So first of all, if anyone has any cases that they had this past year or questions for, you've got the, basically the world's experts on these complex sports injuries in areas that were not helpful. So please come up to the mic so we, everyone in the room can hear you. Thank you all very much, Dr. Dossett, with acute herniated discs, do you sort out, does it truly happen, potentially compartment syndrome, ischemia of a root, acutely you have an athlete that acute event, radiculitis and weakness within 24 hours. Is there an indication to get to those surgically quickly or can they again end up one of those patients with long-term radiculopathy and weakness if you don't get to it soon enough? That can happen. It typically does not happen. You know, if you have someone that comes in and they have significant motor weakness, like meaning significant 3 over 5 or greater, meaning 3 over 5, 2 over 5, something like that, there is a, depending on what you see on imaging, if you see a very large disc herniation, like the first disc herniation I saw you as an example, contained, and so what you're looking at there mostly is probably mechanical pressure and that, the inflammatory aspect of it is probably not as great, it's more mechanical. So to answer your question, it's pretty rare for me to go straight to an operation. I think most people tell you you have somewhere between 4 to 6 weeks but we really don't know. You can, if you look at it, you can say, well I got to it within 3 days and if they have a 3 over 5 power, they may already have nerve damage. There's no way to know that. We have not figured out when the threshold has been reached but the consensus is you have several weeks to figure it out unless they present at 4 over 5 strength and the next time you see them a week later they're 3 over 5 strength and their pain is increasing then there's compelling evidence to operate at that point. Thank you. So Drew, just another question related to spine. So we're hearing a lot now about disc replacement, particularly in the cervical spine. So I'd like to get your thoughts on that in collision sport athletes. There's at least one NHL player that I know of that has one. I think there's a few. I don't know of any in the NFL right now but it's probably coming. So can you kind of share what's kind of the current concepts and thoughts on cervical disc replacement in collision sport athletes and then also really in non-collision sport athletes, is there a difference? I think there is. First of all, you know, my talk was lessons learned and I think cervical artificial disc replacement in collision athletics is lessons to be learned. You know, all, I have a personal bias here, all medical disasters start with new technology. In fact, in 1984 doing a Gore-Tex ACL seemed like a really good idea, right? So I had a Gore-Tex ACL and 14 operations later they decided it was a piece of shit. So that is new technology, all right? And so if you look at the artificial disc replacement, and we've just started delving into this because it becomes an issue. First of all, I was on a sideline for 20 years watching collisions, an NFL sideline, watching collisions up close and personal. And I promise you, there's no way kinematically ADRs are tested under those, that force couple. Not a chance, zero chance that it's tested that way. And if you look at the data now, they kind of test it to 1.5 newton meters. And so we have, the NFL has done a good job of looking at concussive hits with this lab out of Charlottesville, Virginia. And so they extracted some of that stuff to look at what the force couple is to the mid-cervical spine and it ranges up to five newton meters. And so in no way has the ADR been tested to that length. And so what you're looking at is just a catastrophic failure. And so in my hands, as I tell my patients, I'm kind of a second wave guy, right? I wouldn't mind saying I was at D-Day, but I sure would like to have shown up at 6 p.m. And so I think this thing's going to play out. My guess is that there's probably going to be a disaster that occurs with an ADR. And that's in a collision athlete. And I would say that's hockey, football. But the other things, tennis, golf, things like that, I think an ADR is fine. I'm not enamored with it. I rarely use it. The gold standard still remains an anterior cervical discectum infusion. No question about it. The premise that you're going to decrease adjacent segment problems from the fusion, it's a premise. It's not been verified, and the data looks more and more like it's about the same. So you have something that you know works, and you're trying to put in something that seems to be clever. And as we've learned, the difference between clever and stupid is about this much. And so in my hands, it's still an ACDF. How is it fixed? Is it just a press fit? Is there ingrowth? Are there screws? Both. You know, it depends which one you use. And so I've revised a couple that did not grow in, and they have persistent pain. And if they didn't grow in, and they have a little bit of osteolysis, and you subject them to the forces that you're describing in a football collision, well, you've got a major problem. And what's going to happen? We don't know. But we're going to learn that lesson at some point in time. So Kirk, another thing that we see all the time, which drives me nuts, is high ankles. So we see probably like four or five a season. I still don't know which ones, or when we send them to you guys, is going to end up needing surgery, not needing surgery. Is there anything, when I'm first seeing that athlete, usually we get an X-ray, nothing's wide, you know, they're tender over the distal syndesmosis, they can't do a single heelrise, the MRI shows some disruption of the anterior inferior tibiofibular ligament there. It's not an obvious one. How am I sorting that out? What am I telling that athlete? Because sometimes I'm like, yeah, probably, you know, boot, and then we'll see what you do, and then you guys say, oh, yeah, this needs to be fixed, and vice versa. So I'm confused. Yeah, I mean, you know, I think the things that make it hard is that a lot of times these aren't their first ankle injury, you know, so you already have someone who's got pathology that when you look at the MRI, well, is that old? Is that new? It's hard. Because, I mean, and other folks have sat up here and shown MRIs where you show three different MRIs that all, they look the same, they look horrible, it's like, oh, my gosh, it looks like all of them need to be fixed, and then you say, well, hey, this one came back at three weeks and was fine, this one was horrible at seven and couldn't do anything. The reality is that if I had it all figured out, you know, it would be worth a lot because these are obviously major, major debilitating injuries. The problem is we're still trying to figure it out. I think differential injections, not unlike what Craig was talking around the hip, can be of some benefit even just in being able to understand what's acute, what's chronic. A lot of times you may have a stable syndesmosis, but they still have pain posteriorly along their FHL. So an ultrasound-guided injection to the FHL if they're having a problem getting up on their toes, all of a sudden if that cures that, well, that was more FHL-related inflammation than it was instability. You know, so it's working through some of those things, but the reality is that short of putting a scope in that ankle, if there's that much, like, we need to know what's going on, you know, whether it's even a needle scope, I mean, that's what's going to really tell you. Stress exams, you know, they're not as sensitive. They certainly specific when you see diastasis, you know, even weight-bearing CT has not really borne out as a way to clearly identify some of these subtle ones. So, you know, it's using the differential injections. Are they really tender way up? I mean, the more tenderness they have four centimeters and above, the higher of a concern I have, particularly if that external rotation stress is not resolving in a short period of time. You ever use a exam under anesthesia without a scope, or how does that play out? Yeah, so, I mean, you can. The problem I find is that, you know, not unlike even Liz Frank's stress views on fluoro, it is all about subtleties of rotation, and you've got to try to compare it to the opposite side, and, you know, the sensitivity of that fluoro exam under anesthesia compared to even just very basically briefly sticking a scope in there. There are ones that we still miss when we try to fluoro, where you'll fluoro them, and there are studies out there that show that you fluoro, I'm like, man, I think it's stable. You stick a scope in there, you see all the disruptions, like, oh, my gosh, you know, I didn't see that. I still think there's more that are seeing us than we are appreciating when we do those type of, because it's technician specific, we're just not sensitive enough. You mentioned injections for these on the lower grade ones. So we had a player this year during the Stanley Cup run that had a high ankle, wouldn't let me image it other than x-ray, and we injected him to play multiple games, and then at the end of the season, we got the MRI, and I was like sweating it, because I was like, what if this one's one that needs to be fixed? So luckily it wasn't, but how, talk about injections to play for high ankle, and can you make that worse? How do you counsel your players about that? Yeah, I mean, I think the important thing is trying to calm down the synovitis that's in the ankle joint itself. I am not recommending putting a lot of steroid into the syndesmotic space on a repeat basis, but I think being able to manage the FHL posteriorly under ultrasound guidance to place it around that sheath, and then placing it in the joint to calm any of the synovitis in the joint, I think that's very different than continuing to put steroid along a ligament, which any of us have read the studies that talk about basic science, and hey, if you're putting steroid around tendon or ligament, what does that do to the healing properties of it? So I think that's an important differentiator, you know, but being able to use that on a limited basis. I mean, if you're continuing to have to inject every single week for multiple weeks, and once again, there's something seeing you that you're not appreciating, that's where I think it becomes a concern. Doing it within the first couple weeks, that's okay. But you know, the other thing about it is also understanding that with a syndesmotic injury, placing someone in a boot, this is a rotational thing. So for inversion, eversion, a boot, particularly with an insert in it, can help protect that, but rotation, being in a boot does not prevent subtle diastasis of the syndesmosis. It does not prevent you from still rotating because it's not grabbing a hold of the tibia. So sometimes, and Bob has even advocated on this, you put them in a cast, you get people's hands off of it, and just let the thing, when it's really bad, just calm down, even if it's just for three to four days, and not try to do too much, because it's always go, go, go, go, go. Sometimes you just need to slow, slow, slow, and then realize that, hey, these really flat-footed athletes, they're going to put a ton of pressure externally as they pronate, put an insert in that boot, but also realize that just because they're in a boot does not mean that that thing's automatically protected. Bob? Yeah, two questions for Craig. So do the injections always work perfectly for you? Because I take care of the lacrosse team at Penn State, and I've had players where, oh, it helps a little bit, but, you know, in the joint, now we're by the pubic bone, now we're in the symphysis. So if they're not giving you a clear answer, what do you do? And then question number two is, like, what's the indication for rest for these? Like, is this an overuse thing where, you know, like, I've been able to get kids through the season, but then I'm wondering, well, if they rest over the summer and then they come back, is it just, are their symptoms just going to come back? Should I fix them in the offseason? What do you think about that? Good questions. Yeah, I mean, I think the injections, like anything, it's not the be-all, end-all. I think it's a piece of the puzzle, because you're right, sometimes, I like doing it in the office. I know my colleague and our colleague, and I know he does a good job, and I know he gets it in the joint, because part of the problem with these is, oh, they come back and say, oh, the injection didn't work. It just hurt a lot. And we're like, oh, I think they injected it over here. You don't know where they put it, if they were actually in the joint. So I think doing that under your control, examining them right afterward is the best we can do with it. I mean, I give it 20, 30 minutes, and I move them around, and sometimes it's amazing. So that's a very positive value, or kind of predictive study. When it doesn't respond, right, is it just because they don't respond to the anesthetic, or just a vague presentation, or there's a mixed picture? So I don't think it's 100% kind of guiding your treatment, but maybe it can be a piece of the puzzle. Yeah, I mean, I think for the non-high-level athlete, you know, pain around the core, you can certainly treat non-surgically at length. There's no urgency to do anything to it. In fact, you may decide, if it's a hip FAI problem, just take care of the hip and see if it all resolves in the future. You know, the thing we face with some of these athletes in and out of season is now January, they've been dealing with this pain for a couple months. The problem with resting them for three, four months is then it comes back in the summer at OTAs, and the coach is like, why didn't you guys just fix this in January? And so that may push you a little bit in a higher-level athlete to take care of, you know, and frankly, oftentimes, these guys get their cores taken care of because they're symptomatic, and it's a pretty reasonable fix, and the hip is a harder rehab. So in some ways, almost the higher-level athlete, you almost do a little bit less sometimes, whereas your college, I have plenty of college kids where the FAI is the driver, and we take care of that. The family's on board, and you take care of the FAI. I probably, I use the combined, I usually would just take care of the hip in those cases because I think that the core does respond, and a lot of those, you're a younger lacrosse athlete, something like that. That being said, sometimes they have, you know, they know the two pains, and if they have two pains there, we're going to have them under anesthesia, and I have my general surgery colleague, we've done a fair number of combined procedures in those athletes. So it's kind of working through that algorithm and talking to the family and understanding their patterns of pain. Does it change your rehab if you do both? No, I think it's driven by the hip. So it doesn't really add anything to the post-operative course, so you can say, well, why not just do it? It's an additional surgery. There's, you know, they have an incision by their core, so you don't just do it, you know, just to do it, but it doesn't really affect their rehab. Are you fixing both sides of their core if you're fixing the core? We typically just do the symptomatic side, and it's not uncommon for them to have an MRI and have worse-looking findings on the other side. So our approach has been if they have a symptomatic core, just to fix the side that's symptomatic. Steve, question for you. You mentioned it as the bane of your existence, mine too, the wide scapho-lunate area, non-acute injury. So, you know, a lot of these guys will complain of, you know, I got some wrist pain, we get the x-rays, we get the MRI, they've got these chronic scapho-lunate disruptions, widening. What do I do with those guys? Definitely don't tell them to come to me, and, you know, nothing's going to work. I mean, there's different surgeries that have been described to try to reconstruct that ligament for chronic tears, but they're all going to fail. So I basically tell them, you know, I'm sorry it hurts, but you're going to have to try to live with this and play with this. You're eventually going to get arthritis, I don't know exactly when, but it's going to happen. And if that happens, then we'll have to do a salvage procedure, like a prospero-carpectomy or something like that. But there is no, I'll tell you, there is no good answer for a chronic SL tear. If you want to try to mitigate their pain a little bit besides the usual non-operative treatments like injections and stuff, you can do maybe a posterior interosseous directomy, you know, just basically try to cut off the pain signals going to your brain. Maybe you can do a little radial styloidectomy if they have a little arthritis over there. But there is really no good answer for that. So I, especially after, you know, so many years of treating these things and being so frustrated, I certainly haven't come up with the answer and I don't know anyone that has. Bracing, casting, pearls, anything for? Yeah, I mean, a lot of times these guys will, they have pain with extension. So they're going to wear maybe a wrist extension block, a type splinter brace. But that's pretty much it. You know, there's, that's pretty much it. Great. So we're kind of up against the time. Unfortunately, we didn't have time for cases, but hopefully we're able to answer a lot of your questions and kind of talk about the things that I think are most controversial. So I'd like to thank this esteemed group up here. They're my second opinion guys. They're super helpful. So if you have any questions afterwards, I'm sure they'll be happy to stick around for a few minutes. So thank you guys for coming.

sports injuries

acute herniated discs

cervical disc replacement

high ankle injuries

scapholunate tears