there are some risks, obviously, with epi in certain extremity areas. Half percent bupivacaine has a little bit longer onset, a little bit longer activity. And then there's some new things like liposomal bupivacaine that we've used in certain situations like sternum and rib type injuries. So when should you inject them? Well, pregame, I think, is really difficult because for most athletes, like with an AC joint, their pads are on an hour and a half or so before the game, long before warm-ups. And if you're going to put marcaine in their shoulder that lasts for four hours, it's likely to wear off before the fourth quarter. So do you dose them again at halftime? Do you try to wait until right before the game? I think the latest possible injection for most injections is best, but sometimes you don't have that option. In-game, I like using half lidocaine for quicker action and half marcaine because it lasts longer. And then post-game, sometimes I add a steroid for certain new injuries like an AC joint or hip pointer. So where should you inject? Well, an AC joint, when they have an acute injury or pregame, I'll typically inject an intra-articular and the dorsal periosteum. I think technically that can be challenging sometimes. The AC joint only takes about a cc of fluid generally. For the ankle or hip pointer, it's usually the area of maximal tenderness, and for the hip pointer, you really have to pepper the periosteum. The rib and sternum, again, image guidance I think is important. Fingers and toes, we typically do a digital block, but you have to warn the player that that whole finger is going to be numb. I've had a couple of players freak out when their whole index finger was numb. They didn't expect it. They thought it was just a local shot. And avoid intra-articular injections because of the chondrotoxicity of local anesthetics. I like a 22 gauge needle for the bigger injections like AC joint or iliac crest, and a 25 gauge for fingers or toes. But again, be aware of local anatomy. There's some well-publicized cases, dromabeta sebaconoid 2. We had some nerve dysfunction after a local injection for a thigh contusion, and tyrod-taylor with the pneumothorax for a rib contusion. What about Toradol? Big controversial subject right now, and the NFL team physicians back in 2012 came out with these recommendations for Toradol. If you look at usage in the NFL, it's gone from 2008 at 93% of team physicians down to 48% in 2016. Back in 2006, 79% gave more than five Toradol injections per game, pre-game. Now it's down to in the 20% range. NCAA has a similar paper out. Eric McCarty's group has done 62% of NCAA team physicians give Toradol pre-game in 2008. Now it's down in the 20% range, and only 4% use more than five Toradol injections per game in 2016. So I think it's becoming less common. I currently don't use Toradol. We use oral anti-inflammatories, use a diclofenac that's given by my primary team physician, because I want to make sure he knows about their renal status, any other medical problems that may be affecting taking an NSAID. So in conclusion, local anesthetics can be helpful for some stable injuries. Toradol use is definitely decreasing in both the NFL and NCAA football. Be aware of local neurovascular anatomy, and I think informed consent is really critical. Remember, first do no harm. Thank you.

game day injections

informed consent

player safety

local anesthetics

Toradol usage