All right, we're going to go ahead and get started. Good morning, everyone. So this is sort of a sideline team physician discussion. added up all of us, how many years of sideline team position coverage we've done. and just kind of help you all. For faculty, myself, I'm Darren Johnson from Lexington, Kentucky. Peter Indelicato from Gainesville, Florida. Jeffrey Baer from Madison, Wisconsin. And we have Ned Amendola from Durham. So four colleges, different areas of the country. And Peter's going to start us off. You want to come on up, Peter? Peter's going to kind of set the table for us. Big picture type things that maybe you think about, don't think about, should think about on being a team physician and all the intricacies of that, because there's a lot of those. Jeff Baer's going to talk to us about common upper extremity things we might see, how we might manage, particularly in season. What I mean by in season is we need them back now, i.e. the next game. Ned Amendola's going to talk about lower extremity stuff, and I'm going to be the cleanup hitter and just talk about maybe the game day and the next day. What do we need to get right, and how do we need to think about that and use our colleagues to maybe get that player back in seven days, if we can. So Peter, thank you. You're up. Thank you, Darren. Good morning, everyone. So yes, let's get started. So I have no disclosures regarding this particular talk. So again, as Darren mentioned, hopefully this presentation will basically set the table for other speakers that will be coming up here this morning. I'd like to focus on the importance of relationships that need to be established between players, athletic trainers, and coaches. And also to bring up... end up with some final pearls, a few of which we'll be dealing with the NIL issue that is that is apparently here to stay. The team physician basically to start off with it's at least my opinion it's it's definitely the most unique role in all of medicine. Why is that? Because team physicians must navigate a very complex landscape where on the one hand they must support the athletes desire to excel and yet on the other hand safeguard their health both in the short and in the long term. And for many of us these team physician that we either pick up on the fly after it, or, hopefully, in our post-graduate fellowship courses, a lot more focus will be talked about, specifically in regards to these important relationships between players, trainers, and coaches. Let's talk about relationships with players first. It's obvious that nothing is more important than developing a sense of trust between yourself and the athlete. Someone once said, a few years ago, to find the word trust, or the importance of it, and said, with it, to constantly build on. It doesn't develop just because you are a famous, necessarily, ACL surgeon or shoulder surgeon or work at a big multi-specialty group and you're the designated team physician as a result of relationships, financial and otherwise. The only way I know to build trust is you have to spend time with the players basically when you don't have to spend time with the players. What does that mean? That means hanging out in practice, training rooms, traveling, meals, et cetera, et cetera. Obviously there are no RVUs associated with trust, so you have to make a conscious decision that this is something that I'm going to want to do and enjoy doing and understand that it's a critically important part of my practice, but it's not going to generate in and of itself any RVUs. You need to get to understand the players and the team, and they come to know you necessarily in the beginning as a team position, but when an athlete gets hurt, you become, and they need to understand this, you become their personal physician. So saying it another way, you may be the team physician, but when a player gets injured or sick, you become their personal physician. Let's talk about relationship with athletic trainers. Athletic trainers, in my humble opinion, is the most critical member of the sports medicine team, and basically that athletic trainer is your storefront window to how the athlete views his or her quality of health care. So the skills of that athletic trainer reflect directly on you as head of that team. Therefore, pearl number two, whenever possible, I really believe you should try and have a significant input into who that athletic trainer is. Certainly input from the administration, input from coaches, physical therapists, and so forth are important, but the team physician should have a significant say in not only the selection of that athletic trainer, but also their evaluation and their retention. Number three is relationship with coaches. I think it's pretty common knowledge that it's easier to establish a good or healthy relationship with any coach the longer or older you remain in a role as a team physician for that particular athletic program. But the coach and all of the administration need to understand that your job, simply stated, is that the short or long-term good health of the athlete, and not necessarily winning games, and your sports health care team, which you are a part of, should be empowered to help succeed in that single goal. So pearl number three, as far as developing relationships with coaches, and this is something that Dr. Amendola recommended years ago, is to try and schedule regular meetings between the coaches and the trainers, almost on a weekly basis, to discuss the availability and the relative status of an athlete prior to a pending game. These meetings help prevent miscommunication issues that invariably arise and help build trust within that group. It's really no newsflash that coaches can be intimidating. However, you should never lie to a coach about the severity of an injury. You should make sure that what you tell the athlete regarding the risks versus benefits of managing any particular injury is what the coach hears as well. And ideally, the coach and the athlete should hear exactly what you're saying at exactly the same time. You should try and resist the pressure to make too hurried a diagnosis. It's better to make the correct diagnosis than the fastest diagnosis. Let's jump ahead to the other section of my discussion, and that is the art-slash-dilemma of return-to-play decision-making. Clearly this issue is the biggest thing that makes being a team physician or a team physician's role so very unique. These return-to-play decisions are always challenging. Sometimes they are made in a public venue, and they certainly all need to demonstrate a risk-versus-benefit approach. We're all, as team physicians, challenged with, can I go back in, or when can I go back in? And especially when you have established a trust between you and the athlete. And as a result of that, the athlete often will rely very heavily on your recommendation relative to the above question. What makes this so much of an art is how you manage these decisions. Individual decisions regarding return-to-play and practice may be complex, and usually are, and should depend on specific facts and circumstances. What I like to say is these decisions, in making these decisions, you have to accept the reality of possible decision-modifying situations. What does that mean? That means that you have to come to a common ground as to what the risk tolerance is that everyone is willing to accept, the athlete and you. But they're all modifying situations. The most common one to bring up as an example is the timing of an injury in any given season. Whatever the injury is, if it occurs in spring practice versus the week before a national championship game, could have an influence on how you decide. You also have to come to realize that there will be pressure on the athletes, and the athletes' desire to compete frequently results in masking the severity of the injury. Athletes don't necessarily want to tell you just how bad or, in some cases, how good they feel for outside-modifying reasons. You're going to feel external pressures from the coach, the family, the agent, and in today's world with NIL, the marketing agent. Certainly there should be a certain fear of litigation that may modify your decision. If you restricted the athlete too much or let them go back too soon. And then there's the obvious conflicts of interest, whether apparent or otherwise, that may influence your decision because of all the financial marketing benefits we get for being a team physician, particularly for a high-profile team. So we come to the dilemma of decision-making. And what is that? Well, on the one hand, when you inform an athlete of their treatment options, whether it's surgical or otherwise, you often have to sometimes, what someone has said years ago, protect them from themselves and emphasize how important the long-term benefits may exceed the short-term gain. And that's the best decision for them. Saying all that another way, you sometimes have to be their mother and their father. That's on the one hand. On the other hand, you can't be too ambivalent. In presenting different options, try and avoid presenting, oh, these are all good options. Any one of them is a good option. So the team physician needs to guide the athlete into making a good decision. And an easy way or a helpful way of trying to do that or convince the athlete of it is to say, well, if you were my son or daughter, this is what I would do. You need to be decisive. Right or wrong, you need to make a decision. Even if that decision is, you know what, I don't know what the best thing is for you right now, but I'm going to go research the problem, ask my peers, some other people in my profession, and I'll give you a much better answer tomorrow than I will right now. As the story goes, the road is paved with flat skulls who couldn't make decisions. We talk about game day's decisions. These are not easy, particularly today in this litiginous world and how it applies to unique team physicians. Despite the threat of reliability involved in being a team physician, it is incumbent upon team physicians to adhere to standards or customary sports medicine practices, which are often, very often, not well defined, especially when it comes to a sideline decision. Here's a fact. Customary sports medicine practices may often differ from traditional standard of care practices. But despite the variaries, the team physician should always make medical reasonable decisions, the term there is reasonable decisions, and provide sufficient medical information so that the athlete is aware of the risks of returning to play. It's important that the physician resists any tendency to be biased. But in the end, again, this is a shared decision-making process, and a decision needs to be made. We all need to be cautious about documenting everything that you do and tell your athlete, particularly in today's NIL world. Saying that another way, in today's litiginous world, medical liability is a huge concern. Now when you're caring for athletes, but not only in the professional ranks, but even now in college ranks, and this is where NIL now is coming into becoming more and more of a factor. A brief word about NIL and the team physician that now, unfortunately, we really all need to pay more attention to. For example, when it comes to liability, if your medical care is considered inadequate, would you be held liable for another athlete's breach of contract, as far as outcomes are concerned? Did the athlete return to sport, yet fail to return to the same pre-injury level of performance? Does that place you at risk? HIPAA violations. Did you inadvertently disclosure hamper an athlete's ability to maximize his or her income? And like I said earlier, documentation. Did you document every conversation you had with an athlete, a parent, a marketing agent, regarding the risks and benefit of any one particular injury that you're trying to manage? So here's some final take home points. First of all, critically, is the administrative aspect of who answers to who around here needs to be addressed. Frequently, preferably in writing at the beginning of every season. Because it's important to establish a clear chain of command prior to any given season, again, preferably in writing, with you as a head team physician, positioned at the head of that chain. You should support second opinions when requested, and not only support them, but assist in making them happen. But ultimately, the final decision about who plays, when they play, or practice is yours. Some more pearls. Always remain open-minded and receptive to new treatment concepts. You don't have to be the first one to try a new surgical procedure, but it's probably unacceptable to be the last one. Frequently, ask for feedback from the sports healthcare team on how to improve things, particularly, particularly really important is communication. If you share team coverage responsibilities with other physicians in your group, make sure you have the same general philosophy on how to treat any given injury or illness. If not, you are going to embed in that healthcare team a lot of unnecessary stress about who they should go see, or who, more importantly, they even want to go see. Try and hold an annual celebration for the sports healthcare team, thanking them for their efforts in taking care of these unique, extremely unique group of patients. So in conclusion, and we'll get on to the rest of the program, being a team physician is probably the most unique specialty in all of medicine. And in certain parts and many practices, it's the best part of your practice. However, NAL has certainly resulted in additional issues that need to be managed. Given all that, I still think it's the best job in the world. Thank you very much. All right, Dr. Baird is gonna come up and talk to us about some upper extremity, common things we see, and some recommendations. All right, so I'm Jeff Behr. I'm from, oops, it won't let me back. So I'm from University of Wisconsin. I've been doing team coverage for 17 seasons now. And I would say, as Peter and Darren said first, is that getting that relationship with the athlete, having your athlete trainer, having that relationship with the coaches is critically important when you make these decision makings. And when new coaches come in, especially new coaches that are signing huge contracts, which we just had, there's a whole nother level of establishing that relationship that you have to start out with. And then availability is the other thing I think is the key to being sort of team position these days. So I'm gonna talk about a little bit of upper extremity type issues here. If we can get this to go. There we go. Just disclosures, none associated with this, although I will put a plug in for the Big Sky sports medicine meeting out in Montana each year that we do in January, February. A lot of athletic trainers, a lot of team physicians there that really help with these type of same issues. All right, so I'm gonna start out just in the basics. So pain medication, the anti-inflammatories are one of the most commonly used medications. Ibuprofen was developed in the 1950s. So it's been around for 70 years now. Most frequently prescribed medication to athletes, about 10%. When they looked at college football players, about 94% of the players use it. 46% of them started using that in middle school. So it's been going on for a long time. One in seven high school players take it daily. And in the college, about a third of the athletes take it for injury prevention and not actually an active injury. And this is sort of repeats the same thing. The Olympic team from Canada, about most of the athletes there use it. It was prescribed the most by the team physicians. About a third of World Cup players use it for every game. And then just sort of repeating this college football from that. And NCAA athletes, they surveyed almost 1,300 athletes from all divisions. This was over a single season. Followed over that season. And when they did that, 43% of the athletes self-purchased it, 12% got it from the athletic trainers. I'd say at our program, I think almost everything comes from our athletic trainers, although Ibuprofen will leave. They have at home, but we usually have that in the training room that we're providing. And there was a correlation of anti-inflammatory use and increased alcohol consumption in these athletes as well. And they looked at sort of males and females. Slightly more females took the anti-inflammatories than males, and then in reported pain, though, the females had more pain than the males. So more males were taking it as a preventative than necessarily the females were. At Rio Olympics, again, a few years ago, 10% used oral, topical, and injectable. NSAID, 73% prescribed a short duration. 12% prescribed higher than the packaging, although Ibuprofen packaging is 400 milligrams and Aleve is like 250 milligrams. So that's not that unusual. 52% prescribed for prevention, so which is a little bit different, right? You're giving it just in case they're gonna get injured, not necessarily for an injury they're getting through. And injectable was felt to be required more for severe pain than the oral. Again, most of these we've all seen and used. Try to use the lowest dose possible. Avoid with allergy to anti-inflammatories. They have a history of GI bleeds, ulcers, gastritis, renal disease, or cardiac disease. This is just sort of looking at the cardiovascular risk factors and just basically showing the different anti-inflammatories and how they relate to increasing risk or decreasing risk for these different ones. So things you just wanna think about when you're prescribing the different anti-inflammatories. What about cardiovascular risk? And this is in football, which many are talking about. So cardiovascular mortality is in retired NFL players highest among those with the largest BMI, so your linemen. Retired NFL increased ascending aortic dimensions compared to controls. Hypertension and body size were associated with aortic disease, not a big surprise there. AFib was more common in your retired NFL football players and match controls. And again, football associated with weight gain is a predictor of later life cardiovascular disease and mortality. So we do wanna be careful on some of these linemen with this. Pre-postseason comparison of football players, again, high school and college. And then they compared them to your non-larger athletes, so cross-country swimming and other controls. They looked at blood pressure, echo, arterial stiffness, and NSAID use. 244 football, about half of those were linemen, and 60 others. Football had NSAIDs use increased parallel with increased weight, so the bigger guys tend to take more anti-inflammatory than the smaller guys. In football, they had increased diastolic dysfunction, arterial stiffness post-season, but that didn't necessarily correlate with the NSAID use, and no change in the college controls. There is something in football that's different. And then consider the risk in the football players, especially the larger players, and how much you're using and how long you're using them. So Toradol, I think there's always that interesting one about where people fall. It does have strong analgesic properties, acute strains and sprains, using overuse injuries in post-surgical as well. I use it in almost all my ACLs, my rotator cuffs, just to decrease post-surgical pain. Given either orally, IMIV, or intranasal, media really got focused on the use of it in professional football. This was a study, 28 of 30 NFL teams used intramuscular form in the 2001 season, one to two days of pain relief in over half the players, six adverse reactions with muscle injuries, GI upset, and post-injection soreness. Players felt getting a shot was a sign of getting more powerful medication than the other. I did have one of our tailbacks a few years ago, had an ankle sprain. He was doing fine, didn't really need anything, didn't want anything. Talked to one of his former teammates that was in the NFL. He's like, you gotta get the shot, get the shot. You just get that. He goes, I'm fine. He goes, no, you gotta get the shot. And so we had that discussion with him. We don't do the shot anymore, but definitely at that higher level, just the thing that they're using it for preventative a lot of times. Media is focused on players getting a shot of pain medication for return to play. And so that became a big issue that came out with Tordal. Pharmacokinetics, the peak plasma concentrations are actually faster with oral administration than with IM administration. It lasts for six and a half hours, so the length of a game typically. It's treated by the kidney like the other anti-inflammatories. I get equivalent plasma concentrations orally or IM. And typical oral use is about 10 milligrams every six hours. And IM or IV dosage, 30 to 60. I'll sometimes will go up to 20 orally for that. So what, so the NFL had a big issue with that and lawsuits came out of it. So the team physician recommendations that came out a dozen years ago. So players should be informed of the risk and benefits of all anti-inflammatories, including Tordal. Should only be used for documented injuries, not for preventative use. That you give the lowest effective dose. Don't do it for more than five days in a row. I recommend PO dosing over IM or IV dosing. And don't give with the other anti-inflammatories. When they looked at sort of college and pro back in 2002 in the NFL, about 63% reported use of Tordal. Again, I think this sort of the secret that sort of kept on the rug a lot of times. 2016, 48% from my contacts with some of our skilled athletes that have gone to the NFL. Almost all of them are still using it at that point in the NFL. College reported in 2008, 62% usage and then that dropped by over half in 2016 down to 26% usage. Again, that's what people are reporting. So this is what we do. On the side is our consent form. If anybody wants that, they can reach out to me. I'll send them a copy of it. We use it very limited now versus when I first started 17 years ago. We only use an oral use at this point. Usually do 10 to 20 milligrams, most of the time 10. Full discussion with the athlete about the option to use. And so we usually have this discussion on Thursday. So we're already thinking about game day advancement as we go through. Risk and benefits are discussed. They do have this information sheet consent form that they sign, the athlete trainer sign as well. We go through that with them. For that, I do get some labs each week if we're gonna use it. Just that way the athlete knows that we're checking and making sure that it's not just this simple thing that you're just gonna do. So there's a little bit of effort into it. No anti-inflammatories used on the day of the game. And then I provide the medication to them. Usually when they're coming off after warmups before going out to the field for the game. Limited to two consecutive weeks. If they need it longer than that, then we sort of hold them out of play. Local anesthetic injections, just going to this one. They've been used for a long time since the 1960s. In Australian rules, up to 66% of players admitted using it for matches. No randomized trial to look at the effects of it. And studies are limited to case series and cohort groups, professional athletes. And you have to weigh the risk and the benefits of injecting from blocking the pain versus injury progression, depending on what you're trying to protect from. And again, this is where, as Pete was saying, you really do have to have that discussion with the athlete. And you have to have that relationship with the athlete and the athlete trainers to have these discussions about what's the risk, what's the benefit, and what are the complications of doing this. Sites of injections, this was from Russ Warren with the Giants, three consecutive seasons. Anesthetics and steroids, they had 37 injections over the three seasons. Again, defensive backs, linebackers were the most common. If they were injecting near a neurovascular structure, they do that with ultrasound guidance. Again, they usually gave the administration about an hour before game time, and they didn't have any complications or progression. Um, injections by injury. Um, and these were the most common ankle sprains. Um, I will say I haven't done much for, for ankle sprains as far as injections go. Um, MCL sprains, uh, rarely. I've done it, I think once. I know a Sunday at Tingstead, he did a PRP injection for a guy that really got him back pretty quick. Um, not the same day, but soon after. Um, AC joint. That's the one I probably do the most common as far as injections go, uh, with my athletes. Um, again, this is sort of look at sites of injury and injection. This Australian rules football, six years, um, of coverage, 268 injuries, um, 10% of players utilize the injections. No long term complications. You can see here, again, rib injuries, iliac crest. So hip pointers, AC joint were the most common as well as some hand injuries. Um, this is again, follow up study. They followed him for 10 years that over a thousand injections were given. Average follow up was five years. Almost all the athletes said they'd repeat the injections or the procedure, even though a third of them felt there were some side effects associated with it. And, um, about a fifth of them thought it delayed healing, but again, 98% would repeat it for return to play. So again, these discussions are ones you have to have with the athletes. Sites of injections, they were typically divided into high risk and low risk sites. Low risk to be AC joint, uh, fingers, rib and sternum, hip pointer and conic, uh, plantar fasciitis can be used. Higher risk ankle sprains, tendon injuries, pre-patellar electron on bursitis, just for risk for infection, metacarpal and radiocarpal injuries. And so complications, uh, they're rare. Um, they're really hard to sort of determine a lot of these, uh, progression of knee and ankle arthritis, uh, following years of intraarticular injections. Um, I'd say that's something that's really not done much at all anymore. Uh, several former players did sue, uh, in the NFL for, uh, for negligence for that, uh, progression of fracture, uh, navicular scaphoid and lunate need to be ones that you need to be careful of. And watch for us for a tendon rupture, especially with steroid use and then getting a motor block, uh, which has been reported every once in a while. A pneumothorax, uh, famously in the NFL happened with that. Um, so ultrasound guidance, uh, I typically will use ultrasound for, uh, more of a chronic injury. If we had an AC joint injury that we're doing year or sort of week after week for, for a few weeks there, we'll use, uh, ultrasound guidance for that. Um, and this was a study they did in Australian rules football. They did 11 injections, no complications. I think in our situation, if we have something that we know we're going to inject, the ultrasound does make it a little bit more accurate. My primary care partner does that, does an excellent job. It just takes a long time to get it set up. If we have an AC injury in a game, that's one that I'll just do, uh, cause we can do it much faster and get the athlete back. Although I will say that the accuracy of the ultrasound, uh, doesn't make it better. It just takes a long time to get it set. Um, so what have I injected? AC joint, SC joint, hip pointers, rib injuries, toes, um, ankle occasionally, MCL occasionally, but really not frequently at all. Uh, discussion with the athlete, the risk of playing with the injury, complications, benefits all go into that. Uh, typically I use a lidocaine and rapivacaine for that inject just prior to going out to the field for warmups, just because they get padding and everything else. I'll go over that. So typically not when they come in for warmups and I'll, I'll possibly reject that or repeat that at halftime. So going to the upper, upper extremity things, AC separation, uh, usually when they get injured, it'll be hard for them to move. Uh, they'll have a decreased strength, especially when you try to hold them out into abduction. With that, most common is sort of football, hockey, uh, bike racing. We'll get that too, uh, typically sling and ice. Um, they, a lot of times they may need that sling for one to two weeks. Uh, they can consider padding, injection of ibuprofen and Tylenol for the games. Uh, common symptoms last for a couple of months, uh, until they get all the way better. Uh, most of these do not require any surgical intervention. This is one of our linebackers injury while making a tackle during the game. He was completely tender over the AC joint, a little bit of step off there, quite a bit of pain. Uh, couldn't really raise his arm, uh, without, without having a lot of pain. We brought him back to the locker room, got his x-rays at that point. His x-rays otherwise looked normal, just making sure we don't have a fracture that we're dealing with. Um, talk to him at that point about, you know, we were in the, just starting the second half, you know, do you want to try to come back? Um, do you want to try an injection? He was like, yeah, we wanted to do it. Uh, so we injected his shoulder. We did the, uh, padding and taping for this, like this. Um, we did give him ibuprofen. He hadn't taken anything before the game. Tylenol as well. Did the injection in the locker room. Um, and then, uh, after we did the injection, he came, uh, running back out in the field full speed. Uh, we'd just gone to defense. So he just went right into the line, uh, back to play at that point. We did put him in a solid sling. I think that does tend to help provide a little protection for that. Um, again, oftentimes repeat these for a few weeks, the grade ones, one to two weeks in the grade two to three is four to five weeks. Typically, uh, we will use toward all sometimes with that or ibuprofen and Tylenol, although it seems like the block tends to do the best job for them. SC joint injuries. I haven't seen a lot of these, but, uh, they do come along, uh, once or twice, um, every couple of seasons. This was an offensive lineman. He actually injured this initially, um, when he was in high school, when he had just moved to Madison. Uh, acute pain over the SC joint during field goal protection. I feel like in the same injury he had, he was tender over the SC joint. We did, um, on him, we had x-rays before, um, we did examine them in the locker room. We didn't feel there was any fracture. We did get x-rays. Um, he, he did wish to try to, to return to play. We did do an injection, um, in the locker room, basically bathe this area with about five cc's of the lidocaine or pivocaine mix. Um, and then, uh, his pain improved. He was able to protect his arm, able to return to play. Now he was only doing a special team, so it wasn't like every play. I'm not sure he could have gone back as a, as a lineman playing every play at that point. Um, since, uh, in high school, we did do a corticosteroid injection to the SC joint for him. Uh, that worked really well in high school. So we wanted to repeat that again. We did it two days after the game. He was able to make it through the rest of the season without any issues. So this is a little bit different one that we'll all see. This is shoulder instability. This was a freshman, a fullback, uh, that came to us. Uh, he was a local kid, uh, walk on at Madison, which, uh, was a, was a big deal, um, at the time. This kid was like that, just a great kid, great family, um, knew him and his sister and his parents really well, uh, throughout his career, but he had an anterior shoulder dislocation near the end of fall camp, uh, reduced on the field by our athletic trainers, x-rays were obtained, um, that wasn't his x-ray, but these were his here, um, showed the shoulder was reduced at small hill sacks. Um, this kid was one that was probably going to play. Um, he was going to be a starter, play on special teams as well. Um, so we had a discussion with him about what he wanted. We did get an MRI. We showed the Bankart tear, uh, for him. Um, he wanted to try to keep playing. So we, we put him in a, uh, a shoulder stabilizer, uh, type brace, uh, progressed range of motion tolerance. Uh, I got a strength back. We did discuss surgery and non-surgical options. He wished to brace it, tried to go through the season. Um, he was able to return to play a couple of weeks later. Uh, he did wear the shoulder brace throughout the rest of the season. Um, he did have an instability event on kickoff coverage against Ohio state, made a tackle on the sideline. He was down, pain went over, reduced his shoulder, um, on the sideline. He hopped up and like, okay, I'm ready to go back in. We didn't let him go back in. He was pretty sore a little bit later, but you know, once we got his shoulder back in, he felt a lot better. He did go on to play the rest of the season. We did discuss fixing it again. I did repeat his MRI at that point. We fixed his shoulder after the season and continued to play another three years for us and then the NFL for a short period of time. Uh, this is another one. There's a defensive back. Um, I did his labor repair two years prior, uh, felt his shoulder slide, but not dislocate during the game. Mild apprehension, but a good strength. We did place him in a shoulder stabilizer at that point. Uh, he was able to return to play. X-rays didn't show any changes. He did have a small tear on his anterior labrum. Uh, so it did have probably a subluxation event. Um, he wore the brace at the end of his career and didn't want anything else done. Um, he tried for the NFL, but just wasn't quite big enough or fast enough for that. Another one that we see frequently are stingers. Um, and this was one of our starting offensive tackles. I will say I've seen this more in our, in our linemen, our offensive and defensive linemen. I've seen that typically in the other players. Uh, you get pain and numbness down his left arm, down to his fingers. His arm would feel dead, uh, feel like his neck and arm got stretched. He had more of a tension sided, uh, stinger on that one. Uh, no cervical tenderness. Symptoms were really isolated just to that left arm. Four to five weakness on the triceps. Biceps was slightly weak. Deltoid was relatively normal and wrist was normal as far as strength was concerned. Did have some generalized numbness, sort of that stocking glove type numbness that he had. Um, this is just one, let me go back. And again, this is one, this is pretty much isolated to just being a stinger at that point. But if you do get bilateral symptoms, you want to think about cervical spine injury at that point. So serial examination, he had no neck tenderness. His strength got back to normal. Sensation returned to normal. Um, he had some protective strength at that point. We'll let him go back in and play. Um, he did have a couple of poor, uh, mild episodes in that game. Had a stinger last season as well. He got x-rays, MRI after the game, which were normal. We did place him in a, uh, in a CUR collar, um, after that point. Um, just because he had some of those symptoms. Again, there's his MRI results. Um, that will sort of decrease motion, decrease their ability to go to the sides. Uh, we did give him a MedDRAW dose pack, um, and then followed that by naproxen for a month, which really reduced his symptoms. He was able to complete the symptoms with no really significant, uh, recurrent stingers. This is the one where I use a MedDRAW dose pack most frequently with stingers. And it seems to really do have a good effect for that. Uh, this is one we just had. Um, this, uh, spring ball, uh, probably decreased our injuries during spring ball, uh, with this kid getting injured. Cause he's like a missile out there. He's a defensive back, uh, immediate shoulder pain, finally a tackle. Uh, the runner, um, couldn't move his shoulder at 10 out of 10 pain. Um, I was with my kid at a hockey game at this time and was coming over to practice afterwards, my, my fellow was looking at him, uh, we were getting x-rays on him, um, at the point fellow thought his shoulder was dislocated. Uh, again, his pain was all around his shoulder. Sensation of vascular was tacked. Uh, difficult to examine, um, until we got his pads off. And it's still difficult to examine because of pain at that point. Uh, we did get x-rays at that point. Um, and we, on the x-rays, we were able to see this fracture line coming down here on the scapula. Um, so we had the scapular fracture, um, with that, uh, here's, you can see on the CT scan, you can see the, the, the fracture. Oh, it's not showing up here. Um, the fracture line coming right down here. And then you can see the fracture line here on the CT scan as well. These present with a significant amount of pain. Uh, they don't want to move their arms. It takes a while for them to feel better. Um, uh, sling for comfort. It usually took, it took him about two or three weeks to come out of the sling. Um, and then working on range of motion, strengthening the hardest thing we had to do at the end of spring ball was keep him off the field. Uh, this kid was a, it was going to be a senior this year. Um, and just keep him from doing too much to either injure other players or injure himself further. Um, six to eight weeks is usually the amount of time it takes to come back from these. So rib fracture and contusion. Uh, this is one of our, our tailbacks in the side on running play, immediate pain, difficulty taking a deep breath. Exam is directly tended over the mid thoracic level. No crepitus pain with deep inhalation, no upper quadrant opposed to your flank pain. Um, we did obtain x-rays, make sure it wasn't a fracture there. Most can't return to the same, same game. Um, injection can be helpful for a few weeks after that. This is not one I'll typically do just on the sideline or back in the locker room on game day. Um, for these, um, I used to do them blind, but now we do these under ultrasound, uh, just to make sure we don't get a pneumothorax with that. Uh, protective padding can help. But usually those first week or two, they're, they're really too uncomfortable to keep going. Um, this was one of our offensive linemen, elbow injury, uh, arm got caught out during a run set, immediate pain over the triceps. This kid's tough as anything. He dislocated his patella when we were playing Nebraska. Uh, went back and play, um, and just a brace. He was like, I'm fine. We tried to get him for x-rays. He didn't want to do that. Um, we did a surgery on, uh, on Monday, uh, when we got back from Nebraska, uh, to take out about 15 loose bodies from his knee. Uh, but he was tender over his distal triceps, no bony tenderness. His elbow was stable, no nerve injury. His biceps was normal. His triceps was weak. Um, he wanted to continue to try to play. Uh, we tried to do some, uh, run and pass sets on the sidelines. Couldn't lock his arm out. He couldn't really get in position to do that. Uh, we tried to soft strap brace. Couldn't feel like he could do enough. And then we went to a hinge brace. Uh, then we locked it to not allow it to flex too much. Um, and he was able to play in that, uh, his x-rays were normal. Um, we did get an MRI. We showed a partial triceps tear. Um, he wanted to have surgery, um, after the season, my, my hand partner was going to do his surgery. Felt with just with that partial tear that we could wait, uh, on that. Um, he, uh, he was successful after the arm surgery, although he hated the block. And so when I did a shoulder surgery after the season, he didn't want any block for that. Um, so this is, this is one, one we had a couple of years ago, and this is where it's important to have good consultants with yourself. So this is a tailback injured his arm in the third quarter while being tackled. We were playing at Northwestern. I hate playing at Northwestern. We always seem to lose. And it's a horrible place to have to play, uh, immediate pain. Uh, he was down on the field pain over the mid shaft of his radius or his crevices on exam, uh, with that, uh, we got x-rays, um, and it's like, you have to go back underneath the stadium with the crowd there and everything like that, again, just a pain in the ass and we're getting our ass beat. So it wasn't good. Um, we put them in a splint at that point. Um, John Teeting, who's, who's my hand partner. He, he, uh, moved down to Chicago area. Uh, he tends to come to several of our games, especially down in Chicago. He's there. Um, so we had the x-rays, um, for him. Um, and then John, John was like, well, you know, I can fix it tomorrow morning. Um, so in the locker room, after we were arranging a hotel, we were arranging with his hospital and everything to get fixed, um, at that point. So John had talked to him about doing a long plate. This was the plate he used on his arm, uh, for that. So pretty big exposure to get this fixed, but he really wants stability for this kid. And this kid's like just a great kid. He was hoping to go to the NFL, but a variety of injuries that probably held him back from that. Uh, he wants to try to come back and play. Four weeks later, his fracture was healing. Well, uh, we put him in an FRC splint his first game back. He went for 98 yards, probably kept us in a bowl game. Uh, with the, with his, uh, with his play that day, uh, we didn't get x-rays afterwards, just make sure nothing had changed and he did well from that point. I played the remainder of the season, played bowl game without the splint on. So, um, again, being aggressive on some of these factors can make a big difference against some of these kids back. Um, wrist pain is a defensive back fell on outstretched hand and practice radial side, wrist pain. X-rays were negative. Um, at that point, we placed him in removal, a thumb spike, a splint. He was able to practice, uh, with that play in the spring continues that radial side arm pain at that point. We did repeat the x-rays and at that point, and this got sort of messed up, um, in the, in the translation here. But, um, he did have a scaphoid fracture non-displaced. He had a screw placed the next day again by John down in Chicago. I did try to play five days later, but he was hesitant. Just had soreness over that area. That was the last game of the season. Um, and then, uh, I was able to, to come back and play in the bowl game without, without any problem with that full fracture healing. Uh, so being aggressive with some of these fractures, and if you have good athletic trainers with good confidence discussion with your hand surgeons, as well as with your, um, with the player getting these and protecting these, you can allow these athletes to go back to play pretty quickly. Um, this was another one of our, um, uh, tight ends, uh, jammed his thumb during the game, he's actually done this to both sides, get MCP pain. He wanted to tape it up at that point, be able to complete the game after the game, he was tender at the MCP joint tenderness over MCP UCL and did have some laxity testing at that point. X-rays did show the small avulsion fracture of the UCL, the proximal phalanx, um, he had surgery on Monday, um, repair to the UCL. Um, he had a internal brace placed with that as well. Uh, FRC cast, um, with the thumb covered and we went down to the wrist initially, um, at that point, but we didn't go across the wrist. Um, he was able to play that following Saturday with the brace on and sort of modifying his gloves so that could work as well. Um, we would slowly cut down on the braces. We went through the season. Um, again, he's gone through this twice and has done well with it every, every time. So, um, these, you can get back to play pretty quickly, um, with these and just make the progress going at, this is where we moved this point down to eventually just doing that to, to nothing at about the six week point. Um, this was, uh, another, uh, tight end. This was in a practice. Uh, I got stepped on, um, we had his glove on at that point. We took his glove off. He had this deep laceration on his hand. Again, this is where you want to have a good hand surgeon. Um, so down in training room is a Saturday practice or I guess Thursday practice. Um, we had that, these were his x-rays, his x-rays were negative. So at that point I gave, uh, John a call. Um, he came over, grabbed, he stole instruments from the OR. He said he borrowed them. He sort of stole them, went up and just grabbed them. I came down, we washed it out real well. We did a little block on him, did a layer closure. Um, we did put them on Keflex just to protect that. We did have a custom, uh, carbon fiber, uh, uh, basically a split made for the back of his hand just to protect that. And he was able to play without any issues with that. So again, being active. So PIP dislocations, um, starting cornerback, um, acute PIP dislocation, uh, dorsal dislocation, obvious deformity, reduction down the sidelines as he comes off, his finger did feel stable at that point. Uh, buddy taping that, allow him to return to play. Um, at that point, x-rays again, after the game were negative, uh, on him. We utilized buddy taping for a few weeks and just sort of progressed him with that. Um, this is a safety sort of with a thumb injury, uh, trying to break up a pass, swallowing antennas at the CMC joint. Crepitus, uh, was novice. These were his x-rays. Uh, not quite as good as the other ones that we saw. So we had a little bit more than we're dealing with than, uh, than a UCL, uh, type injury. And that we did have a CT on Monday morning, which is shown here in pretty complex fracture. So, so this is one that had the Bennett's fracture there. John, uh, fixed this one on Monday morning as well. Um, his, his feeling on these is sort of overtreat these. So if you do put pins in these, which is completely acceptable, and this is sort of what Pete was saying about sort of the difference between just sort of standard care and then tearing for the athletes is you have to be more aggressive with your fixation on the athletes. If you put pins in this kid, he's out for probably the remainder of the season. But if you go and do internal fixation and put more screws in, then you might do in somebody else. So you allow these athletes to get back fairly quickly. Um, and him returned to play and missed one week, uh, play with a thumb spica with a tip protected on that. And that's sort of the glove he had on. Uh, this kid happens to also be the athletic trainer or athletic director's grandson at the time. So a little bit of pressure on John, uh, but we were able to get him back without any other other issues. So again, another dislocation, MCP joint, uh, attempt to body tape, can't push or grab with his hand, uh, wants to try to play. We did place him into a club where we protected it at that point. Um, this is what we sort of put them in. He's able to play the remainder of the game. Here, here was his X-ray. John would call this sort of the Pac-Man injury. Um, again, it's the ring metacarpal head fracture CT scan. That's that on Sunday morning, this was surgery on Monday, uh, with that again, a couple of screws inside that metacarpal fracture. Um, there you can see the screws placed there again, if you pin this kid's done for the season. Uh, so internal fixation gets that done. He was able to play the following week, um, utilizes the club for the next six weeks and felt protected in that he actually could have come out of it earlier. He just liked having the club on. I think he could hit people more was part of it. Um, so there's inclusion. Uh, many of these injuries, uh, can be managed on the sideline and allow same day return to play. I need to have a discussion with the athlete is as Pete was saying, uh, to discuss the full risk and benefits and potential damage of playing with the injury or, or coming out sports position and time of season is all important for that. And anti-inflammatories are commonly used in this population. You can use toward all, but you need to have a discussion with that. Um, I use it, but last year I think we used it five times the entire season. Um, so really not very frequently, um, need to have that full disclosure. Local anesthetics can be helpful. Uh, most are safe without complications, but a few you need to be careful with ultrasound. We'll use typically for long-term injuries that we, we know we're going to inject ahead of time. Um, and high risk ones, uh, long season sports with multiple games per week are less commonly used toward all injection for gameplay, except when you get into playoffs. Um, avoid intraarticular injection for athletics and for game day play as well. So I have, thank you. And I think Ned's coming up next. All right. Thank you, Jeff. Dr. Amendola is going to come up and talk to us about some common lower extremity injuries we see. Thank you. Good morning. So I think the foot and ankle is probably one of the areas that you do have to make sideline decisions much more frequently, because they are frequent. And I think if you're on the sidelines, team physician, you're going to have to kind of assess them and make a decision, sometimes even without any imaging. All these injuries are a spectrum of severity. So I think you have to individualize your approach to the, so how are you doing this, Jeff? Just by pressing it. There you go. Anyways, in general, to make decisions on the field to let people go back and play, I think you should be able to understand what the actual injury is. Is it a stable situation that they can go back and play? And is the risk low to subsequent injury or more severe injury? And I think if those questions are answered, you can let them go back and play. Can they play safely? Meaning, is their pain at a level that's not going to prevent them to protect themselves? Can they play effectively? And you're not going to be able to make that decision that's probably due to the trainer and the coach to make those decisions in terms of they can play after you say you're going to medically let them go play. And can they play generally pain-free? Again, I think that allows them to protect themselves and not have any subsequent injuries. I think these are factors that will, and I'll show a couple of examples. The game situation, I think Pete already touched on that. And the athlete status on the team, the type of coach, you have to understand the type of coach you have. Some coaches are very aggressive and progressive. Some coaches are very safe and cautious. And I think you have to understand where they stand. And then the patient's history of injury. So obviously, you're communicating, get to know the players. And you can decide if you should let them go back and play or not, depending on the injury. Here's an example. This was a very big game at Duke with North Carolina and Zion Williamson. And here he is just at the beginning of the game. He slips and falls there. And he ends up basically tearing his shoe. His foot goes through the shoe. And he slips on the floor. And he has a very mild MCL injury. And he probably could have gone back in and played. It was very mild. But since it was in the season, there was no reason to let him go back and risk anything. We decided to keep him out of the game. So again, as Pete mentioned, the sports medicine team, I think, is really an enjoyable part of my job. And that's why I keep doing it year after year. But I think you have to manage things properly. And you have to make the right decisions. You have to keep everyone aware on the team what's going on so that you develop that trust. And the way you do that is to make sure you have clear, transparent communication with everybody on the team. So if everybody's functioning together, you have a seamless approach to every injury, then I think you're going to get much better outcomes, much better results. So if I think that we should do something and the trainer thinks we should do something else, I don't think that's a good situation. I think you kind of have to be on board and do what's required. So again, we talked about building trust. And again, I'm not going to go over everything again. But these are the common foot and ankle injuries that we get. And again, there are various severities. And so the mild ones generally get to go back and play. The more severe ones are not going to be able to play. And they're going to need some surgical treatment. So here's an example. This was a female basketball player had an acute lateral ankle sprain. And we thought that she could go back and play and continue playing after a few days and really was not able to play. And when you look at her x-rays, everything looked pretty normal. And then we got more imaging because she was not able to go back and play. Now you can see she's got an anterior process fracture of the calcaneus. And that's the reason she was unable to return. So it's not a simple ankle sprain. It was an ankle sprain associated with a fracture. So again, with ankle sprains, the most common reason athletes are unable to return to play is because they have an associated injury. So they have a syndesmotic component. They have a deltoid component. If they have a periarticular fracture, so anterior process of the calcaneus, base of the fifth, medial or lateral dome of the talus, avulsions off the medial or lateral malleolus, they're going to keep the athletes out. And they're not going to be able to return to that game. So it may require further investigation. We'll move on to high ankle sprains. This was the AFC championship game a few years ago. And I don't know if you guys remember this game, but the tight end, Gronkowski, had a severe syndesmotic sprain right here. And you can see here, he's wailing in pain. He's unable to weight bear. And you can tell this is a severe injury. It's a severe high ankle sprain. And again, I just want to show it again here just for the mechanism. It's an ideal mechanism here with the loading of the foot, external rotation, as you can see there. And so if you remember that game, that was two weeks before the Super Bowl. And he tried to play in the Super Bowl and was unable to play. He was in for one series. And so here was a much more severe injury, unable to play, unable to continue. But because it was the Super Bowl, they tried to get him back. They used some local anesthetic, used everything, but really was too unstable to continue playing. So here's another example of one of my players, offensive lineman. He's the center, very experienced. And he sprained his ankle. And he played the whole game, not like Gronkowski. He played the whole game. At the end of the game, he basically complained of some mild ankle pain and swelling. He really did not have much to find on physical examination. We thought he had a high ankle sprain. And we did X-rays. And we did an MRI, which kind of confirms that he had a mild high ankle sprain, but not a severe sprain. And so we just allowed him to play the next week. He played the next five games. He wasn't 100%. And then at the end of game five, near the end of game five, he re-injured his ankle, could not weight-bear, much more significant findings. And I wanted to show this just so you learn from all your experiences. So what's wrong with our screen down there? Not working so well. It's like a psychedelic screen here. It just keeps going on and on. But this one's fine. Anyways, I just want to show here. So here we repeated the X-rays. So he got injured near the beginning of the season, played five games, got re-injured. And now here's the repeat X-rays. And you can see the amount of calcification he has there between the tibia and fibula. So what does this mean? It means that he probably had an unstable high ankle sprain. We made the conclusion it was stable. He was able to play. He played at 80% or 90%. His ability allowed him to be at the level to be able to compete. But again, this shows the issue with high ankle sprain. Sometimes it's difficult to assess the severity. So that amount of calcification indicates it's probably worse. And now he's got widening. You can see he's got widening between the tibia and fibula. And it's a much more unstable situation. And the MRI confirms that. Now you can see he's got both anterior and posterior disruption on the cross-sectional cuts. He's got some deltoid edema. He's got some posterior and anterior bone bruising on the tibia. So we ended up doing surgery after this injury. And just to show you the pathology, you can see the drive-through sign on the arthroscopic views here. And you can go from front to back. And so there's the pre-reduction and then the post-reduction. And I think arthroscopy in these situations helps you a lot. It helps you assess the extent of the injury, any cartilage injury, any chondral scuffing. And then after you reduce it, whichever technique you use, we use tight ropes on this one. So here's the pre and post, the arthroscopic confirmation of the reduction. And so everything worked out well, stabilized. And we got him back to full activity. So again, reviewing high ankle sprains. So this is what we see arthroscopically in a normal ankle. So that's the distal tibiofibular ligament right here. And this is a normal ankle, normal ankle arthroscopy. And so just imagine, you can have a high ankle sprain where you can just tear a few of these fibers. So that's just a very mild injury that occurs with every ankle sprain. So sometimes delays the return after a regular ankle sprain. Now, if you have a external rotation mechanism, you can tear the whole ligament. And that keeps going through the space between the tibia and fibula. It goes posteriorly. And then you tear the posterior ligament as well. So if you keep that in mind, you can see you can have different severity, where you have a normal ankle. You have just an injury to the distal fibers, the second image there. And then you can have complete disruption. And then you have basically tailored displacement and tibiofibular widening with a complete injury. So I think you just need to keep that in your mind when examining these athletes, all the structures that can get injured and the severity of injury. So in these cases where the x-rays are normal, there's no radiographic widening, we don't really have an accurate test of figuring out if it's a stable, unstable injury. So you have to look at the injury mechanism, examine them and re-examine them over the first couple of days. Get the imaging and see if the imaging correlates with their examination. And then sometimes you have to do an arthroscopic evaluation. We actually go in and confirm if it's stable or unstable. And if it's unstable, then fix it. Move on to stress fractures around the foot and ankle. Again, this is a common occurrence that happens in sports. And this is the question. Is it a high risk or a low risk fracture? So this is one of our basketball players. He's currently playing in the NBA. He's doing really well. But he started to develop some lateral pain in his leg. And you can see his x-rays are completely normal. And then here's his MRI. And he's got all this edema around the fibula. And he had basically a fibular stress fracture. So how did we treat him? Well, we just kept on allowing him to practice and allowing him to play. He didn't miss any games. And he had a fibular stress fracture, which is a stable, low risk stress fracture. On the other hand, if you have a tibial stress fracture, I think that's a different story. As you can see here, a tibial shaft stress fracture with a tibial edema. I think that's a much higher risk stress fracture. And I think you really have to consider things carefully if you allow athletes to play with a tibial stress fracture. You don't want this to happen. So a much more high risk fracture. And I would recommend with the tibias that you probably should fix them and take them out of activity. Fifth metatarsal fractures, you can see here. So these are common stress fractures that happen during the season. The athlete will twist their ankle and they'll start complaining that they have some lateral foot pain. But they've had some lateral foot pain probably for a while. And so this is a typical fracture through a stress fracture in the base of the fifth at the junction of the metastasis and diastasis. And obviously, these are treated with screws. And I just put this up because my general approach is to use physical examination and recovery to allow them to go back to play. So I usually let them weight bear right away in a boot. After a couple of weeks, we get them weight bearing in a shoe, start some pool work, pool running. And depending on the athlete and depending on the sport, they can go back and play with an orthotic. You can use a clamshell brace to protect them. And again, you can use everything to help the healing, bone stimulator, vitamin D, orthotics, I think are all required. Now, there is a risk of refracture. And again, this question may come up with the discussion. And some surgeons don't like to send athletes back until you have complete healing. They may not send them back till three or four months after fixing a fifth metatarsal fracture because of the risk of refracture. And I think that's a point that is controversial. I think if you're waiting for complete healing of the fracture, it's probably going to take a long, long time. So generally, I don't depend on complete healing on x-rays or CT scan. But again, if the athlete's concerned, if the agent's concerned, then I think you may have to do that. As I just move through here so we get through the messages, high risk versus low risk stress fractures. And a little bit about LISFRAME. A little bit about LISFRAME sprains. Again, this is a common injury that we see in football and we see in other sports. And again, it's a spectrum of severity. And I think it's important to assess if these are stable or unstable injuries. And again, if they're unstable, they need stabilization. They're going to be out for the rest of the season and probably be out for six months before they get back to activity. So the important thing to understand with LISFRAME injuries is the medial column is the stability column of the foot. People need it to push off. They need it to jump. So it needs to be stable. So if there's some instability, they're not going to be able to do that. So it's really crucial to determine the stability of the medial column for LISFRAME injuries. And how do you do that? Well, this is a good study that shows that if you do an MRI of the foot and you can see the LISFRAME ligament on the MRI, it usually indicates that it's stable. If you can't see the ligament on the MRI, then I think you have to do some stress testing and further evaluation to determine some instability. And there's a lot of articles written on LISFRAME injuries. I like this one, Christopher Tullo and Jim Nunley, in terms of the classification. So you can have a sprain with the ligament intact, and those are stable. And those can be allowed to rehab and get back to play quickly within one or two weeks after the initial sprain. If it's a stage two, where they have a little bit of widening and the ligament is disrupted, all of these are going to require surgery to stabilize. So that's the key question. Is it a stable injury? They have normal X-rays, normal weight-bearing X-rays. The MRI, you can see LISFRAME's ligament intact. And if you do a stress test under anesthesia, you don't get any widening. If that's true, you can let them go back and play without doing anything to the LISFRAME joint. So here's an example. This was a lineman. He got caught up with his foot. It's a game situation, you know, you have to change game plans as things move along. But anyways, this is a football lineman. He got his foot twisted. X-rays are normal. You can see his weight-bearing X-ray relations are normal. But he had a lot of pain and swelling around the lisfranc joint. And so we decided to do stress views under anesthesia and determined that everything was stable. He basically, you know, he had no translation. You can see a little bit of widening, but really no translation and no movement between the first and second metatarsal and the medial cuneiform and the second metatarsal. So we basically didn't do any surgery, just woke him up, rehabbed, and he ended up playing two weeks later. So the non-operative treatment is to make a clear diagnosis. You know, you just rest him until the pain is resolving and then get him back to play. Often a custom orthotic with a UCBL insert will protect the foot, you know, from further injury. Here's a very similar example. This is another lineman. You can see the X-rays are normal. There's a hint of widening, but, you know, they're relatively normal relationships. And we took him to the operating room. And here's the stress X-ray under anesthesia. And it's a lot different. There's widening between the medial cuneiform, the base of the second, and some lateral translation. So we just went ahead and fixed that with a Lisfranc screw percutaneously. Just move on. And so with Lisfrancs, again, the key question is, is it a stable injury? And it's up to you to determine the stability of the injury before moving forward. And then finally, just turf toe is a common injury that we see. And most turf toe injuries, the plantar plate's intact. It's stable, doesn't need surgery. It just needs some rehab and splinting, you know, with a turf toe insert in the shoe, a stiffer shoe, and allow him to get back to play. This is a defensive lineman had a severe injury. You can see the bruising. You know, you can predict this is gonna have a significant injury to the plantar plate. So initially you get x-rays, and you can see the medial sesamoid. It's displaced compared to the lateral sesamoid. So this is an incomplete injury, but definitely the medial sesamoid part of the plantar plate is injured. And then this is confirmed on the MRI. You can see the location of the medial and lateral sesamoids are different. And so we went ahead and we ended up doing surgery on this case, but this is a case that you could consider, depending on the time of the season, allowing him to play with a rigid, you know, spring light insert in the shoe. So again, I think these are common questions that we see. We had a couple of these last year. One of them ended up having surgery. The other one did not have surgery after the injury, ended having surgery at the end of the season. But one of them had surgery during the season, just because they didn't wanna, you know, play with the injury. So this is, my approach is this medial, plantar medial incision. You can see the ruptured plantar plate right here. And it's a good surgery. This is really good tissue, and you really get a good repair of the plantar plate. And this is another point of controversy is returning to play after turf toe surgery, and plantar plate repair. And again, this varies between surgeons. I generally let him go back to play after four weeks, because you can split the foot, you can put a rigid insert in the foot, and you can progress him to playing football or whatever you want him to do. So, anyways, that's a lot of information on foot and ankle injuries, but I think the key points as a sideline physician is really understand the injury, understand what the key issue is that you're trying to determine to allow him to go back and play, and then determine which cases are at risk and which ones need surgery. And so, you know, returning to play, generally speaking, low risk injuries, low risk of recurrent injury, low risk of more severe injury. I think you have to clearly communicate with everybody concerned why you're recommending one thing over another. You know, Pete made a good comment about not being wishy-washy with your communication and giving too many options. I think that's true. I think you should give your opinion on what you think the best option is and the reasons for that. And I think coaches appreciate that, and I think the athletes appreciate that as well. Thanks for your attention. Thank you. Okay, so I'm gonna talk a little bit about just sort of the actual game day, and I think those things are important. So that first 24 hours, if you will. Let me just say pre-game and game day, I think all those things that all of us have talked about, but particularly on game day, I would recommend you, athletic trainer, athlete, they've been injured already, you're allowing them to play, but I think it's our responsibility as the team physician that during the game, I have to observe my problem children. So who am I allowing to play that I'm a little bit nervous about? And there's gotta be good communication between myself, all the support staff, the coaches know we're gonna be watching this kid, because ultimately, it probably is gonna be my job to say, we tried, but I'm watching this event, and you're not able to perform at the level you think you are, because they wanna play, and then I gotta pull them. So that game day event, no matter upper extremity, lower extremity, whatever, is really, really important, because ultimately, it's the safety of that athlete that we are responsible for, right, wrong, or indifferent. First 48 hours, right, so let's just pretend it's Saturday and it's a football game, those first 48 hours are really important. I would argue, I would think Sunday is the most important day. I think game day's pretty easy for team physicians, because really, are you in or you're out, right? Can you play or can you not play? I don't need to make a diagnosis immediately after the game. If it's obvious, of course, but as Dr. Andocato said, you don't wanna make a wrong one, you don't need to make a quick one. You gotta figure it out, and you gotta be confident that you know all the information before you do that. These are all the things that I think are important, right? You know, advanced imaging, DNA of athlete, all these things I think Peter and all the speakers have talked about, definitely don't be in a rush, and it's okay to say, I don't know. I don't know, but it doesn't mean I don't know for a week. We're gonna get this information figured out. It might be Sunday, it might be Monday. You know, maybe they got a bad turf toe injury and I gotta send an MRI to my buddy Ned and get Ned to call me on Monday, but those are things that you have to happen and you have to do. Don't rely on the athlete to explain to everyone else what's going on, because if you do that, you're gonna get sandbagged, I can tell you, because the athlete, even though you're very careful of what you say, often they don't hear it correctly, and then next thing you know, you have mixed information and confusion, and I tell our fellows, once you have that in the training room, confusion, oh boy, I don't know if there's any turning back. I don't know of one, and then your next thing, you know, the parents wanna take them here, take them there, second opinions, third opinions, fourth opinions, so you gotta be really accurate with what you say and when. When to get imaging. I think, you know, fractures, those kind of things are easy to do, you know, both those injuries, the ankle, the knee, I think most of us would say, yeah, we're probably gonna get an x-rays, MRI. I don't get a ton of MRIs, I only get them when I need them, particularly in the knee. I think if they got an effusion after one or two days, I think we have to, I think all the things that Jeff and Ned talked about, we have to get advanced imaging. In the collegiate environment, and I'm sure in the professional environment, that's easy for us to do on a Sunday. I realize in high school, it might be a little more difficult, but if you need to get that imaging, try to get it as quick as possible, because you and I both know there's a lot of people who wanna know what that shows and the communication back to them. So what about 24 hours later, right? So now we're Sunday. I think, you know, that's, Saturday's the event, Sunday comes, sometimes you get surprises on Sundays, the athletes wanna get out of the training room on Saturday, they won, family's in town, they leave, we all see some shaking of the heads in the audience, and then Sunday comes and they magically show up in the training room and their knee's about the size of a pumpkin, and you're like, well, why didn't you tell me this yesterday? So that happens. So again, you can review some imaging. I like to just wait 24 hours, no matter what injury, to see what's happened, and I think the biology and the DNA of the athlete, you know, you can have an MCL tear in one player, the exact same objective MCL tear in another play, and how that person responds to that injury can be totally different. So I like to wait 24 hours before I go out on a limb and say anything, you're out a week, you're out three weeks, whatever, and make sure they all understand that. Communication, right, you gotta really, and Peter stressed that, it can't be stressed enough, the communication to trainer, athlete, and then coach, so that we're all on the same page is really, really important. When do you say done for the year, right? I think that's one of the hardest things, I can tell you, this will be my 28th year on the sidelines for UK football. That's a hard thing to say, if you're really a team physician and you know your athletes, because you know how much they invest, right? And if an injury happens in the fall, in September, so that athlete has been working, what, nine months, year round, to get there, you gotta say, I'm really sorry, but you have this injury, and you are done. You gotta make sure, I try not to do that on a game day, I think there's a lot going on, so let it settle down, get your advanced imaging. I mean, this kid here from this picture, so this was two years ago, played at Florida, we beat Florida, you hear that, Peter? We could beat you again this year, you never know. He tore his patellar tendon, right? Parents are at the game, and you can't lie, so if the kid asks you, well, Dr. Johnson, what's my diagnosis, well, your patellar tendon's torn. That's all I say, I don't say any more, right? Your patellar tendon's torn, we're gonna fix it, you're gonna be fine, but then they ask the next question, you know what the next question is? Am I done for the year, right? And I can't say, well, no, we're gonna get you back in two weeks, no, I think you gotta be honest and you tell them, but sometimes there's great stories, right, so the picture there on your right, a year later, right, he gets back, picks six, scores a touchdown, right, happiest kid in the world on the sideline. I think that's why all of us probably in this room enjoy this profession, because I think most of the stuff we see, we take care of, they get back to doing what they like to do, and they're very appreciative, and sometimes there's a good ending at the end of the story. So these are the things I may inject post-game, first 24 hours, I think most of this stuff Jeff covered, most of us would agree, again, not in everyone, you have to get the athlete buy-in, may return to play quicker. Monday, right, so now we're on to Monday, so Sunday you've seen him in the training room, now you gotta start planning for Saturday, right? Is this something on Monday that we need to plan to play Saturday? So it's Monday, they gotta know, right, the coaches gotta know, they gotta get a game plan together, practices start Monday, so that first 48 hours, communication, diagnosis, plan, Darren, are they in, are they out? Yeah, the coach needs to know, right? So you need to develop a plan, make sure you communicate that plan, what are the risks, have you discussed those with the athlete, does the athlete want to play, right? Every athlete's different, what I've learned. Same injury, every athlete is different. And then during the week, right, if you're getting this athlete back to play, whether upper extremity, lower extremity, how do they perform in practice, right? Because typically most coaches, I think, you gotta be able to practice to play, I think for most sports. Now, do they go through the whole practice? Maybe not, but they gotta do something. So if it's something that I'm concerned about, that means I gotta get my behind to practice and watch them play. As Peter said, to get that trust with that athlete, they gotta see you there, that you're invested. You're not just the team physician, you're their physician. Once they have that trust with you, I think things go much better and much easier. Shoulder instability, we talked about. I would just ask Jeff real quick here. So Jeff, on a shoulder dislocation, x-rays, you showed the MRI of your player. What on an MRI, so simple anterior shoulder dislocation, you know, no fractures, all that stuff, is there anything on the MRI, first shoulder, you say, nope, you can't play. We are fixing you in September. Is there anything on that MRI where I have to say that? I think the biggest thing to me, it was you already said, if they had a fracture. Okay, fracture. That'd be one I'd go with. I think some of them in your position might determine that, and then I think the other thing that's not on the MRI is where are they at? Are they a freshman, are they playing, are they redshirt, not redshirt? Okay, any difference in the other? Ned, same, pretty much? First shoulder dislocation, MRI. Is there some that you say, I gotta fix it, I can't let you play? Yeah, no, I agree with you. I think, you know, things have changed a little bit over the last few years because of the, you know, the progression of severity by the end of the season. Do you think that if you repeat the MRI three months later it's gonna be worse? If we let them play? Yeah. Yeah, yeah. So do you discuss that with the athlete and the family that he can play, but his surgical findings at the end of the year are gonna be worse than what they are now? Yep, and I think we have some pretty good data that says if you're gonna do a traditional arthroscopic bank cart, suture anchors, perfect surgery, if they've come out multiple times, then your failure rate may be higher, is that fair? Yeah. So they need to know that. Can I say something? Yep. So most of us as team physicians would say, okay, the shoulder came out, get an MRI, you got a soft tissue bank cart lesion. Most of us would say, well, let's see how you do, all right? Then the question comes up in the training room now with a parent or an uncle or whoever says, okay, if it comes out a second time, we'll all agree you're gonna have it fixed. And most people would say yes. And then if there's a smart person in the room, they're gonna say, well, what's the success rate if it comes out a second time versus the success rate if it comes out after the first time? And I've queried a bunch of well-known shoulder surgeons who take care of athletes. And what Ned said is true, what everybody, yeah, there is probably gonna be more pathology in that shoulder if you let them go back after the first dislocation. But the real tough question to answer is, is the surgery that you're going to do after that second procedure gonna be significantly, is the prognosis gonna be significantly less so much so that it would justify really trying not to get that athlete back after the first one? And that's where all the modifiers that come into play in making an appropriate decision. Is the delta between success after the first or the second? And I'm not talking the third, the fourth, the fifth, or the sixth. But between the first and the second, is the delta in success significant enough to support your decision that you shouldn't go back after the first or it's okay to go back but you're getting a procedure done after the second? Right, something to talk about. MCL injuries, we didn't talk a lot about those, but if you take care of football, high school, college, I think it's probably the most commonly knee ligament injury you see. Often can be non-op. Be a little bit careful on the tibial base one, that center lesion one. Sometimes we do have to fix those, but I would just generally say most of those we can treat non-op. I have injected them before if they're real painful. I think Jeff mentioned PRP sometimes can be helpful in those, particularly the femoral base ones. What about meniscal injuries? So I think meniscal injuries probably, if I scan my entire UK football team right now that supposedly is healthy, somebody's got a meniscus tear that's plain. I think in season, the one that you're done is that entire displaced bucket handle tear. I think most of us would say, particularly on the lateral side, if the entire lateral meniscus is in the notch, I would say most of us are not taking that out. We are repairing that, and you probably are done for the year. So that's the one I never wanna see. I do see maybe once every two years, twice every two years, that complete bucket of the lateral side. In general, if they've got joint line pain or something like that during the year, no mechanical symptoms, no effusion, they're plain, I'm probably just gonna watch it from afar. I think if you start getting mechanical symptoms and you do get recurrent effusions, then I think you're a little bit stuck and you do have to scan them and have that discussion with the athlete. Obviously, repair versus meniscectomy, downtime, huge, huge difference, right? Simple meniscectomy, particularly on the medial side. Lateral side is more meniscal dependent, but on the medial side, if everything goes right, we get that person back plain in two or three weeks. Lateral sided meniscectomy, it takes a little bit longer. So this guy, I wanted to ask my esteemed colleagues here. So this is my athlete. This is a scope from January. So tight end, big kid, entire lateral bucket two years ago, fixed, inside outs, all the right stuff, repeat scope. This is January of this year because he kept having recurrent effusions. So got him through the end of the year. This is what the inside of his knee looks like in January. Hopefully it's not worse than that in July. But I would ask the panel, so if he keeps getting recurrent effusions in season, so let's say in season, what are my options? And we'll start with Ned. So this is your athlete. You know what his knee looks like. There's the inside of his knee. They keep swelling up every week and they're saying, well, Darren, do you want to just drain it every week, inject it every week? So I do have him on an unloader brace. So this is a lateral side. He's a tight end. So I'm making him wear a lateral unloader. I think maybe it helps. But recurrent effusions, Ned, what's your kind of, with that knee? Well, I would get him through the season. You know, I get long limb x-rays just to look at the alignment and all that. But I would talk to him about it and tell him the plan is to get you through the year with as minimal symptoms as possible. I would probably do something at the beginning of the year like aspiration and synvisc injection at the beginning of the year. Optimizes muscle conditioning, strengthening core strength, everything like that with lower volume work before the season started. And then as the season progresses and have, you know, probably do another synvisc injection in the season, do a steroid injection in the season. So I would kind of space them out, you know, over the year and get them through the year and have a plan at the end of the year if we're going to do anything. Do you think that the unloader brace helps a little bit in these? It depends on the patient. If they're a 300 pound lineman, no. If it's a defensive back or, you know, basketball player, I think, you know, the brace fits well. Yeah, I think that works much better. Anything different, Jeff? Like in-season managements of this knee? I mean, I would do the same thing. I like synvisc in my athletes who are doing a steroid injection, although if he has a lot of recurrent effusion, I'll do a steroid injection. I don't want to repeat that during the season. I will repeat synvisc, though. I'll do that every couple months if I need to because I'm not worried about that as much. Aspiration, only really if he needs it. And if I do have that problem, that's why I'll do a steroid injection for him. Keep him on anti-inflammatory. And then the other discussion I would have with that knee is where are you going afterwards? Because this is a knee that's not going to do well in a long time, right? And so if this kid has NFL aspirations, you have to have an honest discussion with him about that. And if this kid's like that backup tight end that's not playing or is, you know, going to go to business school afterwards or something like that, then you may have a discussion about this may be a time to cut back. Because I definitely have kids with bad knees who have lost the weight they don't need to play football before and their knees no longer hurt. They don't swell. They have this issue. So that would be only my thought on him. Peter, you've had a few of these knees over the career. Yeah, I have nothing more to add than what's already been said other than that, you know, at some point, at some point, somebody's going to have to be honest with the kid and say, look, especially if you're a down line or something like that, you're going to be looking after that knee for the next 60, 70 years of your life. And it's as good as it's going to be right now. And you just try and manage it through the, you know, the length of time that they're under your care. Very often, they'll be calling you after their eligibility is up because if you have, in fact, established that relationship and that trust as you try and manage it beyond that, but at the end of the day, as a team physician, you need to be telling them, you know, we can try and manage you on a, through these particular issues, but you're going to be needing medical care for that knee probably for the rest of your life. So let's start looking at the longer plan as well as the short-term benefits. Ned, just a quick question about the high ankle sprain. So you showed a case, kid had one, played, end of the year, he had lateral x-ray, you showed gapping, whiting, that scope picture you showed was pretty impressive and that kid played on it, right? He played on that and you showed the scope pictures. So do we know, so let's say high ankle sprain, stress test negative, MRI, lot of signal, right? Stress test negative, but you're like, you know, this is a bad one, it's gonna be out six weeks, maybe. This is August, September. Is there some window there that we've learned now that obviously if he gaps on the stress test, I think most of us are gonna fix him, but if he doesn't gap, so maybe the continuum of injuries, they're somewhere in the middle there, is there any value after the discussion, all that stuff, to doing the tightrope early? And this one I'm pseudo describing, I know I'm putting you on the spot a little bit, because it's August or September and man, I can maybe get him back, he's gonna play three or four more games this year. So can you help, you're helping me, but them as well. What do we know about that person kind of right in the middle of that high ankle sprain? No, that's the question is, you know, if you can identify that athlete, I think you should do early surgery and you make something that is questionably unstable, you make it stable, like you're doing that with the surgery and it's not a bad surgery, you know, like it's, and I think you can rehabilitate them very quickly, so, you know, we did that in 2009, we did that with our quarterback at Iowa, you know, he had a high ankle sprain six weeks before we played in the Orange Bowl and he played in the Orange Bowl, you know, after getting two tightropes in his ankle. So, you know, I think that's the question is identifying the ones that are going to benefit from that. So I think we still don't have an exact way of doing that. Do you have an exact way of determining? I hate the high ankle. Yeah, the high ankle is the one like you showed, right? A lot of those kids will play Saturday and they'll look okay after the game Saturday and then Sunday morning they're coming in on crutches or they're just hobbling in because they hurt so bad. I think the hard part, you know, we had Bob Anderson who was close by up in Green Bay there for a while and Katie Williams who's my foot and ankle surgeon trained with Bob and Bob's not super aggressive on putting tightropes in those that don't open or something like that. I think the hard part is when do you make that call, right? Because if I have that kid that still looks like crap at four weeks, then I'm probably, we're probably looking at that and they probably have more injury than we thought initially. I do MRI all those as well, but I'm not sure the MRI helps me that much either. Because we had a kid that was a defensive end, had a bad high ankle sprain, came in sort of hobbling, but we were playing Iowa the next week. The kid was from Iowa. He transferred from Iowa to Wisconsin. He wanted to play and that kid, we put him in sort of one of the stirrups braces designed for high ankle sprains. I don't think anything works well, but that tape job. And the kid played really effectively. You have another kid whose MRI doesn't look as bad and he's out for six, eight weeks with me. So I think it's always hard. You're trying to make that call early on and I always wonder is that kid that got the tightrope early on, this was Bob Anderson's thought too, is that the kid that got that tightrope early on that's back playing in a week or two, but that kid you've been back playing in a week or two if you hadn't done anything. And that kid that took six or eight weeks that you find out at six or eight weeks that took him that long, you wish you'd put that tightrope in back at week one, right, because he's probably back. All right, so it's 8.30, but we're happy to take questions. I want to thank all the speakers, but there's got to be a few questions here. Don't be bashful. Oh, come on. No questions? Yes, sir. How long is too long to wait for a prior surgery to be cancerous? So how long is too long, Ned, to wait on one of these syndesmosis injuries that's probably unstable? I don't think there is a too long. I think the key is if you're trying to be efficient, you know, you're trying to make that decision early. So if they get hurt on Saturday and then by Tuesday or Wednesday the next week, there's been no improvement, you know, they're still sore, they can't put weight on it, they can't get up on their toes, that's probably the time that I would be making that decision would be in the middle of the week. If by Tuesday or Wednesday, they're showing a significant improvement, again, assuming these are all, you know, stable, x-rays are stable, everything's stable, then I would continue on the evaluation and go on to the progression of activity, progression of practice, you know, they probably missed the next game. And then on that Sunday or Monday of the second week, if he doesn't look like he's gonna be able to play that next week, I would fire ahead and do surgery. So there's probably that one week window from I would say three or four days after the initial injury to 10 days after the injury. Peter? Just a quick little sideline test I've learned over the years, somebody comes hobbling off the field, putting some weight on it, it's an ankle sprain, and you wanna know and everyone's so, well, how bad is it? If you have that athlete stand still and then jump forward two or three feet and land on the injured ankle, if you ask them to do it and they do it, it doesn't have to necessarily be as bad, but if they won't even do it, just how now they feel, then you'll probably be looking at an earlier MRI that day or the next day. It's more likely a severe high ankle sprain if they won't even, right after an injury, jump and wanna land on that foot alone. Or even just get up on their toes. That's one thing we do, try to get them up on their toes. And if they have that ankle sprain, that none of us wanna see, they're not gonna do that. Don't hold on anything, don't get up on your toes. There's another easy one you can do on the sidelines. Any other questions? Yes. You've had two of them? I've had zero. Thank you. Thank you. What any, Peter, or anybody want to comment? Two hip dislocations? Look at that. Yeah, I've had two hip dislocations in 30 years of team coverage. And one of them was a cornerback. One of them was a 350-pound offensive lineman who dislocated his hip on a point after a touchdown. And they both ended up doing well, but they took a long time to get better. Yeah, I think you need to establish as quickly and accurately as you can the blood supply to the femoral head. Because you can pretty much determine within the first 7 to 10 days if that's an issue. If it's not, and there's no significant acetabular component to the injury, they do pretty well, at least one or two that I've seen. But they're not going to come back in three or four weeks. There's too much guarding and unavoidable atrophy of the supporting muscles due to the pain and guarding. Other question? Yes. Can you go back to the in-season role of biologics? So in-season role of biologics. Jeff, Ned? Well, we use them. PRP is the most common one that we use. And then stem cells, bone, marrow, aspirate, stem cell concentrate. And so we use PRP for soft tissue injuries, for hamstrings, and partial muscle injuries, partial tendon injuries. We tend to use ultrasound guided PRP injections as the initial treatment of those injuries. That would be the most common thing. I don't use much orthobiologics in the joint for knees, for hips, and stuff like that. I don't know what your experience is. Yeah, I'm sort of like Ned. I'll use PRP for some hamstring injuries or quad strains where it's focal. We're on the MRI. We see a focal area. I think the diffuse injuries, I don't think it does anything for. After we talked last year, I was going to use it on MCIs. I didn't have anyone that needed it this year, because I know you had success with that. I have used PRP in the joint a couple of times. I don't think it did anything. But it was a recommendation from NFL for a younger brother. But I didn't get great success with that. Otherwise than that, we don't have a huge biologics practice. I'm not sure there's a lot of literature that strongly supports it. What about this? You guys got to turn around. So these hamstring tears that we all see, the bad ones, where are we at with aspiration, injection? What do you guys do? So your bad hamstring in season, what are you guys doing? Hoping that he plays for Kentucky. So do we inject them all? Do we not inject them? We would. Yeah, we inject them. We aspirate and inject. But again, if it's a complete injury, they're going to have surgery, approximately evulsion. But if they're mid-substance and muscular injury, yeah, we tend to aspirate and inject all of them. And what do you inject? PRP. Soon as you make the diagnosis. Jeff? If he had a big injury like that, if he had a big hematoma there, I'd probably try to get that aspirated under ultrasound. I'm not sure PRP is going to do a whole lot with that personally. But you could have that discussion. OK. I had, that's a hard one. I had a collegiate wrestler. He injured this in the Big 10s and had that exact injury. Partial injury there, I had one of my trauma partners who was a former, almost Olympic. He got up to the Olympic team when he got cut. So he was a high-level Olympic wrestler. And we looked at this kid, and he had it in the Big 10s. And we talked to him about it, because he wanted to go to the Olympic team. And we were like, we probably need to fix it, to the level you're at. And the kid left our hour discussion, went out and got on the bike for two hours. And then he ran for another hour afterwards. And then he wrestled with one of his teammates after that, and came in the next day and goes, I think I'm fine. And so he went on. And if the official had called a stalling penalty, we would have a national champion. So I think those are hard. And I think that's one, when they acutely have it, I think you have to see how they respond over the next few weeks or so. I think the complete one's an easy decision, right? It's pulled all the way off. That one's pretty easy, I think, in this group. But that partial one, I think you see how they respond. Because if you go in to fix it, you're out for the season anyway. So I think that's the discussion where they're at. Some of those heal up just fine. It's just like the partial LCL that I see in my wrestlers. And you've probably seen it when you were at Iowa, too, a lot. Those wrestlers, you'll get an MRI that shows a complete LCL tear. And it's just pulled up a little bit. You examine them, they're stable, that kind of stuff. Usually two weeks, those guys are back. Full go, no problem. So I think that's a tough one. The USA field has a player, and so it was very difficult. That's a long discussion. Because if you fix it, they're done. And if they're on the US team, that may be the end of their career at that level, too. Jim Bradley published a series of partial repairs, right? Is that where your experience is coming from? PRP, you can, and PRP, those can do fairly well. I've found my experience, and my experience with the partials has been more in my 50-year-old triathlete and distance runner. I see a lot of those. And after, was it with Anil talking about it, the ischiofemoral impingement? Yeah. And maybe there's a little bit of a role in that, too. But that's where I've seen those. And my experience on those is that taking it down, for me, does better than leaving and just trying to repair underneath it and bring it back down. I used to do that. I've just had more success in that older athlete, taking it all the way down and fixing it. I did have a younger, former professional soccer player that she had overuse from hers. And we tacked hers down without just sort of opening up, taking it down. She recovered very quickly from that. I'm not using a brace for those anymore. After, I just do protected weight bearing with crutches. But it's still, for an athlete getting back, it's still four months at the fastest and probably more reality of six to nine months to be back. There's one more question here. Go ahead. Is it clever to have a brace for that part of the career? Now I've moved, because I used a hip abduction brace once. And the kid was absolutely miserable, so I never used it again. I've been using a hinged knee brace, depending on the tension, 20, 30 degrees of flexion. My ones that are under no tension at all right now, I've been going to just taking them out of a brace. I had a guy that ruptured both. He was sprinting his nephews, popped his left one, popped his right one on the next step. So I had both of them, so we couldn't do anything with that. And protected weight bearing and those, I think, do well. Just use crutches and just tell them to take it slow. And I've been happy with that, and success has been good with that. But if I have tension on it, then I put them in just a knee brace. Just going back to hamstring injuries, I think that they are one of the most difficult things to manage, not the severe ones, but the mild to moderate ones. In terms of how safe it is to progress them, where the intensity or the desire to play could be a very counterproductive component of how successful you are in getting these people back. So I'd rather deal with a severe ankle sprain 10 times more likely than I would deal with a mild to moderate hamstring strain. And I'm talking even after you get an imaging study of the degree of damage. They're terrible. In my mind, they're really frustrating. I think hamstrings are really hard when you have the discussion with the player and with the coach. Because I'm not sure. I mean, I know if the MRI looks like the one Darren showed there, I know they're going to be out for a long time. But the one that looks mild, that's when you say, oh, yeah, you're probably going to be back in a week or two. And it takes the kids six weeks to come back. And a lot of them will be back and up, and then they'll get that mild twinge again to it. Just send them back a week. It doesn't send them all the way back. But usually a week or two, they're down again. But I hate the hamstring injuries. I always guess long on those. All right, guys. I want to thank the speakers. Thank you all for coming this morning. Enjoy Denver and the meeting.

athletic injuries

team physicians

return-to-play decisions

NIL implications

upper extremity injuries

pain management

NSAIDs

local anesthetics

lower extremity injuries

surgical interventions

orthotics

game day management

MCL tears

meniscal injuries