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IC 205 - Sideline Decisions Every Team Physician makes on Gameday (5/5)
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Controversial stuff, so questions, answers, and then questions from the audience. You guys got to have some questions here. All right. Go ahead. Seth Rosenzweig from Louisiana. The antibiotic choice, when you're doing some training medicine, lacerations, things like that, is there any role for something more than the Keflex, augmentin, maybe double coverage when we're doing things in the locker room? So Jeff, that hand injury, what about ... I heard you guys washed it out in the training room and sutured it in the training room. Yeah. We did grab a surgical tray, so I mean, we did, but typically just using Keflex. Every once in a while, we're concerned about a little bit more dirty or wet. You do have to worry about their gloves and stuff, but we've gone with Keflex most of the time. Every once in a while, we'll switch something up, but mainly Keflex. I have not. Intra-articular Toradol from our panel? Yeah. I've ventured into that jungle with ankle injuries, and level 10 speculation is that I thought it was helpful in the relatively mild, like Dr. Amendola said, high ankle sprains. I actually think there was a paper given, I think it was here at the Cherry Blossom Festival a few months ago, that looked at the potential negative effect that Toradol would have on chondrocytes with an intra-articular injection, found out that there was no negative effect. So it's a very empirical thing. I don't think there's a lot of experience in it. I have very limited, but I have done it. The other thing, maybe I've given the opportunity to go back and emphasize something that Darren said about waiting a couple of days to really get a much better assessment as to the accuracy of the return-to-play decision. It's much more accurate two days after the injury than two minutes after the injury. And we're all pressured, either in the sideline or in the locker room following a game, how long is he going to be out? And I have no problem telling the coach, I can give you a crazy guess now, but I'll give you a much better guess if you let me look at it over the next day or two. Ned, go ahead. You know, repeated steroid injections I think are a concern too. Darren, you sounded a little bit, I hate to say cavalier, but steroid injections for joint sprains and ankle sprains. But I think rather than doing multiple steroid injections, I think doing a Toradol injection I think is better. We didn't do repeat ones, it's just one time. I'm just giving you a hard time. Anyways, I did have a question for you. The question about MRIs. Like I think over the years, you know, I've been at this as long as you have, I find now that I'm doing MRIs like all the time. And I think that's the way it is. The parents ask for it. If somebody's got a joint sprain, I usually get a call from the trainer that, you know, the parents after the game are asking when are we going to do the MRI. They have friends of the family that are associated with healthcare providers and stuff like that. So I just wanted to ask you, I mean, I think it's changed. The environment's changed where I think it's better to get an MRI and just say you don't have a meniscal tear. There's nothing wrong. We'll let you play. Yeah, if there's any gray area, you have to get it. And parents are very involved in collegiate athletes nowadays. That's changed a little bit in 25 years. And you'll immediately get the feeling like, just as Ned said, just get it, get it done Saturday night, Sunday morning. We try to do it Sunday morning so that when I come to the training room at noon or one o'clock on a Sunday, I have the MRI done. And then we can sit down and review it with the kid. And that gets you started on the right foot for that next week. Yes, sir. On that, some kids will want the MRI. Other kids won't. Yeah. And so that's the discussion too. I'm the director of scheduling for our MRI's son for his ACL. And so we have Sunday morning at 8 o'clock, we have standing MRI slots. And then also because you just call her if we need to, we get to, and whatever. So know those people well. Jeff had mentioned the consent form for the TORADOL, whether it's now or before a season. So for TORADOL or for any injection, we would get a blanket consent form for the use of TORADOL before a season because it's just we felt more comfortable doing it. And every year they would re-sign it. As far as the use of local injections, that's an on-the-day discussion and consent. Just along those lines too, we've also found that it may be helpful if you're looking at a Tuesday or Wednesday game week about an injury and you're uncertain about the availability of that player to be there on Saturday, we've often used a sort of a test trial of a local anesthetic or TORADOL and see what that response was an hour or two or three after on a Tuesday or Wednesday. And that gives us a much better, a much more accurate assessment as to availability of that athlete again on Saturday. Because if they have a very poor response, the likelihood of them playing Saturday isn't very good. If they have a great response, obviously the likelihood of having that injection repeated before the game on Saturday and playing is much better. Go ahead, Nick. At the beginning of the season, we get consents from the athletes mostly about disclosure of information, you know, who is allowed to look at all their information. So all the trainers, physicians, and even the coaches, and basically it's a consent form for us to be able to communicate everything that's wrong with them to the whole team. All the people listed, you know, they're enlisted on the list there. And then we get a consent every time we do an injection. Every time we do something, it's a new consent form every time. So we document every Toradol injection, document every steroid injection. I do Toradol only orally. I haven't done injection of Toradol for probably 10 plus years now. We had, the reason we went to the consent form is we had a kid several years after playing started doing a lot of revisionist history on things and saying, oh, they didn't talk to us or anything like that, which we had. And so that's why we went to the consent form. But for us, it's two weeks in a row maximum and you sign each week for it. I will use Toradol game day. Somebody gets a, you know, the kid that broke his arm. We did Toradol. He wasn't coming back to play. So we weren't using it for a return to play situation, we were using it for pain control, which is different. But we talked to him about the injections. I don't do a consent form for injections, but have that discussion and document it in the notes. My problem with Toradol was that you would give it for appropriate reasons, but after a few weeks, the original injury gets better, but the athlete still wants the Toradol. And you ask them why, and they say, you know, I just feel, generally feel better the day after a game having had the injection rather than not having the injection. So in a way, it becomes somewhat of a semi-addiction that they want Toradol before a game, irrespective of the fact that nothing hurts. They just don't want to hurt as much after the game. And that's, you know, that's a debatable point. But another practical problem that it causes is that the trainers find out that athletes may be more reluctant to come in for their treatments during the week, knowing that they're going to get a Toradol shot on Saturday. And that creates some polarizing situations in the training room. So those things have to be factored into how available you're making any kind of pain-altering injections. Especially if their position coach gets a Toradol shot every Saturday morning. Yeah, then you're really screwed. Yes, sir. Just on the topic of Toradol, are you using Toradol for recreational athletes or community patient practices outside of just that training session that we've been talking about? For sport? For sport, well, recovery or return to sport. I use it post-op on almost every case. Toradol, post-op, three days. And the anesthesia people, if I'm doing knee ligament surgery, they give 30 milligrams IV at the end of the case. It's pretty common for them to use it as well, I think. Most of us do that. We use it for everything. What about Medrol DosePak? I think Jeff mentioned it. Stingers, I've used it for. And it's been pretty effective in that group. But it's really for the person that has repetitive stingers. It's been the one I've used the most. Ned, do you guys use them? Yeah, I use it, again, for more diffuse problems. So, you know, lumbar pain, neck pain, burners, and just kind of diffuse discomfort. You know, if you have just whatever that's inflamed and you can't locally inject it, I'd rather use a Medrol DosePak. Yes, sir. Yeah. Matt Panzarella from Charlottesville. Just a comment. I take care of people on the U.S. national team in kind of Olympic-type sports. We're not allowed to inject anything because it violates their doping agreements and stuff like that kind of stuff. And there's different rules on that. But just a comment on different athletes that we may take care of. We just can't do some stuff because it can take them out of the season or violate a doping and they're out for a year or so. So people who are taking care of different sports, it's something to think about before you stick a needle in somebody, in season particularly. I didn't realize that anti-inflammatory steroids were against the doping rules. Not anti-inflammatories, but injections. You can't inject Toradol. You can give them oral Toradol, but you can't inject Toradol. Particularly with USA and mountain biking, we can't give them any injections at all within a few days of the game or their races. But even an injection of saline? No injections at all. No injections. Yeah, no IVs unless they're in the hospital and we've got to do a therapy use exemption. There's a lot of things you can't stick a needle in them. Unless they cut something and you're sewing them up, you have to write that all up. But it's interesting here talking about football games, you can just inject them right ahead compared to other sports. I think it's knowing each sport too. Because every sport's a little bit different. Even Olympic sports with wrestling and stuff like that, chondral injections are real common in that group. What about ACL tear? Have you guys had a kid play with an ACL tear? I think I've had two in 25 years. I was going to comment on your comment because I think it does depend on the sport. This year we had one of our baseball players play through the end of the season and went to the Super Regionals, had an ACL tear, and then just had his ACL reconstruction last week. You had a lot of Iowa pictures in your talk. It's usually a win. Not in the last couple of years. Anyways, the Iowa wrestler last year, national champion with bilateral ACL tears, Lee. I had a long snapper that he just snapped our field goals. Didn't snap the punts ready to do coverage, but he snapped the field goals. We had one of our wrestlers tore his ACL at the NCAA Championships. He wasn't able to go on. It was an acute injury versus one that was a little bit older. We did have a kid that had one ACL tear before he transferred to us, wrestled the rest of the season, tore his other ACL this year early in the season. It took him about four weeks. Wrestled the entire season. Close to being All-American. We fixed his ACL as soon as the season was over. I think it depends on the sport. When you talk about wrestling, it depends on their weight class and everything else that the kid can do. What about, Ned, the risk? All of us treat Jones fractures. Put a big screw in, obviously. Don't put a small screw. You mentioned that maybe you could get the kid back, but it takes so damn long for that x-ray to look good. You made the comment that treat them symptomatically. Maybe don't get an x-ray every week because you're going to be disappointed when you look at it. But you also run the risk of fracturing through the screw. We've seen those. Some of those, athletes have ended their careers with the Jones fracture, non-union. You still say, let's not worry about the x-ray. Let's treat it symptomatically. So far, it's been so good? Generally speaking, yes. I've been doing the NBA Combine. We assess 60 or 65 players every year. Everybody who's had a Jones fracture, they get imaging. You get MRIs and CTs of every injury the kids have had through their career. If they've broken anything, they get a CT scan. If they've had a fifth metatarsal fracture. Even a year or two after they've had the fracture, they've played all season the last season, and they get a CT scan. Now, before the NBA draft, it's very rare to have 100% healing. Most of the time, it's 50, 60, 70% of the bone is healed. It does take a very long time to get complete healing. If you're waiting for everything to look perfect, it's going to be more than a year. I think that's what most people do. I think because of some high-profile athletes that have had a redo surgery because of re-fracture. There have been three or four NBA players in the last couple of years. There's been a little bit more concern. Now, with this liability and litigation, there's been some concern that maybe you should wait longer to let these people go back and play. That's what we've been doing. Bob Anderson does the same thing. I do a CT scan at six weeks or seven weeks, even though they're doing well, just to confirm that it's healed. He says, I don't even do x-rays. He says, once they're good, I let them go back and play without any imaging. One more question here, and then we'll finish up. I'm Hong, team physician from Taiwan. I appreciate for your tremendous and inspiring talk. Here's my question. We all know that high ankle sprain or leg sprain injury is hard to identify. What is the timing for them to return to play? Because the injury is minor, but the instability means a lot. My question is, does dynamic ultrasound imaging play a role in the U.S.? Thank you. So, Ned, using an ultrasound to maybe help you diagnose, is this a mild one or a moderate one? Maybe they've got a little opening if you can really stress them. Anybody using ultrasound to help with that? Yeah, there's been quite a few papers on the use of dynamic ultrasound to assess particularly syndesmotic stability. For lateral ankle sprains, I don't think it really matters. But for high ankle sprains, I think ultrasound is another way to assess the stability, but it's still not 100% objective. So, again, just to give you guys some more information, so this year we're going to get weight-bearing CT scans on the whole football team before the season starts. It's a study looking at weight-bearing CT to look at dynamic stability of the syndesmosis. So we're going to get a weight-bearing CT scan, and then when they get injured and have an ankle sprain, we get another weight-bearing CT scan. So we compare the new one to the baseline one to see if there's any way to really predict. And that's what we need for the ultrasound too. We should ultrasound everybody before the season, and then you can use the ultrasound to measure stability. We don't really have a good baseline to use that. We looked at MRIs for a little while because we were trying to predict how long somebody would be out, not necessarily looking at it from a stability standpoint, but, you know, is this going to be a high ankle that's out two weeks versus a high ankle that's out eight weeks? And we couldn't tell the difference. Bruce Miller tried to do it using ultrasound, and they couldn't come up with anything that made a difference. But they weren't looking at the instability part. And then the other question is if you have a lesion. Let's see here. If you have a lesion that has little or no progeny bone, particularly in the trochlea, does it change your approach? I think if you're looking for that instability, I think the better question now is if you're looking for that instability, and maybe Ned will be able to answer this, is if you get that little opening, is that one that does better if you put tightrope across that? And then they're back playing at, you know, two weeks or four weeks, if you can get that right away. I think, you know, talking to Bob Anderson, because Bob was up near us for a while, and Bob wasn't a big believer in doing that at all for those. All righty. I want to thank the speakers. Great job. Thank you all for coming this morning. Appreciate it. Please fill out.
Video Summary
In this video, a panel of experts discuss various topics related to sports medicine. They address questions from the audience about antibiotic choices for injuries, the use of Toradol and Medrol Dosepak injections, the use of MRIs for joint sprains, and the use of consent forms for injections. They also discuss the use of Toradol for recreational athletes and the limitations on injections for athletes in doping agreements. The experts share their experiences with ACL tears, Jones fractures, and high ankle sprains. They mention the use of dynamic ultrasound imaging for assessing syndesmotic stability and the potential use of weight-bearing CT scans for predicting injury outcomes. The video concludes with a thank you to the speakers and a request for audience feedback.
Asset Caption
Darren Johnson, MD; Geoffrey Baer, MD, PhD; Peter Indelicato, MD; Annunziato Amendola, MD
Keywords
sports medicine
antibiotic choices
Toradol
Medrol Dosepak injections
MRIs for joint sprains
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