up quickly. I think we talked about all these injuries and gone over some of that. I'm gonna give you sort of my some pearls about first 48 hours after things have. I think Peter talked about these things. A lot of tough decisions you need to make. A lot of people involved. Every person is different who's involved and not involved. As Peter said, it's probably getting a little more complex because now the lawyers are involved, agents, but it is what it is. We can't change that, but those are all the decisions we have to make. I think the good news, Joe, you know, you're not on an island. You got partners, colleagues, right? I have these three people I can reach out to during the year and I might, but never be afraid to ask for help and get everybody on board when you're having to make that tough decision. Are we talking about return to play, return to sports, with or without restrictions, same level of play? Those are all variables you're gonna have to think about and they're different for probably every sport and every athlete and every injury. So a lot of variables go into that particular injury you're seeing for that athlete and it can be different amongst players on the same team in the same sport. These are decisions you have to make, right? Pre-game, in-game, post-game, next day injury clinic. I would say for, you know, during a fall football year, I think the most important decisions I make are probably after the game. I'd say Sunday's my most important day and then Monday you get some idea, is the kid gonna make it back for that Saturday? So I'll give you some pearls about those important 48 hours. It's really 48 hours. First thing, we have to have correct diagnosis, right? Are you gonna get imaging or not? What's the DNA of the kid? Does he want to play, not play, wants to be out? Who's involved? Make sure you communicate. Don't be in a rush, as Peter said, right? Get everybody on the same team. Make sure the, everybody knows the diagnosis, the plan, and that's conveyed to the coaching. Be truthful. Okay to say, I don't know, but I'll get back to you. So you don't ever want to create a gray area and make sure everybody on the team understands the plan. If you create mixed information, then you got problems, and you got severe problems, because then you lose the trust, and if you lose the trust, you're done. So when to get imaging, I think all of our speakers talked about that, right? X-rays, MRI, we live in a world where everybody's got to have an MRI. I will say to you though, you know, sometimes they'll say that, they'll say, Darren, Coach Stoops wants an MRI. I'm like, what? So I say, okay, well, you go back and tell him that if I get the MRI, then guess what I'm gonna do with the kid? I'm gonna tell him everything honest about that MRI. So if we get the MRI, we're gonna have a go with that, and then he goes up to the office, and Stoops says, well, we maybe won't get the MRI, we'll just trust Darren. When do you say done for the year, right? Hard decision to make. I think somebody said, Peter said, you can't lie. So this is one of our kids last year, tore his extensor mechanism at Florida, and he just had to answer the question. He says, well, Darren, what's my diagnosis? You tore your extensor mechanism. Am I done for the year? I'm done for the year, right? But I didn't need an MRI to make the diagnosis. His parents were at the game. Hard to do, but I just had to be his personal physician, not necessarily the team physician. You put your arm around him, you grab him, and you say, I got you. You're gonna be fine. We'll be okay. He's got to deal with that. So what about 24 hours post? Confirmed diagnosis. Are you gonna get the MRI? Do you need the MRI? How do they respond to those first 24 hours? So game's over, say, Saturday at noon. On Sunday at noon, I really want to see what that injury is behaving like, right. And every player is different. Every MCL is not the same. So I really got to figure out in those first 24 hours, how are they responding to the injury? And have the athlete repeat back to you what your diagnosis is. Confirm plan, right. And if you need to, get help, but create no confusions. So things I may inject post-game first 24 hours. I think we've heard about all of these. You know, not too awful. A little bit out there, a little bit. But these are things I'll do, injections. And I've found that we can get a player back a little bit quicker by doing that. What do you mean by quicker? Well, it could be a week or two. Well, if it's, you know, collegiate or professional football, a week or two is two games. And two games to them is a lot. What about Monday? So you've made the diagnosis, advanced imaging's done, you have a plan, you've got 24 hours where you've done your injection, your MedDrawl dose pack, your Diclofenac, all those things. And then a Monday is when you really have to kind of say, are we going to make it to Saturday, right? What is this injury looking like? Because usually somebody wants to know above my pay grade, are they going to be ready this weekend? So these are all the things you have to go through again, right? Do you have the right doses? Are you missing something? You know, are you missing a stress fracture? Or do you need to, you know, really look at that Lisfranc joint? Is this behaving like a mild one? Or is this behaving not like it? So in those first 48 hours, I cannot stress enough. It's so important. And you've got to go over the injury again and again and re-examine them. And are we all on the same page? The athletic training staff's on the same page. What can we do on Monday? What is this injury behaving like biologically? Really important. Shoulder instability we covered. I think, you know, I get x-rays and an MRI on all of them. I think in season a lot of us, quote-unquote, let them get back to play. I think there is a risk for further dislocation. And then if you come out again, I think by now we have enough pretty good data about the more you come out, the less successful you may be with an arthroscopic procedure. But that's a discussion you need to have with the athlete and parents, trainers, agents, whoever it may be. But you have to have that discussion and be honest. I think, you know, particularly in football, they're vulnerable. I mean, we'll have one. I'm sure we'll have one this year. We have at least one every fall. And all things being equal, we try to get them back unless they've got a large bony Bay card or some crazy thing on the MRI. These are things you should consider in those types of injuries around the shoulder. But we use braces just like Jeff talked about and things. AC separations, we've talked about that. I have nothing further to add. Pretty aggressive about injecting those. One thing we do do, inject to play. But if it was just diagnosed before that athlete goes home Saturday night, we put a little steroid in the joint. And we have found it decreases the inflammation and we get them back quicker. So I'll just add that to what Jeff talked about, AC injuries. MCL injuries, we all see a ton of those during the year. Can be a little bit painful if they got a tibial one, right? And the x-rays go okay. MRI, it's not that MRI. So please don't think I'm injecting that MRI and they're getting back. It's just an MRI of an MCL there. I'm talking about a mild one. And that seems to work fairly well if they're point tender along their tibial metaphyseal area where the MCL is. Meniscal chondral injuries or knee injuries, in general, in general, so be careful now, if they don't swell up, if they got no infusion on Sunday, I'm not a big MRI guy. That's just the way we do it. I've done it for 25 years. If they have an infusion on Sunday, they all get scanned. So the first thing I do on Sunday when I talk to the athletic trainer on the phone before I come are the fellows. I say, I just need to know one thing, is there fluid in the knee? If there's fluid in the knee, then I get nervous and have to do other things. So I don't get a lot of MRIs during the year unless they swell up. Meniscal tears, you know, in general, if they got a displaced tear, can we get that person back? Probably not. They're going to need surgery. Are there mild meniscal injuries that will try to get the player to play if they can be functional? Yes, there are, but you got to evaluate each one. Obviously, if they have a bucket tan, you know, if their entire lateral meniscus is in their knee, probably done for the year. We don't want to see that. We do see that. Ankle sprains, I think Ned covered. I think routine ankle sprains. We've done an injection post-game of steroid. Our athletic training staff looked at it and it gave us about seven to ten days. Injection of steroid versus no injection of steroid, and we found getting a routine ankle sprain, not a syndesmosis injury, typical lateral injury back, and we've injected them post-game. Hip pointers, I think we've all seen this. We do exactly the same thing post-game before they go home. We generally palpate over the iliac crest. They're pretty sore there. We inject it with a little steroid at the end of the game, a little lidocaine-marcaine concoction, put all that in there, and again, we have found it helps them get back a little bit earlier and maybe an injection to play the next week. ACL injuries, can they play? I think in 25 years I've maybe had two kids that have played. Obviously it's position dependent, risk tolerance. You have to talk to the athlete. A kid recently of ours, two or three years ago, wide receiver. Last year playing, just didn't want to have it fixed. He said he needed to play. Luckily, you know, we rolled the dice. Everybody was involved. He did not re-sub lux. You know, my concern is he re-sub luxes and then gets a meniscus tear that is unfixable. Because then I feel bad. I'd be like, you know, we could have avoided that. But these are decisions that are tough to make, right? I mean, everybody just thinks they're out, but I wouldn't say necessarily all of them are out. So for that kid with the ACL tear, these are the things I had to think about. Ultimately, who makes the decision? The player. I think as Peter said, you know, it's kind of a shared decision process. You hope to lead them down a road. I like Peter's line about, you know, this is what I would do if it was my son or my daughter. But those are things you need to think about and consider. Patellar dislocations, we'll get an MRI. As long as not large loose bodies and stuff that we need to go in there for, we'll aspirate it. We'll put a little steroid in the knee and we'll try to get that person back. First-time dislocation, no, you know, large chondral bodies or anything like that, then you're going to have to fix it. But we can usually get these kids back in about three to four weeks if they had a first-time patellar dislocation without any associated crazy stuff in there. Thank you very much.

injuries

decisions

communication

imaging

injections