I've been in Wisconsin for 16 years, my 15th year as team doc, and I took care of hockey, football, soccer. So this will mainly be some football stuff, though. I'm a consultant for ConMed. I do course direct the Big Sky meeting. I would encourage people to come out to that. It's a great time skiing and everything else, but as I was saying earlier, the team is an important part. I'm going to go through a little bit of pain medications, injections, and then do some of the upper extremity stuff that we do. Anti-inflammatories are super common. They're used a lot. Ibuprofen has been around forever. About 8% of athletes use it and have it prescribed to them. Adverse effects are there, about 20%. Most of them are sort of GI. I looked at college football players, 96% used anti-inflammatories, 46% of those. So half of them started in middle school, so it's been going on for a long time. A lot of times you don't even know the kids are taking it, so it's something that you need to know when you're talking about game day activities. When they looked at college football players, a third of them take it as just a preventative, so they don't even have an injury they're taking it for, but they've been taking it for so long. They looked at NCAA athletes, surveyed those. This was a few years ago, following eight weeks, about half of them self-purchased anti-inflammatories. Only 12% got them from the athletic training staff, and there was a correlation between increased alcohol use and anti-inflammatory use. If you looked at both males and females, take the anti-inflammatories, and then the males took it a little bit less for reporting pain compared to the females for that. When they looked at the Olympics, this was down in Rio, and they looked at, surveyed the team physicians, 10% would use oral, topical, or injectable, 73% prescribed anti-inflammatories for their athletes, 12% prescribed doses higher than are recommended. But if you look at like the Aleve, it's like one capsule twice a day, I think we almost all prescribed twice, and 52% prescribed for prevention, and not even an injury that's happening. And there was this thought that injectable was preferred for severe pain versus oral. Here's just a list of the commonly used ones. If somebody has a history of allergies, obviously you're not going to give it. GI bleeds, if they have renal disease or cardiac disease, you want to be careful in those groups as well. Tortol, so this was the big question mark. It's been given a lot of press. We do use it. I think if you ask everybody, almost everybody's used it at some point. For certain athletes, I think the use of it has decreased dramatically. It has very strong analgesic properties for it. You can give it PO, IM, IV, or intranasal. The media was really focused on this in the NFL. When they did a survey of this in 2001, 28 of the 30 NFL teams used an intramuscular form of it, and this is sort of a list of players, 98% said that typically you get one to two days of relief for over half the players. There weren't a lot of adverse injuries with it. For as many of us, good, just some muscle injuries, some GI upset. Players did feel that getting the shot instead of taking something orally was a sign of a more powerful medication for that. This is not an uncommon thing. A lot of our tailbacks go off. They talk to our current tailbacks that are there, and you get somebody that has a mild ankle injury or something like that that's doing fine, you know, talk to one of his NFL colleagues, and he's all, get the shot, get the shot, and this is when you have to have the discussion with that. So you do have this coming down from above, especially at the college level. In the NFL level, it's become very common. If you look at the pharmacokinetics for Tordal, both orally and IM actually start working pretty quickly. Oral is actually a little bit faster than the IM form of it. It's excreted by the kidney. Again, you get equal doses, both PO or IM. With oral, 10 milligrams for every six hours or so. IV, 30 to 60, but even some of our anesthesiologists, like 30 is the maximum dose. You don't get any effect for above that. So the NFL Team Physician Society looked at this after some of these big studies came out, and they were, players should be informed of the risk and benefits for using it. Should only be used for documented injuries, not for prophylactic treatment. Give the lowest dose effective, limit the amount of days that you're giving it. That NFL team physicians did recommend giving it PO, and don't give it with other anti-inflammatories. Was there a change? Yeah. So in 2002, about 60% of the NFL and NCAA football teams used Tordal. 14 years later, you can see those numbers drop significantly. What do we do at UW? So we do use Tordal. We use it very limited. Oral use only for that. Do have a full discussion. This isn't a discussion that's happening Saturday morning before kickoff. This is a discussion that's happening Tuesday, Thursday, usually with the athletic training staff. We have a discussion. This kid may be a candidate for using Tordal for the week. Wednesday, we're talking about Thursday, we have the discussion with the kid. We do discuss the risk and benefits. We actually have a consent form so that the kids have the information on it. They read it. They sign it for the use. I do get labs on them. I don't know if the labs have drastically changed anybody that I'm not giving it to. But for the kid, they're going through another step. So there's another step they have to go through. They're realizing this isn't just I'm giving them Tylenol, I'm giving them ibuprofen. No anti-inflammatories on the day of game. And then we provide the medication usually when they come in. There's some injuries. I'll do it a little bit earlier. But usually when you come in from warm-ups, that's the time. Ned was talking about some of the high ankle sprains. Some of those guys, if you're seeing if they can play, we'll do that before they go out for warm-ups to see how they can function that day. And then the other one I'm talking about is just injections. I'll go through this briefly as well. Antiseptic has been around for a long time. They look to Australian rules. Over half the players admit to using them in matches. There really aren't any randomized trials with that. The case studies are fairly limited for this as well. And you have to weigh the risk and the benefits of doing the injection to block the pain versus the ability to return to play. And so how high risk is that injury? What are you allowing them to do? And then the team physician, again, you have this discussion of the risk, the benefits, any complications that may happen with that. When they look at sites of injection, this is a study by Russ Warren's group, they looked at three consecutive seasons with the Giants. They did 37 injections, so about 10 a season or so. If they did have an injection near a neurovascular structure, they tend to do those with ultrasound guidance. They would give them about an hour or so before game time, and they didn't report any complications or any advancement of injuries. It's sort of locked, there we go. And this is just sort of looking at the injuries that were done. You can see that ankle sprains are really high on the list, MCL sprains there as well. I can't say I've done many ankle sprains or MCL injections, but AC joint's one that we do fairly frequently for that. Again, when they looked at, this is again Australian rules football, they did 268 injuries, 10% of players had utilized those. Again, no long-term complications. You see here's the list with rib injuries, iliac crest, hematomas, AC joint, and then finger injuries were pretty common for the injections. Another study, again, in rugby, over 1,000 injections, they followed those, and again, a lot of those were upper extremity type injuries that they did. So when you look at the injections, sort of divide them up into these low risk or high risk sites. Low risk sites that I look at is AC joint, sometimes finger injuries, rib and sternum, although you have to be a little careful of how you do those, hip pointers, and then some chronic plantar fasciitis can be used as well. High risk, I do worry about ankle sprains, any tendon injuries I think are high risk. Bursa I worry about for any sign of infection, and then metacarpal or radiocarpal injuries which I avoid as well. Complications are fairly rare. You can't, you don't want to do intraarticular steroid injections like it used to be done just for risk of progressing arthritis. Again, as Dr. Amendola said, avoid the navicular, you worry about scaphoid, lunate injuries as well. You do want to avoid around getting any motor blocks, those have been recorded a few times and obviously pneumothorax has sort of happened out in San Diego at that time. So my experience, joints that I inject, we'll go through these, AC joint, SC joint, hip pointers, rib injuries, toe, ankle MCL, really haven't done much of that, with that. Again have a full discussion, I use lidocaine and ropipocaine for this, I inject just prior to going out in the field for warmups, if we're going to do it, and then possibly repeat it at halftime. So go through a few injuries here, AC separation is really common, they'll lose strength in motion after the injury. Typically sling for a week or two, can pad it, inject it, use anti-inflammatories for that. Again, depending on the sport, depending on the season, these can last for a different amount of time. Rarely do these need surgery. So this is one of our linebackers, injured his shoulder, was making a tackle, came off, couldn't really lift his arm, tenderness right over the AC, did have a slight step-off pain in that area. We did take him back to the locker room for x-rays for this and we sort of had a good feel what it was. His x-rays shown here did not show any significant step-off, did not show a fracture. At that point, again he was pretty hard and trying to get his shoulder pads off was really painful, the guy's screaming. We were able to get his shoulder pads off, we talked about those options where he does want to try to come back and play, we did discuss trying to do an injection for that. So that was our thought, we did inject it. He hadn't taken any anti-inflammatory before, so we used ibuprofen and Tylenol for him, did the injection. This was our padding for that, we put a gel pad on it and then taped that down on top and then put the shoulder pads over the top. After the injection, his strength was a lot better, he was able to protect it at that point. We put him, padded up, got him back on. We did use a Soli sling for these as well, it tends to provide a little bit of protection, it decreases that shoulder motion a little bit, which I think helps him, he was protective. At that point we allowed him to go back into the play. With AC joint injections, grade one, grade two, at least one to two weeks typically you're going to be doing these injections. Grade threes, sometimes they last a little bit longer, again you can do those for a month or so. We'll use Toradol, we'll use ibuprofen in subsequent weeks if we need to. Usually they'll get better eventually, but they take some time. I have not really seen many of these progress too quickly. This was an SC joint injury, it was an offensive lineman, acute pain over his left SC joint. It came during field goal protection. Feels like the same injury that he had in high school, actually saw this kid in high school and then saw him again when he came to play for us. Examined him, I think now the tent on the sideline, if you're covering college or pro we all have the tents, it's always a good spot to bring somebody into. You get a little bit away from that pressure, if you need longer take them back to the training room to evaluate them. In high school you don't have that and you have parents sitting there looking on seeing what's happening. So the tent's really become a good thing for that. But he was tender and palpation directly over his SC joint, he had no deformity, but he was able to push off. He couldn't get his arm extended, he didn't really push with that. We did take him back, his x-rays were otherwise normal, no fracture, no dislocation. He wasn't having any breathing problems so we were pretty sure it wasn't posterior at that point. He wants to try to play, did ibuprofen, Tylenol, we had discussed an injection with him. He had one done in high school so he was considering about that. So we did an injection just topically over that area, just sort of bathed that area. I didn't want to go deep, obviously I was nervous about everything behind there. His pain was able to improve, he was able to push off. Again, he was just doing a special team so it wasn't quite as much as he'd be out there normally. He was able to come back and play with that. He did have, again, a steroid injection in high school. A couple days later he wanted to repeat the same thing, we got a radiologist to set that up for him. So to play the season was only some mild soreness after that, no long-term problems. So shoulder instability, another one that we see all the time and how we're going to manage it. I think this is sometimes the difference between being an arthroscopist and being a team physician. So this is a freshman, fullback, one of the toughest kids that we've had for a long time. Anterior shoulder dislocation. At the end of fall camp he was reduced by our athletic trainers. Reduction was done on the field. X-rays were obtained afterwards on his X-rays. He was reduced nicely. No bony lesion with that. He was a projected starter on both special teams and a starter as a fullback. This was his first time dislocation. We did get an MRI on him. One thing about being at a big school, we get MRIs pretty quickly. Again, he had a Bankart tear, a small posterior tear. The posterior was probably old, the Bankart was new. With that, we discussed options with him. The kid did want to play as a walk-on kid that's just, you know, will run through a wall if he had to. So we did a sling with him. He was able to work his way out of that. Worked on strengthening. Once he had good strength, we talked about bracing options with him. We discussed about surgery with him. He didn't want to try to play. And so we've gone to sort of this type of a brace a lot of times for these guys. Straps into the shoulder pads, the shoulder stabilizer. Douglas makes one as well. You can go with a sole or some of the other type ones as well, but go with that. He was able to return to play at week three. He had one additional dislocation. We were playing Ohio State, it was on the opening kickoff. He goes down the sidelines, go over, reduces his shoulder when it comes back. He hops up, wants to go back in the game right away. We hold him out, but he was able to play the rest of the season, and then we did a surgery when the season was over without any further complications. He went on and played in the NFL for a few years. This is a different shoulder instability. This is a defensive back. He did have a history of a label repair two years ago when he was in high school. Did feel the shoulder slide, but not dislocate during the game. He had mild apprehension, but he had good strength. We discussed with him options. He was like, I'm fine, I want to go back and play. We did place him in, again, a shoulder stabilizer type brace. He was able to return to play. We got x-rays after the game, no changes, MRI. Again, had a small labral tear, but he didn't want to do anything. He was able to play his career in the brace. So the bracing can be a really good option with players. You just have to have the discussion about further instability or other problems that they have. Stingers is one, again, that we see fairly frequently. This is a starting offensive tackle. He had pain and numbness down on his left arm to his fingers. His fingers feel dead. I felt like he got sort of his neck stretched in that situation. He had no cervical tenderness. Symptoms were isolated just to the left arm. He did have some weakness in the triceps, but otherwise his strength was pretty good. Generalized numbness to the hand, and this was brought up yesterday. People who went to the sideline emergency situation, if there are bilateral symptoms, that's not a stinger. That's a cervical spine injury. Those need to be evaluated and taken up further. That's not a return to play type thing. So this kid was all isolated to that. One, again, serial exam, again, no neck tenderness. His strength returned to normal, sensation returned to normal. He was able to return to play. He had a couple other mild episodes in that game. He had a stinger last season as well. We got normal x-rays on him. During the week, he did have a, again, he got his neck. We practiced pretty hard, and so our guys get banged up pretty good. So again, another couple symptoms that week. Less severe, but again, had the stinger symptoms come back. At that point, I did get an MRI on him. Had no cervical discs, stenosis, or ligament injuries. Placed him in this CUR collar. I don't know if people have seen this, but it goes sort of inside the shoulder pads, and it'll decrease neck motion, which could be helpful for that. I did use a MedDRAW dose pack with him, and we've used that a few times for our stingers. It has seemed to really calm down those symptoms pretty quickly. Followed with naproxen for a month, and it's really helped these guys not have as many problems with recurrent stingers. I do have a discussion about risk for AVN, risk for other complications with the MedDRAW, though. Again, he was able to come back and play. So another one that we see, this is a tailback again. Rib fracture, hit on the side during a play, immediate pain, difficult taking a deep breath. This time, he was directly tender over the ribs. He didn't have any crepitus. He did have pain with deep inhalation. No upper quadrant, opposed to your flank pain, so we weren't really worried about internal injury to the spleen or kidney there. We got x-rays, and the x-rays were relatively normal, maybe a little bit small crack there. He wasn't able to come back in that game, but we did talk to him about injections afterwards. For these, at that point, we didn't have ultrasound in our training room, and so I injected directly over the ribs, and I allowed him to play in subsequent weeks. He needed to do it for a couple weeks, and he was fine. But now we've done some ultrasound guided for this, again, so we just don't get a pneumothorax with that. And you can do a lot of padding for these guys as well. Elbow injury. This is, again, an offensive lineman. These guys, as you can see, get beat up quite a bit. The arm got caught during a run set. He had tenderness over his distal triceps, no bony tenderness. Elbow was stable throughout range of motion, no nerve injury, a little bit weak in the triceps. He wants to try to play. This kid dislocated his patella when we were playing at Nebraska. He was like, I want to go back in. We were like, you can't go back in. And he was like, I'm going back in. So he played with it, had surgery on Monday where he had about seven loose bodies that we took out and went on to play, but this kid's like tough as nails. It feels like he can't lock his arm out on a pass set, and so we talked to him about braces. We tried a soft strap brace. He couldn't do it. And then we went to sort of this hinge type brace. He was like, okay, that feels better. We did lock it, so he couldn't get his elbow flexed all the way up. We couldn't get his elbow locked all the way out, but it allowed him to play with that the rest of the season. We got x-rays after the game, probably hard to see, but he had a little small bony fleck with that. Did get an MRI, which was a partial tear to his triceps. My hand surgeon was around as well, and he was, oops, my hand surgeon was there, he was like, yeah, I think we can wait until the end of the season. Kid waited until the end of the season. We had to operate on his shoulder at the end of the season as well. They did a block for his triceps. He was ready to kill the anesthesiologist because he hated the block, so we didn't do a block for his shoulder surgery. But again, some of these kids can play with stuff that you don't think they normally can. This happened last year, and this is not a game day thing, but this is a tailback. He gets tackled early in the third quarter, we're on the road, immediate pain, he's tender over his radius. When we press on it, you can feel some crepitus with there, we're like, oh shit. One of our two tailbacks get x-rays, he has a displaced radial shaft, replacing the splint at that point. John Teeting's my hand partner, he's now down in the Chicago area. So John's at the game, see him, we're sitting there after the game, this happened late, we're all talking about it, and he's calling his surgery center and saying, hey, this kid broke his arm tomorrow morning, 7.30. So we had to find a hotel, John volunteered to let the kid stay at his house, but they stayed at a hotel next to the surgery center, surgery the next morning, gets his arm fixed. Now this is one where you have to have a discussion, and I think this is where you talk about consultants and your team surgeon that goes with it, and your consultants have to understand what these guys want to do in trying to get back. So John has a good feeling for that, and so he plated him and put a long plate on him to give him a lot of stability with that. Pain and motion improved, he wants to try to come back. So we were about four weeks out from it, we placed a splint, you can sort of see the splint on his other arm here, it's sort of hidden underneath the white, he didn't want it to show off. His first game back, I hate to say it, we were playing Nebraska, which was always fun, but he had 98 yards in that game back, really allowed us to win that game at the end. Post-game x-rays were unchanged, he went on to play in the bowl game without a splint, so some of these guys, people can get back from these injuries. So this was another one, again these are the ones that you'll see on the game day, defensive back, fell on his outstretched hand in practice, he had some radial-sided wrist pain, we got x-rays, the x-rays are shown here, the x-rays are otherwise normal. At that point, put him in a removable thumb spike, a splint, he was able to practice, we made him non-contact, in the game he was able to play with a splint on, had some radial-sided pain, got x-rays, these didn't show up right, sorry I got switched there, but he had a non-displaced scaphoid waist fracture. At that point, surgery the next day, we just called John and said, hey, scaphoid, bring him down tomorrow morning, we'll fix it. So got it fixed, he played in sort of a splint where we did the thumb spike, it covered him at first, he wasn't able to play that first week just because of soreness, but he was able to come back the next week after that and be able to play the rest of the season without any problems. These you'll see all the time, this is a tight end, thumb injury, pain on the ulnar side, so a UCL injury with that. At the game, we taped it up, he was able to complete playing, x-rays after the game, exam was concerning for the UCL, here's the injury, you see the small little bulge in there that comes with that. Again surgery the next day, or I guess surgery on Monday, repaired the UCL, he's using an internal brace for that now, made an FRC again, just hand-based, thumb covered at first, he was able to come back and play the next week, and then able to come back with that, and each week we sort of made it smaller and smaller, that gave him full ability to play. So if you really work with your athletic trainers and work with your consultants, you can really get some of these guys back play quickly with this. This was another tight end, our tight ends get beat up a little bit, this is a hand laceration, got stepped on on Thursday in practice, these cleats will just tear, this was through his glove, and we saw this, we're like oh this is great, so we washed it out, in the training room, got some OR equipment, brought it in, injected him, you can see no fractures were there, we were able to close it, we made sort of a custom splint to cover the top of it, and again allow him to go back and play, we did place him on antibiotics with that, but he played with this no problem either. This is another one you're going to see all the time, PIP dislocation, not Russell but one of our other players, had acute PIP dislocation, his dorsal dislocation, obvious deformity, came off the sideline, I reduced it on the sideline, his finger was stable at that point, we buddy taped it, we got x-rays after the game, no evidence of a fracture, he again used the buddy tape for about two weeks and was able to go back. Another thumb injury, this is safety trying to break up a pass, immediate pain and swelling, he was tender of the CMC joint, and there was crepitus, it was unstable, these were his x-rays, he had a Bennett's fracture, you can see that down here with displacement, he was not able to go back and play, with that we got a CT scan Sunday morning, surgery on Monday, again, more bomb proof, you could put pins in this, stabilize it, knock on play for six or eight weeks, put screws in it, and John's really aggressive so let him come back pretty quickly, returned to play, missed one week, came back after that, again here's his cast, with that, and when he was in that cast he actually had an interception for a touchdown, 99 yards in that game, so able to come back pretty quickly and reduce as the season went on. This is another hand injury, ring MCP, dislocation reduced on the sideline, they did have some laxity, we attempted to buddy tape it, but he couldn't really push or grab with the hands, it was still painful for him, we did place him into a club, this is sort of doing the club with a gel pad over the top, take an ace wrap and put it in the hand, and then sort of club over the top of that here, that gave his thumb free, but he was protected for that, we got his x-rays, CT after the game where he had this sort of Pac-Man bite off the back of the metacarpal head there, surgery on Monday, again a couple headless screws, these were his radiographs, so stable fixation on that, again he was able to come back, this is him in a club, this was in the bowl game, so this was a while later, he used it for the rest of the season, didn't need it afterwards without any problems. Finally, in conclusion, a lot of these injuries can be managed on the sideline, allow same day return to play, need to have a discussion with the athlete, as Dr. Indicato said, is that you really have to have that discussion about what is, what's the risk, can you go or not, you can use anti-inflammatories for this as well, Toradol can be effective, but really have the discussion of when and how, local injections again can be effective but have discussion about the risk of playing without an injury progression, ultrasound can help with accuracy, and long season sports are a little less common to use Toradol or injections than short season sports unless you're in the playoff situation, and avoid intra-articular injections. Thank you.

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