Welcome to AOSSM's webinar, Handling Sports and COVID-19. I'm Alexandra Campbell, AOSSM Education Coordinator, and I will be the operator for the webinar this evening. Before we get started, there are a few items that we will reveal. First, AOSSM is asking you to complete the Practice Response to COVID Pandemic Survey. The link for this survey is available in the chat box so that you can click and then complete it after the webinar. During the course of the webinar, you may send in questions by typing within the Questions tab and then pressing the Send button. Questions you submit are seen by today's moderator and may be addressed at the end of the presentation. And now on to the webinar. Our panelists will turn on their webcams, and I will turn the mic over to our moderator, Dr. Bush Joseph, who will introduce tonight's speakers. Thank you. How are you doing, everybody? My name is Chuck Bush Joseph. I appreciate you all taking the time, and hopefully we've got a very experienced panel tonight that's going to help give me and give you some guidance on how to help all of us get through all this. Our first, let's see, I'm not sure how the cameras are arranged, but to my right is Dr. Karen Sutton. Karen's an attending and associate professor of orthopedic surgery at the Weill Cornell Medical School in New York, and she's a surgeon, a sports medicine surgeon at HSS. Karen's got the unique qualifications of both being a college athlete, she was a star lacrosse player and has remained very active. She's currently the medical director for USA Lacrosse and head team physician, I'm sorry, chief medical officer for Weill Lacrosse and head team physician for U.S. Lacrosse. Our next speaker is Dr. George Champas. I've known George for a hundred years. Unfortunately, George hasn't aged and I have, he's still got a full head of hair and he's a vibrant guy. George is a very prominent emergency room physician and sports medicine physician here in the Chicagoland area. He's certainly medical director of the Chicago Marathon, which is the second largest marathon in the world. And George has handled that flawlessly for many years over very difficult conditions with very large populations. In addition, George is also the medical director for USA Soccer Federation, which clearly one of the things why we'll both, we've asked George and Karen to speak tonight is because of their role in dealing with the national federations. And I think many of our listeners would be interested in that. The third panelist is somebody who is really dear to my heart. I've known for a long time, a wonderful orthopedic surgeon. She takes care of both professional and collegiate athletes and probably one of the most foremost cartilage transplantation surgeons in the world, Dr. Rachel Frank. Rachel is an assistant professor at the University of Colorado School of Medicine. I've known Rachel for many years. She was a college athlete as well. She's unfortunately suffered many of the injuries that she treats nowadays. And so she's got that perspective of both patient and physician in addition to her duties and taking care of both high level professional and collegiate athletes. So Karen, I want to start with you and I just, I'd like you to kind of give your perspectives about number one, briefly, how your life is different from what it was three months ago. And then if you give us your thoughts and perspectives on how you're guiding your national federations. Sure. So three months ago, we were planning our world championship in Ireland for world lacrosse. Three months ago, we were working with our US national team in terms of selecting our women's team for our next year's world championship. Both of those have been put on hold. I've been working a lot more with the WHO and CDC, various organizations to understand the updates with regards to COVID-19. It encompasses a lot of different things for our athletes. I've learned a lot on mental health and learned how to counsel our athletes on mental health. I think that's a big component of it that initially was not as regarded. The physical component and what effects COVID-19 had on the body were initially brought out first. And then in terms of our athletes, a lot of them, ACL patients who had injured their ACLs recently were having increased rehab time. So three months ago, it was about four to six weeks for them to have surgery. And now they've been waiting three months. So we've been working with HSS and developing protocols for longer prehabilitation for ACLs and rotator cuffs. George, why don't you give us your perspective? Obviously, as an emergency room physician, I think, unfortunately, you're much more equipped to handle these, both the acute and the chronic nature of this condition. Why don't you give us your perspective and then your thoughts on how you're guiding the Soccer Federation? Sure, Chuck. Obviously, being on the international side, back in late February, we had teams that were either out internationally. So we rapidly made sure we got them all home and safe. And then since that period of time, our national team players from our women's national team, men's national team, our youth national team players, our staff has been in constant communication with them for so many reasons. Our coaches are talking to them, making sure that they're engaged with them, keeping them in some sort of level of fitness and being a resource for them while their clubs are also giving them that information. At the same time, trying to discover a re-entry phase. So that's a little bit on the national team side. But definitely leaning on our sports performance folks, our athletic trainers who are doing an impeccable job, making sure that we're focusing on mental health and so that they're not feeling lonely. Recognize we have players that are in different parts of the world. Some clubs are trying to move forward. Some clubs are not moving forward at all. And so we're really trying to give them that information and answer questions for them. Otherwise, in the emergency room, extremely busy. COVID is real. And managing a lot of things that we've never seen. And some of them I think are going to flow over into the elite athlete and athlete population with regards to COVID, having symptoms or not, which we'll probably talk a little bit more into. We'll get through that a little bit. Rachel, I'm going to get your perspective. Where are you seeking your guidance for? Obviously, with your professional soccer team and University of Denver and University of Colorado athletes, who's going to be driving the bus on opening the door? Obviously, the medical professionals are critical, but will you be relying on the infectious disease as an off-on switch or what kind of guidance are you getting from your specialty consultants? Well, I think that's a great question. And thanks for that very kind introduction earlier. You know, I think this is a challenging area because there are so many cooks in the kitchen right now. There's a lot of moving parts and even guidance from our national leaders within government seem to change by the hour, if not the day. And so from the professional and collegiate sports side, and even youth sports, I think it's challenging to have a unified voice for guidance and what might be going on, say, in the MLS could potentially be different than in the NBA or NFL. And so that can be a little bit challenging. Here we've been pretty lucky. We have a multidisciplinary approach to our athletes with all care, regardless of whether it's a pandemic or strep throat or chicken pox for one of the patients or athletes' kids or something like that. So we'll rely heavily on input from infectious disease, internal medicine, sports medicine, primary care, sports medicine, and orthopedics to come up with some ground rules. But a lot of this is going to come from above in terms of the governing bodies of the organizations. And so whether that's through the MLS in the case of the Rapids or through the PAC-12 in the case of, you know, the University of Colorado. So we locally are using all the resources we have at our disposal to come up with good game plans for our athletes, but a lot of the decision that are coming from the conferences and the governing bodies. Karen, from the lacrosse world, how's it going to come? I mean, how many people are going to be inputting on the decision and sort of is going to be who's got the say? Is there a vote? What's the mechanism? So we have a return to sport committee that just started about last week that encompasses a lot of the multidisciplinary personnel that Rachel had talked about. So that's coming together. We're actually reviewing a lot of the latest literature. We're lucky from world lacrosse that I have colleagues in Japan. I have colleagues in Hong Kong who have gone through some of the MERS and SARS before. So we're looking at some of that historical data from MERS and SARS and return to sport after that. We're reviewing a lot of the literature. And then what's going to happen is similar to what George was saying, is US lacrosse is hoping to guide some of the collegiate lacrosse. And then we're seeing that there will probably be an emergence to a lot of local lacrosse. So we're trying to support a lot of the local youth organizations and get them moving forward with some sort of play, whether it's backyard or it'll probably be small group play soon. George, obviously you deal with a sport that's international in scope, you know, and clearly this pandemic has hit different areas in different ways and different intensities. Obviously what's happened with Karen in New York is dramatically different to a point that what's been seen in say Tulsa, Oklahoma or Ogden, Utah. Is the US Soccer Federation going to consider a regional approach on things or are you going to just provide guidance that'll go out to support the local or the regional associations? Yeah, Chuck, I think it's a great question. And back in February, if you recall, most of the impact was either in the Northwest. California started getting impacted in New York. And we made a very clear decision as a federation that we're all in this together. And we're not going to play this sport unless all of us across the country can play this sport. Now we're also in this phase now where you're seeing states reenter. And so we're all rapidly now trying to put together an assemblance of guided principles as it rolls out and it gets deeper into our game. Without question, we want to make sure that our message is that as a sport across the United States, we're doing this methodically and we're doing this in the safest way. You know, I want to remind our listeners and those who've joined the webinar tonight, please, I want to make this as interactive as possible. So take advantage of the chat box, ask us your questions. I'm sure there's a lot of specific things that you'd like to focus on. Rachel, I want to get back to you a little bit. To me, there's three phases we're concerned about right now. Number one is, what are our athletes doing in an unsupervised manner? Number two, at some point, we hope to get back to that competitive training phase where we're in a group phase or more supervised phase. And then three, we're in that pre-competition phase. What's been your assessment of the athletes that you deal with and what are the concerns you have over quote, the unsupervised training athlete? That's a great question. This varies depending on the level of athlete, whether it's one of our pro soccer players, for example, one of our collegiate athletes or a weekend warrior training for a local race or a national race. I would say from our organized sports, so from a professional and collegiate perspective, at first, when everything kind of immediately shut down, at least in Colorado in mid-March to late March, there was a sense of panic. We're in the middle, we're just about to start our season for the Rapids. We're fit, we're at the peak of our fitness right now. What do we do and how do we continue to maintain that fitness when we don't know how long we're going to be shut down for? And so at first there was a sense of panic, I think amongst really everyone. And then that turned into, okay, what can we do as a team while we're still social distancing? And whether that's team workouts through Zoom or other webinars or other types of video activities. And now it's kind of turned into this waiting game of when can we get back going? We see the country starting to open up. We're getting a little bit anxious and our season is technically a fifth to a fourth over already. When are we going to be able to start playing? So I think now we're getting back into that concerned, I don't want to say panic mode, but that concern mode about when we get back into organized training, how can we do this safely? And I think that that's going to be team dependent. A lot of reliance on our strength and conditioning coaches as well as our athletic trainers to make sure that we ramp up in a safe fashion and not try to get back the last six weeks in one week. And so I think there's a lot of different strategies for that, but it's really going to boil down to a team-based approach with the athletic trainers and the strength and conditioning coaches to ensure a healthy return without overusing or overdoing it. You know, I want to give you just a brief example, I guess I hate to say it, you know, it's a controversial thing in baseball, but the use of weighted balls as a means of improving arm strength and stability, you know, and the literature is actually pretty good that weighted ball programs and certainly supervised core and lower extremity strengthening programs can add velocity to a thrower, even a young thrower. But the literature is also very clear that in an unsupervised situation, weighted balls on adolescent athletes is really a high risk for injury. Karen, what are your, have you ever had an interaction with your trainers and the different levels that you've talked to? What kind of feedback or concerns you had from your mid-level providers or those boots on the ground people who are handling athletes or handling the concerns? Right now we're actually doing some boots on the ground work with U.S. lacrosse. Each of our athletic trainers and medical staff for the national teams are calling every individual athlete and seeing what the needs are, whether they need mental health, strength and conditioning, nutrition advice. And then what I think as, you know, you're talking similar to baseball, I think similar to football where we have that getting acclimated to pre-season. So I think just as Rachel's saying, we can't get into six weeks of season in one week. We're going to have to break it down where if the athletes come back, the coaches, just like they do in NCAA, you have the five day getting acclimated to pre-season. They won't test the athletes. You're not sprinting. You're not doing all the strength and conditioning in, you know, one day and all the testing. I think we have to ease back into things. And then we do have to partner with our infectious disease folks who are starting to suggest that we need to be very efficient with our practices. So not as much huddling time, not as much standing on the sidelines. But if you're in there, maybe it's some position specific workouts that you're doing on the field, off the field, and not as much of that interaction in between. Well, one thing I think has been pretty clear, and I think most of the information that I've read about this is that outdoor activities certainly dramatically lowers the risk. I think there was a recent study out of China that out of 7,000 traceable cases, only two of them had occurred from outdoor contact or contagious. George, how much time does it take for, you know, high level soccer players to get from, all right, we're back in team activity and conditioning. How long are we ready before we're ready for competition or at least high level training? Yeah, the number of days that constantly gets thrown out there is about three weeks. So three to four weeks. One of the areas, as you know, Chuck, is, you know, the fulcrum is in the pelvis. And so in this period of time, you know, we're really trying to guide our athletes to make sure they're doing those side to side movements, the lateral movements, because you get very comfortable in just the forward and back movements. But if you're not incorporating that right now, you can, as soon as you increase your load, start kind of having some issues in your core. Rachel, what's your thoughts? What's the concern you have from your soccer guys? Yeah, I would echo George. I think three weeks is a very reasonable number and I, you know, back, I can remember when I was playing, you know, three weeks preseason is very, very normal for college and I think higher level athletics. I think the biggest concern I have is ACLs, especially in the soccer population. You know, I think we, if we don't have good core, good pelvis, good abductors, and we start throwing our mechanics off, I think we're going to run into a potentially an ACL epidemic to go right along with this COVID pandemic. And I think this could be not just in soccer, but in any cutting pivoting sport where athletes may potentially try to ramp up too quickly and may in the last six weeks, because they've been unsupervised, may have only been focusing, say, on quads or biceps or whatever it might be to do the exercises that are easiest and most familiar for them to do in an unsupervised fashion. And so that's my chief concern right now. And I think we have to be very cognizant of that and make sure we have good, healthy, active warmups for our practice or for during practices and games, good, healthy cooldowns and make sure we handle the nutritional side of things and recovery side of things. That's going to be critical, but also difficult because that requires the athletes potentially to be in the training room together or in the ice bath together. And that doesn't really go with social distancing. So we're going to have to get creative. And like Karen was saying, potentially staggering positional players for different times of the day so that we can get all the athletes the care and training that they need without putting them at increased risk of being in such close proximity to one another. Karen, obviously, your lacrosse federation has almost 450,000 members. And so what's your advice for those lowest levels, those youngest athlete levels of competition? What are the advice that you're going to give those youth coaches and those youth programs where you just got a bunch of little kids, they want to get it going. But, you know, even at the lowest levels, even in soccer and lacrosse clubs, there's a lot of scrum activity and physical nature. I have to say, in my experience, my son played college lacrosse and usually they go from that beehive to that brunt physical activity before really, I think it's later on where they get to really that skillful execution of lacrosse. How are you handling those younger kids who just want to go whack somebody with their stick? Well, the younger kids were doing a lot with challenges. So we're putting out challenges that they can do in their backyard. One example that some of the club teams are doing is you take a deck of 52 cards and each one has a little skill that you do. So if you pulled up, you know, the 10 of diamonds, you have to do 10 ground balls in a row. If you pull up a four of clubs, then you have to do four wall balls. So trying to make it fun. I think a lot of the developmental strategy, even before COVID-19 with soccer, with lacrosse, has focused on that younger level and just having fun. They just want touches with the ball. They want to be with their friends. So making it somehow interactive, even if it has to be virtually interactive. But you need that camaraderie between everybody. And then not that you want to make it a challenge, but they all put what their time is with the deck of cards or how many wall balls they're getting. And I think I think getting back to focusing on the fun rather than that burnout from sports, you know, sometimes at that youth age, we'll get a lot of the burnout in sports. So trying to make it fun again, I think, could be an advantage coming out of this. All right, George, I'm going to ask you the hard question now. What role is testing to play in the U.S. Are you talking about testing as far as for COVID? Yeah, I mean, whether it be for a return to play, for presence of antibody, is it going to be a repeated testing or or will you think the Soccer Federation will just rely on just I hate to say it, the standard screening techniques, which is obviously fever history contacts? Yeah, I mean, I think that's obviously the question everyone is asking is testing. And I do think that testing at the professional and at the elite level is going to be a passport, essentially back to play. It's the only way we can have some objective information, understand the disease, understand if you can be reinfected, understand the immunity and how long that immunity is there. It's not only it's not only important for the sports population, it's important for the public. From a youth perspective, I think in the short term until testing becomes much more widespread, we're going to have to rely on symptoms, history, really honesty and transparency amongst players. But then at some point, testing will be, I think, the pathway to being able to get back to some normalcy. Rachel, the University of Colorado, University of Denver, do they have the resource and ability to repeatedly test or test staff and staff and athletes? I think that's an evolving situation. I think our testing capabilities are growing by the day. And that was one of the criteria for us to start revamping surgeries in terms of having testing abilities for our patients. I think in terms of the CU and DU athletes, it's not really available for all athletes currently. And that's just a limitation of the resources within the state. But I do think that as as George was saying, this is likely going to be a ticket to get on the field at some point. But whether that's for spring athletes now or for fall athletes this coming fall, it's to be determined. And I think the other question that our viewers may ask and that we're all wondering is about antibody testing in addition to testing for active COVID, but testing for prior exposure. And again, I think that comes down to testing availability as well as testing accuracy with what we're going to do with that information. So that's you know, I think that's probably the one question most of our viewers are going to want to know from our perspective is what are we doing locally and nationally and internationally? And I think we don't necessarily have that information yet. There's certainly no consensus among NCAA conferences currently, at least to date. And within the MLS, we've been discussing testing in terms of testing all the pro athletes. But we don't necessarily know when that's going to take place, which test that's going to be and what a positive versus a negative test will mean, given that no test is perfect. You know, I think maybe, George, you may have more information on this. But my understanding, there's 14 different tests on the market right now, all of which certainly from a just the point of contact testing have variability or essentially reliability perspectives anywhere from about 85 to 92 percent. And so there's really going to be that false negative. I think we're more concerned about the false negative over the false positive. Do you see any of these tests sort of gaining value, at least as a screening before we go to, you know, a patient, you know, with any kind of positivity would go on to a more definitive serologic test, which is obviously much more expensive and time consuming test. Where do you how do you see that evolving? I think you have to first start off and say there's there's no ability to have zero risk, Chuck. And that has to be an honest conversation with athletes on the athlete side, with owners, with sport and with the wider public. So you have to start there and say there's no way we could do zero risk. We're all about trying to mitigate risk as much as possible. With that being said, testing, I think, has two components. One is the antigen, which is the PCR and recognize even when you do the antigen, it has some of that false falseness because the antigen could be down in your lungs encapsulated. You don't get it on the swab. And so at the same time, doing the antibody, the IgM one especially, which in combination is one that potentially captures those athletes. Also, you also there's a rhythm of testing. So you might want to do it and then do one in 24 or 72 hours to get, again, better accuracy. And then there's going to be a rhythm of doing it weekly. You're isolating your athletes, mitigating the risk, and then there's going to be a rhythm for a long term. But I think that is going to be a pathway. It's just a matter about securing tests. Recognize, Chuck, and I will say this is health care workers are not getting that sort of testing. Police officers are not getting that testing. So there has to be an honest conversation with athletes to recognize when you're getting this testing, you're getting actually more than what front line workers are. Interesting. We're kind of in the midst of the COVID pandemic, hopefully off of our peak now in New York, but we are getting antibody testing. And when you talk to the nurses who are giving the antibody testing to some of the health care workers, even people who have had symptoms may not specifically have tested positive for COVID, but we're working with COVID patients, you would think they would have positive antibody testing. But she's seeing more where people developed more moderate symptoms are getting the positive antibody testing. And people who had the more mild symptoms may not be positive on the antibody testing. So I think there's a lot of work to be done. And people want a quick answer. They want, hey, you had testing, you didn't have testing and black and white. But that's not where we're at. You know, and I would agree. I don't think we're going to get to the day where certainly we have certain levels of athletes can wear that badge. I've got I got IgG antibodies. You know, I don't think we're going to get to that point. And I think the thing that George is saying, and that's the job of you three, is to help guide your federations, guide your trainers and guide your general managers and medical staffs of say, of what level of risk? And I guess that's the question. I, you know, we all make our patients sign consents left and right. We make our athletes sign consent. There's obviously inherent risk. It's just a matter to what level that risk goes. And in my mind, and Rach, I'd almost get your perspective of both a high school and college athlete. To me, I'm willing to sort of as a professional, you're a professional. There's things we do to professional athletes we would never do to our high school athlete. How what's your thought process on that? How are you going to guide a parent who says, listen, my daughter is a really good soccer player, but I don't want her in a scrum with a bunch of sweaty girls of who I have no idea of the opposing team and what level of diligence the teams that we're competing against, quote, that chaos of competition really seems to wipe away a lot of those risk mitigation things that we do. Yeah, I think that's a great question and a great concern. Like George was saying, we're never at no risk. I mean, no one is ever at no risk. You don't know who the person next to you has been in contact with and who that person has been in contact with. And that's going to go for any of our high school and college athletes who are in the practice environment or in the game environment playing against athletes. They don't know and they don't know where they've been. Also, as mentioned, you know, having say we say the parents say, well, my daughter was covid antibody tested and she's got antibodies. So I think she's fine. We don't know necessarily if that gives you immunity to getting a second a second infection or a different type of infection. There's so many unknown. So I think it boils down to this. It's what we tell our patients for surgery and any procedures. There are risks and benefits, but you don't have to do anything. So if you're concerned about your daughter playing, you don't have to have her play. And that's an OK choice to make, even if she's coming up on, say, a scholarship year, a recruiting season. You have to do what lets you sleep at night and what you think is in the best interest of your family member, your kid, in our case, your patients. And so I think that it really boils down to that is being humble and honest with your players and their family and saying this is what we know. But really, this is what we don't know. And the risks are potentially real. Fortunately, in young patients and particularly in healthy athletes, the risks are pretty low. But I'm sure we've all heard or maybe even treated a patient who is a high level triathlete or a high level professional athlete who's gotten sick with real symptoms and has been in the ICU and potentially even been intubated. And so even though for most healthy young athletes, even if they're infected, their chances of having true symptoms are low. It's not negative. It's not zero. And so we have to just be honest and humble with our patients and their families and let them know there's a lot more we don't know than we do know about this disease process. We're learning. We'll know more in a year. But it's always your choice not to participate or not to play. George, I want to ask you, obviously, as medical director for the Soccer Federation, you've got lots of professionals out on the line, your trainers. How do you how do you guide them? I mean, they they've got to protect themselves. What's the what are the risk mitigations that your medical professionals who are on the front lines, how are you going to guide them? Yeah, I mean, obviously, fortunately, health care providers are committed to being service providers like all of us. So you're going to you're going to implement the mitigation factors, whether it be hand washing, PPEs, social distancing as much as possible and objective information as well. Obviously, they're going to be wearing masks, but we also have relationships with these individuals. I think that there's a there's relationships that are based on honesty. There's relationships that are really, really important right now, more so than probably ever in the past. But I think those same mitigation factors are going to apply across every aspect of our life. So you apply them, you make sure everyone's educated, you communicate, you communicate those things. And if you go in that in that manner, I think everyone understands. Karen, let me ask you about the athlete who had coronavirus is now recovered. Do you have concerns about their degree of their illness and whether they have any permanent sequela regarding their their ability to condition or get back to a high aerobic level? I mean, do they believe that they may have intrinsic lung disease or secondarily, were they treated with medications that may place them at greater risk for structural ligament or tendon damage? Yeah, we started talking about that with both at HSS as well as with U.S. Lacrosse in terms of any permanent sequela of COVID-19, one being, as you mentioned, the pulmonary function. So is there any scar tissue in the lungs that may affect the pulmonary capacity as they're going back to doing some endurance sports and conditioning I think we really need to make sure that all athletes have a self-awareness of their body and give their specific symptoms So this is not the time to lie to your coaches to lie to your trainers and say I'm fine I'm fine but I do think the pulmonary capacity is something that we're going to have to look at and Secondarily, you know as we know there was a cytokine storm that affects COVID-19 patients as well So a significant degree of inflammation we have to see how that affects the muscle at HSS. We're doing some tests run by our basic scientists to see what how the muscle is affected after COVID-19 and did the Inflammation change any of the function or capacity of the muscle tissue Rach are you going to handle invasive treatment whether it be injections or some invasive forms of physical therapy such as dry needling or PRP injections Obviously you see yourself doing this differently than what you've done in years past Well, that's a great question. I think for our average weekend warrior, you know for the last six weeks. We haven't really done any Injections at least in my clinic and in most of our clinics even for those patients with debilitating arthritis or that you know that athlete who just needs to get by for a few weeks where we normally would have no concern about giving a steroid injection or or an HA or a PRP So that has given me some pause because over the last six weeks I've been able to see what patients can tolerate without having these injections and not because we want to torture them It's because we're not really able to do those procedures that being said I think there's been some discussion especially on some of the online forums about steroid injections and Potentially systemic absorption of that steroid and potentially weakening the immune system and the risk of sustaining a kovat infection I think the literature to support that is just not conclusive So now that we're ramping back up at least a little bit here in Colorado with clinic I have been offering steroid injections and my usual, you know, PRP and HA injections to appropriately indicated patients But explaining that along with everything that goes along with kovat There are potentially unknown risks that are unclear right now and you have to be willing to accept those I'm saying that same thing to my surgical patients. We've all heard about reports of blood clots, particularly in younger patients Don't know how surgery will exacerbate that as surgery is a risk factor for blood clots So any procedure really anything I'm doing for patients right now Whether it's giving an NSAID or giving an injection or doing a surgery I'm telling them there are associated risks with kovat that we just don't know right now and Oftentimes the literature is not there until we have numbers and you may be one of those numbers I hope not doing every precaution to prevent that. I haven't had anyone say I don't want the therapy, you know at this point But I'm making sure I have that discussion George let me ask you this and I'm sure there's people or patients are gonna ask, you know I had some sniffles or I may have tested positive and I'm no longer symptomatic Are there any serologic markers or values that tell me that I still have any physical? Physical sequela of the problem or condition or is it just clearly physical parameters? yeah, and I want to touch back on what Karen was talking as well as I and Rachel as well as the What we don't know is we don't know quite a bit right now and there was a paper that Dr. Baggish from MGH just put out with regards to from a cardiac perspective Anyone testing kovat positive you may have to re KG them and if they have any shortness of breath, you're reechoing them So imagine if we're trying to do that at the elite level try to bring that down to the youth level as far as markers there's discussions about high sensitivity troponin following that with regards to myocarditis or Assessing risk CRP or inflammatory markers. So those are those are the ones that are being discussed at this point Rachel do you think as pulmonary function testing necessary on anybody who tested positive at a collegiate or professional level? It's a great question again. I don't think we know the answer to that because we don't have a baseline for this. I think that Potentially we're going to see some patients or some athletes who have had sustained a kovat infection either with minor Moderate or major symptoms and they continue to have respiratory issues down the road with their fitness with conditioning, etc And those patients likely do warrant additional workup, which may include pulmonary function testing But we don't and those patients necessarily have their baseline We don't know if they had an exercise induced asthma prior to all of this and it was just undiagnosed Because they were pushing through it So if we start getting PFTs on every athlete who has a cough or has some respiratory distress I'm not sure we're gonna know what to make of that data So I think in this case, it's it was it's warranted in patients who are you know Symptomatic who we would treat with PFTs in any other scenario But I'm not sure it's warranted in every athlete just as a baseline unless we're going to do it pre kovat and at this point In life, we don't have a pre kovat way of life. We're all post kovat now Karen, how are you going to discern? I hate to say it those budgetary issues, you know Yeah, I think I hate to say it's one thing that if we ask our infectious disease colleagues, how do we minimize risk? We'll say well no no exposure, but no exposure means never going back and never getting back to competition Where do where do you decide? What's that that economic threshold of risk versus business risk associated? What's your take on this? So a couple things one would be if you're talking about assessing the athlete I think the athlete does need to be very honest at a basic level with the athletic trainers I think getting some sort of feedback with the performance coaches the athletic trainers the physical therapists where they talk about Their perceived rate of exertion. So as we're they're getting back into competition and we're worried about their pulmonary function How are they feeling so can they give some metrics back to the coaches to say how they're feeling in terms of budgetary issues? I think across the board working with The national governing bodies that I work with that's a major concern And I think the couple things to mitigate that one would be to try to keep it to local play That helps a bit for infection control. So you're all and they're the same Department of Public Health if possible and abiding by similar guidelines Two would be potentially Along those same veins decreasing travel So if you're a school that likes to play the number one school in a different region of the country all the time You may start making relationships with more local schools including You know I played at Duke and we would have a couple big trips a year where we'd go to the West Coast But maybe we look at all the Carolina schools and play all the schools in Carolina. And then I think just efficiency So, you know just as Rachel was talking about and we were talking about earlier just focusing on You know if coaches have a certain amount of time They may just bring in certain aspects of play and then to restrict some of the Budgetary concerns to the athletes may have to do conditioning on their own outside of practice They may have to do strength and conditioning on their own outside of the practice It's gonna take a lot of self-motivation by these athletes during this time George I'm gonna I'm gonna get direct with you. You've got a daughter who is an aspiring collegiate player and at a very high level How are you handling her and then how is she how is she responding to you? Yeah, I think it's it's different, you know on the female side versus the male side, you know, fortunately or unfortunately They they tend to commit earlier So she's gone through the process where schools have seen her and she's gone on different visits And so she's at a point now where it's it's while it's still complicated They've at least been able to see her but without question if you're if you're a student athlete, you know This is really really important time that your communication skills have been good that you're you're really Attacking the this this part of the part of the year communicating with coaches. They're not even in their offices. So You have to email them make sure that you're constantly communicating to them if you had created videos You're sharing those because that's really the only opportunity for them to have seen you and then you know Hopefully your communication skills what you're looking for out of college and in a student athlete experience is is vitally important And that has to be resting it has to resonate without question Last thing I will say though Chuck is we're taught we're saying post COVID and I'm seeing a lot of documents that are that are Suggesting post COVID. I think we have to change the language and we're in this Perry COVID period And because sometimes you put your guard down and so we're gonna be in this Perry COVID Period for the next 12 to 18 months and everyone has to get comfortable with that It's okay to not travel to to Karen's point, you know out west to play. It's okay to To not have that big game or play 32 games in a season And so we have to start changing that that dialogue that that our safety is most important across the game We'll come out of this at some point, but we all want to come out of it together Rachel do you think our current athletes our high school athletes and even youth athletes? Is it safe now for them to work one-on-one with their performance coaches or their individual? You know not strength coach but pitching coach or whatever coach Are we okay right now or do you are you advising against that? And what do you think your parents would feel about saying? Yeah, my son is safe to go back to his performance performance clinic You know, I think first and foremost if your state has a current stay-at-home order I think you got to follow that and so if there's you know Working out with your personal trainer your personal coach is not urgent or necessary as much as when I was back in the day when I used to be an athlete I Would think that it would be It's not and so, you know, we got to follow the stay-at-home order and not do any unnecessary You know travel and whatnot. I think once those restrictions are lifted I think if both the player and their coach or trainer have been symptom-free for 14 days without risk factors When social distancing guidelines are somewhat relaxed, then yeah, I think it would be okay to work one-on-one But again, I think there is risk because it most many people are asymptomatic carriers And you never know when you might infect someone or get infected. I think parents are gonna be all over the board I think there's that you know that group of parents who want their kid to get a scholarship at any cost and so they're gonna try to Get their kid as good as possible at their sport or their activity I think there's parents who are uber cautious and are not going to want to expose their kid to anything and then probably most parents fall somewhere in the middle and so I think we'll find a mix of how willing parents are going to be to let their Kids go one-on-one or in small group training chess sessions or with their entire team But yeah, I think as states start to see curves flatten Certainly, they won't disappear but hopefully flatten to a point where this is manageable I think and as social distancing guidelines get a little bit released then it would be okay to start training again But we have to be cautious and as George was saying we can't forget that. This is where we're at right now This is the new normal and we don't know if there'll be a second spike in the summer the fall the winter There's a lot of projections about what that might look like and we have to be ready to respond to that Karen do you think there should be no indoor lacrosse this summer or or you know The spring and summer that all indoor competitive activity should be banned until quote next year. What's your thoughts? I do have a concern about the indoor activities. I've like With we have a world lacrosse sports medicine working group and one of the doctors is in Hong Kong where they do have to play Indoors pretty much year-round. They were playing after even the SARS initial Infection out there. They were playing with masks indoors and they limited the indoor time I think the indoor game is much more risky than the outdoor game So we were on a call with US lacrosse yesterday And we all felt that for certain the outdoor game was much safer than the indoor game at this point George I want to take you over to the to the to the marathon side of your career Can you give us some guidance about nationally and internationally? How do you see? these large sanctioned events happening, obviously, you're you know, you're Supervising their Chicago Marathon. You've got what 45,000 competitors What what are other jurisdictions and other countries thinking about this and what's your perspective I know you can't it's too early to give definitive Guidance, but what's your thoughts? Well, Chuck, obviously, you know large-scale mass events are obviously a hot topic right now and federal governments are intervening with regards to setting parameters The Boston Marathon, which is an icon Obviously had to cancel their event or actually postpone it till the fall so did London So now we have some of the biggest events scheduled for the fall most recently Berlin was forced to cancel their marathon in September based on Germany's Stay in shelter and no large-scale events With that being said Chicago's in October to have an event like that requires so many different Public and private partnerships and those include, you know Our city and state and federal agencies Chuck to be quite honest with you So for us as a private event to lean on them right now would be extremely difficult Where we are a couple months from now because it takes us a huge amount of planning But also we have 12,000 volunteers. And so we there are so many aspects of that that the challenge can be very immense But we are actively working with international groups the International Institute of Race Medicine World Athletics Aims, which is another organizing body collectively trying to determine the best pathway Rachel what do you think you're gonna have students on campus at the University of Denver and University of Colorado this fall? I Honestly don't know, you know, I think We don't know. I mean, it's it's a great question. I you know, if selfishly I hope that we do I love the college atmosphere It's one of the reasons I came to work at the University of Colorado is to be a part of high-level Athletics take care of those athletes and and it's just much more fun when students are on campus for sure But safety is paramount and we just we don't know the answer to that question And I think that's probably a national thing I mean, I think it's really difficult for any university right now Whether it's division 1 division 2 division 3 or you know Any other university private public whatever to state that we are going to have students on campus this fall I think everyone like us in medicine are preparing for virtual and online Mechanisms for conducting our business whether it's seeing patients or educating students and student athletes But I think it's premature to say if we're for sure going to have students on campus Because we don't know what's going to happen throughout the rest of the spring and summer with regard to this pandemic Karen let me ask you obviously there are things that we do that are elective some things we do are urgent Obviously you being in New York where we're really just had such a high penetration How are you counseling your patients? I mean, what are the parameters of somebody with a large rotator cuff tear and acute ACL? That has does have a time constraint about their ability to get back to their sport What are the judgments you're making about when to go ahead and recommend to go ahead with definitive surgery surgical treatment versus quote deferring Even if that deferring may prove to be problematic for their ability to compete either later this year or even next year The nice thing I think that we've been doing in New York is there's been communication between Our surgeon-in-chief. Dr. Brian Kelly has really kept us in touch with all the guidelines very specifically which changed frequently From the governor from Department of Public Health. So communication has been very helpful with all of us Then in terms of making some of these decisions We were just emergent surgeries for a significant amount of time May 4th We're going to be able to see some patients in our office, but that's going to be very limited including patients drive up We will call them when they can come in for their appointment So the waiting room will be pretty empty during that time The only the patient can come in unless there's a pediatric patient and one Guardian or parents can come in with them So that's the office setting from the operative setting just as you're saying with a potential acute rotator cuff There's a couple different columns that you have to look at one would be their COVID screening We have a COVID screening guideline in terms of how sick the patient could be and the risk factors During this time that's based on age other pathophysiology issues And then some of their medical concerns as well as their length of stay in the hospital And then the second category of that is the emergent urgent priority or elective aspect of the surgery So you have to weigh those two columns match them and then we are doing some more urgent cases starting May 6th But with a great deal of caution and just as we were talking To Rachel before we got on the air a lot of these cases as we do at HSS are done without general surgery So we try to limit the general anesthesia that's happening with these cases, but it's it's so Multifactorial and our biggest priority is keep patients safe Yeah, I would say certainly at the Rush Medical Center where I work the majority We're virtually doing no elective cases at all on main campus and we've started we've been doing urgent cases and now we're going Semi-urgent cases starting May 4th at the peripheral Surgery centers, which are off campus and certainly distant to the main hospital and inpatient care We don't see I honestly don't see inpatient care or inpatient elective surgeries Probably before mid to late June and those, you know larger surgeries patients with multiple medical comorbidities requiring hip or knee replacement or spine surgery certainly our sports medicine procedures We we feel it starting early May that we'll be able to do those procedures in the remote Outpatient facilities that are right from downtown Georgia Can I ask you what can I ask you a quick question? Sure, if if Major League Baseball determines to have all their games down in a single state Well, will there be a rotation of physicians or will you have to isolate yourself down there as well? Yeah, you know one of the current plans is that They would isolate everybody down and down in Arizona And maybe have a second division in Florida Although Florida the teams are so remote to each other that they would take everybody in Arizona They would have essentially pare down the scout the working staff the medical staff Yeah, so I could find myself having to live in Arizona for a couple weeks at a time I there's right now George and my thought there's so much resistance from the players side And you think about really very prominent players Mike Trout Justin Verlander these you know Obviously, they're there are the bell cows of the league and they're they've got young families. They got children They're gonna say no way in hell. Am I gonna go, you know, isolate myself from my family for you know for 80 games The intent is all the leagues want to get a season in and I think even in Chicago Mayor Lightfoot has said that she could see baseball in Chicago But probably with no fans and so Major League Baseball has come up with several plans about regional teams you know with the Cubs the Brewers the White Sox the Tigers the St. Cards would be in a simple division obviously to minimize minimize Transfer and a lot of cross-country travel Certainly, there's these plans of evolving and I could tell you from baseball's perspective There's at least the 10th plan in the last last three weeks. So I I don't think we really have a guide on that I do want to get our listeners and our members again, please hit me on the chat box I know you've got some specific questions. You want to ask to our esteemed panel? We've got some very very smart people got a wealth of experience and they're happy to give you what we always say They're inside baseball secrets George. I want to give you can you give me some thoughts about what's happening at Northwestern? It's obviously the largest most prominent Medical Center in Chicago What do you see is happening downtown versus the peripheral peripheral hospitals and outpatient centers Yeah, I think it's a it's a good question And sometimes you can get a false sense of what's going on based on where you're working, you know at Northwestern we're fortunate because we have quite a few layers and and and quite a quite a binge a Bit of multidisciplinary approach that is protective for us without question. We're busy It's pretty much 80% kovat is what we're seeing. So it has a taxing Element on you both mentally and physically But we're fortunate because we are resource heavy. I will say that in other community hospitals inner-city hospitals such as Trinity St. Bernard's and Ingalls. I think that those hospitals are what you know You're seeing where they're having difficulty with PPE Managing a high volume of patients, but also high-risk patients. So there's absolutely a varying degree in Chicago they've talked about our peak being now in the next couple weeks and we are starting to see a little bit of an Increase the number of patients and sadly the number of deaths as well Rachel which are how do you see it happening in the the various layers of University, Colorado? One of the largest medical providers in the state Yeah, you know we were the kind of the only academic medical center in town and as such with the University of Colorado in our hospital system we've seen a tremendous amount of kovat positive patients and unfortunately deaths and We last week got a little encouraged as we had a little dip in the numbers But unfortunately those numbers are starting to climb again And I think similar to what's happening in Chicago the next few weeks will be very telling Fortunately, we have great Department leadership within our Department of Orthopedic Surgery and within our hospital system And we're really trying to focus as we ramp back up with so-called elective surgeries Although I'm not really a big fan of the word elective because a lot of these are are Truly elective but so is brain surgery in many cases You know the word elective really Simmers down into life and death and much of what any surgeon does let alone orthopedic surgeons Do is not really focused on life and death But a lot of these patients have debilitating pain and debilitating unstable knees or locked knees and whatnot We've got to help them. So we're very fortunate. We have a lot of satellite hospitals and satellite facilities there where there are no inpatients and no Kovat positive patients to date that we know of and we're able to focus our outpatient procedures and surgeries in those areas While still ensuring that we have a backup plan to stop those if needed to conserve resources ventilators masks PPE, etc For the main hospital and for any outbreaks that occur So we're slowly ramping up what if one of your athletes test positive or develop symptoms and subsequently test positive How are you going to contact trace it? Will the team be can't will the entire team be quarantined and will you say listen? We got to pull this entire team out for how long? This is the one thing. I think all some of our listeners are worried about Yeah, if everything goes great, everything goes great But your everything goes great to get punched in the nose and somebody comes up symptomatic and test positive. How you gonna handle that? You Was that sorry was that for me no for Karen, I'm sorry Oh, so in terms of I think you have to just as we have emergency action plans for other aspects of our teams whether it's high school college or The Olympic level. I think we need to have emergency action plans for this So you need to work with your public health authorities one thing if you are starting to have sports You need to make sure you do have the resources. So just as George said is saying at his institution They do have certain resources if the Department of Public Health can't handle their own Just public right away. It's not appropriate to bring in other athletes that are going to retain resources from public health So you need to figure out where these athletes are going to go both from if they have significant respiratory issues So is there a place where they can be? Ventilated if they need to can they get the emergency services they need to so you need to work on that beforehand and develop an emergency Action plan for kovat prior to Having an event Rachel, what do you see if one of your athletes? comes down Symptomatically and then develops and then subsequently test positive Do you think you have the resources at University Denver University, Colorado to essentially to quarantine isolate? What is your emergency action plan allow for these contingencies? You're still in formulation. I Think we're still in formulation But I think one of the main key aspects to any of this is our athletes can't really come back and to a group scenario Unless we have that plan in play so that if a patient or athlete becomes infected We have to have an ability to treat them appropriately Which oftentimes is isolating and then isolating the contacts that they've been in contact with Which in this case might be the whole team the trainers the coaches the staff so we're still working out those plans It's not currently known But I think any any university any team is going to have to have an action plan in place Such that we are able to manage that single athlete that gets infected and reduce the amount of exposure to them to the neighboring athletes George, how about you just from a coaching perspective? You've got a lot of coaches who've been involved in USA soccer for many many many years They travel a lot, you know, I don't know if they fit that age of high risk from an age perspective But I think just their their lifestyle and their multiple contacts What how are you gonna advise the you know, the evaluation and screening of your coaching team? Yeah, I think it's a good question. I think you have to have a very open and honest question, you know Conversations with them and identify those that are high risk, you know US soccer and I'll come to the coaches question But we have to have honest conversations about referees coaches And and really highlight those who are at risk and make sure that they understand and maybe this is a year that they shouldn't be refereeing or coaching Specifically in our national team environment with our coaches obviously minimize travel we're talking about within our budgets is chartered flights Implementing testing and to what Rachel was describing for everyone on this call using, you know trace track and treat Those are the the three words that everyone is using to be able to as much as you can put parameters around your team and Your staff so that if someone does test positive You can potentially try to track who was exposed to them and then be able to have an emergency action plan to implement So trace trace track and treat are three of the words that everyone is using Rachel I want to ask you real quickly before we we've only got a few minutes left ACL prevention plans program. So we think they work especially in a female athlete and they seem to work best in a structured environment How would you coach your parents and your athletes nowadays? We're trying to prevent injury in a non-structured situation What are the resources that we can give our families our parents and our athletes to sort of? Give them at least that kind of leg up Great question. I think there's a lot of resources for ACL prevention I think one way to keep this structured within a team or organization is this is something where a group Webinar or zoom or I don't whatever company you like to use But a structured lesson going through an active warm-up an ACL prevention program would be very helpful where we get all the athletes particularly the female athletes on a meeting if they can't be in person together due to social distancing and Having the trainer or the coach go through this prevention program now in terms of which program to use that could be the topic Of a whole entire webinar because there's a lot of debate on that both nationally internationally and locally But there are good programs and I'm sure through a SSM We'd be happy to share some of our favorites but I think the way to do that now and to have some structure is to really do this through video conferencing and that way the coach can see the athlete the athlete can see the coach and to get the parents involved because a lot of this Is going to have to be done offline at home with the parents as well And this is where really our technology can be leveraged to really come into play for our athletes Karen I'll give you a last word on the topic Sure, so us lacrosse we developed a cell injury prevention program. That's very similar to that used in soccer So some of the basic ones in soccer, but two two things one, I would say learn a ready position So just like in tennis you're ready that that's what we teach a lot of the athletes That's a great position to be in and to change directions So a ladder drill something like that that you can just put in the backyard a couple cones Do forward and backwards running side to side running get your diagonal running in there, but really work on plyometrics and agilities Well, it's a it's about eight o'clock and I want to thank our panelists. Dr. George champas. Dr. Rachel Frank. Dr. Karen Sutton for really an outstanding discussion We're gonna allow all our listeners if they'd like to send in questions and we can forward them to our panelists and certainly we can post those We appreciate all the support that the American Orthopaedic Society for sports medicine has provided and certainly they have we have a great website sports med org For you to kind of resource. We've got outstanding Information there and a variety of other topics So I want to thank all our panelists today and I appreciate everybody taking their time out for the busy schedule and dr George we're gonna say to you, please stay safe I think you're sort of more at risk and online than the rest of us So, thank you very much and give yourself a hand. Thank you. Thank you. Thank you very much. Thank you very much Alexandra we're gonna take it back to you Great. Thank you. Dr. Bush Joseph for Moderating tonight's webinar that concludes this evening's webinar handling sports and koba 19 Thank you all for joining and participating and sending in questions for tonight's tonight's discussion. We appreciate you joining us and thank you All right guys, thanks very much Thank

Handling Sports and COVID-19

American Orthopaedic Society for Sports Medicine

webinar

mental health for athletes

rehab time for ACL patients

challenges of managing athletes during the pandemic

testing for athlete safety

unsupervised training concerns

phased approach in resuming competitive training

COVID-19's impact on sports medicine