CDC's New Guidelines For Youth Concussions

The CDC has released new guidelines for youth concussions. They are reasonable for parents to read and understand. HERE is a good overview

Is American Football Safe?

Is American Football safe? The answer may surprise you when compared to many other sports. Read details HERE

A New Look At Ulnar Collateral Ligament "Tommy John" Elbow Injuries

My partner at Washington University Matthew Smith MD an elbow ligament and throwing injury expert and Spencer Lake PhD a Washington University Mechanical Engineer have received a grant to look at innovative ways to image the ulnar collateral ligament in the elbow utilizing polarized light. This should give us more information regarding structural properties and how better to treat these injuries. This work featured in the St. Louis Post Dispatch article from the Business Section HERE is truly exciting given the number of these injuries that are occurring in younger and younger athletes.

Lab Grown Cartilage At Washington University

Farsh Guilak PhD is growing cartilage in the lab and is one of the leading cartilage researchers in the world. Read about his work at Washington University in St. Louis HERE

MOON-MARS Revision ACL Graft Study Presented Toronto AOSSM Meeting

A combined MOON (Multi-Center Orthopaedic Outcomes Network)- MARS (Multi-Center ACL Revision Study) looked at patellofemoral (kneecap) cartilage changes after allograft or autograft primary ACL reconstruction as identified at the time of revision ACL reconstruction. This study presented by Robert Magnussen of Ohio St. at the Toronto AOSSM (American Orthopaedic Society for Sports Medicine) meeting in July. 134 patients had undergone MOON primary ACL reconstruction followed by MARS revision ACL reconstruction. Progression was identified as progression of one grade worse or a 25% increase in size of the lesion. 31 (23%) had worsening progression of arthritis. Results showed allografts had a 15.5 times higher risk of progression. Odds also increased 10% with each unit increase of BMI. Age, sex, activity level, meniscus status, injury mechanism had no impact. The association between graft choice and damage was surprising. Previously it was thought maybe a patellar tendon (BTB) autograft might be at more riskk. Allografts with more laxity may place more pressure on cartilage, but we cannot be sure. Further work will be necessary to sort this out.

Kids' Sports Leagues: A 15 Billion Dollar Industry - Time Cover Story

There are many issues surrounding the burgeoning kids' sports phenomenon. Some good, some bad including early sports specialization which may lead to more injuries. Read this week's Time Magazine cover story on the topic HERE

It's Marathon Season: What Are The Side Effects?

Spring is marathon season. While running has many positive effects there are some mild negative effects to consider -- especially for longer running sessions. Read details HERE

Hockey Lacerations: Life in the NHL

As evidenced by Zach Werenski of the Columbus Blue jackets last week hockey players are tough and always want to come back and finish the game. Our job as team physicians is to protect the players and make sure there is no additional damage beyond the face laceration. Additional injuries can include eye damage, facial bone fractures, dental injuries and concussions.

With the St. Louis Blues we are fortunate to have excellent consultants to help me rule out any other injuries. We have a dentist (Ron Sherstoff) and oral surgeon (Ken Kram) present at every game. Additionally, we have opthalmologists (Gil Grand) and plastic surgeons (Tom Francel) available some nights in the arena, but always available for follow up exam.

With every facial laceration we do a neurological exam to rule out a concussion and if there is any doubt we will hold the player and do additional testing. 

To finish the story of Zach Werenski he returned for the game in a shield, but he developed significant bruising and swelling. He tweeted his own picture after the game below and then was diagnosed with a blowout fracture of his upper facial bones surrounding his eye.He missed the rest of the playoffs with Columbus

How to Survive a Shark Attack

While you may think this does not belong in a Sports Medicine blog I would feel terrible if a reader needed this information this summer and I had not provided it ---so here we go. If you are unlucky enough to be attacked by a shark look HERE for how to survive.

Cartilage Replacement in the Knee

Articular cartilage covers the ends of bones in joints throughout the body. Normal cartilage is smooth allowing easy gliding of the joint. When cartilage is injured, the smooth surface can become rough. Cartilage is unable to heal or replace itself. Occasionally the cartilage injury is severe and there is complete loss of cartilage resulting in exposed bone. Sometimes called OATS or Mosaicplasty osteochondral grafting is a method of treating cartilage injuries that expose underlying bone. Osteochondral grafts

replace both the articular cartilage on the surface and the underlying bone. The tissue can come from other parts (typically knee) of the patient’s body (called osteochondral autograft) or from a tissue donor (osteochondral allograft). These techniques are commonly used in the knee but can be used in other joints.

The injured area of cartilage is identified and a core of the injured cartilage and the underlying bone is removed in a method similar to coring an apple. A replacement core made up of cartilage and bone from another site in the knee (autograft) or a tissue donor knee (allograft) is then made to fit into the hole. The replacement core is gently tapped into place until it lines up with the surrounding tissue. It acts as a pressfit. No screws or other devices are typically needed to hold the replacement core in place since it fits tightly. Frequently it can be performed all arthroscopically.

Patients can usually start to bear weight within 4-6 weeks of surgery. Activity is gradually increased with return to sport typically occurring after 6-9 months.

Patients often recover very well from both of these procedures. One advantage of these techniques is the ability to replace both cartilage and bone with similar tissue. There are limitations to the amount of tissue that can be taken from within a patient’s own knee so larger areas of cartilage loss may not be best for this approach. A potential concern with the use of donor tissue is the very low risk of disease transmission (like a blood transfusion). Although these techniques are new to have data on how well patients recover in the long term, it has been seen that these patients frequently do very well.

Knee Bone Bruise: Their Affect on Athletes and the 2016 Baseball Playoffs

The Blue Jay's playoff hopes were hurt when Devon Travis was diagnosed with a bone bruise.

He underwent a cortisone injection, but has not improved enough to play. These injuries which are increasingly diagnosed require a traumatic loading of the knee. In the isolated situation there is no structural damage. The knee will be swollen and painful with activity. Bone bruises are also frequently noted with ACL tears (80%) when the tibia (leg bone) subluxes and strikes the femur (thigh bone). Diagnosis can be suspected based on clinical exam and history, but requires an MRI for confirmation. That is why they were not known to exist before the mid 1980s. 

In the common isolated situation there is little that can be done to speed recovery. Most physicians have felt that the recovery to full activities is 6 weeks, but in this study I published in 2000 we demonstrated different results. This was the first ever report of a series of isolated bone bruises. In this study published in the American Journal of Sports medicine it was shown that the average time to recovery and full normal activities was 3.1 months. This was much longer than health care professionals had previously thought it took for recovery. This has ended up as very helpful information in advising athletes, coaches and general managers as to the timeframe for their recovery from these injuries. You can read the entire study HERE

Shoulder Separations

It is football season with hockey not too far behind so we are beginning to see shoulder separation injuries showing up at the Washington University Orthopedic Injury Clinic. Patients always are confused as is the media on the difference between a shoulder separation and a shoulder dislocation. A Shoulder Disloction and its Treatment as previously reviewed on this blog refers to the humeral head (ball) sliding off the glenoid (socket). This frequently needs to be put back in place and frequently requires surgery to prevent future episodes.

A shoulder separation on the other hand is typically treated conservatively and rarely requires surgical reconstruction except in severe circumstances such as the injury Sam Bradford sustained while playing for Oklahoma. The injuries most commonly occur in contact sports but are also frequently seen in cycling injuries when riders fly over the handle bars and land on their shoulder. It is typically a blow to the point of the shoulder that drives the shoulder blade down and stretches or tears the ligaments that connect the collar bone (clavicle). These ligaments are called the coracoclavicular

ligaments and are 2 tough bands running from the collar bone to the coracoid -- a bony prominence projecting from the scapula. It also occurs frequently in hockey when players are checked into the boards or fall and hit the ice. Typically it causes local pain in the shoulder area with limited range of motion and weakness. Initially it is treated with a sling ice. A plain x-ray showing the depressed shoulder blade and ruling out a fracture is all that is necessary. An MRI is not required.

Physical Therapy is begun soon after the injury with a focus on motion and strength. Once the pai n is tolerable and full motion and strength is regained the athlete can return to sports with no long term sequelae except some prominence of the clavicle in that area.

 There are 6 grades of injury with most falling into Grades 1,2 and 3. Grades 1 and 2 are always treated conservativeley. Grade 3 with worse ligament damage and more deformity is still usually handled without surgery. Occasionally throwers or other overhead repetitive workers require repair/reconstruction of the ligaments. Fortunately, despite several injuries of the Type 3 severity with the St. Louis Blues we have never had to perform a surgical reconstruction. Grade 1 injuries typically require 1-2 weeks for recovery, Grade 2 2-4 weeks of recovery and Grade 3 treated without surgery are 6 week injuries.

Oblique Muscle Strains

Once again this season baseball players have been affected by oblique muscle strains. Most recently it impacted the St. Louis Cardinals when their All Star infielder Matt Carpenter sustained the injury missing a month of games including the All Star Game. Why are these such significant injuries for some sports and playing positions while you never hear about them in other sports?

The oblique muscles reside on both sides of the abdomen and chest running from the pelvis to the chest and ribs in the front and chest and spine in the back. There are 2 muscle groups on each side--- the internal and external obliques. Rather than running straight vertically or horizontally they run “obliquely” across the body and thus their name is derived.

These muscles are critical for rotational activities and that is why they are more impactful for certain sports. While challenging for any athlete an oblique muscle strain is the worst for those athletes that repetitively rotate. Thus baseball pitchers and hitters are highly affected. Hockey players are also bothered by it while shooting especially during slap shots.

We have had several with the St. Louis Blues over the years that resulted in several man games lost. It much less frequently affects sports that are more linear such as track, swimming, football or basketball. It is an infrequent injury even for quarterbacks and I can’t remember a significant oblique injury with loss of time for any of the Rams quarterbacks.

Treatment is similar to other muscle strains and involves conservative management with ice, NSAIDs and rehabilitation including stretching and strengthening. Nothing seems to shorten

the recovery which for baseball position players is typically a month. If anything more than a minor strain for a pitcher it can cost 6-8 weeks. Cortisone injections can be utilized, but still time is the best ally and cortisone is relatively a quick fix. These muscle strains typically are diffuse over a relatively large area and thus difficult to pinpoint for an injection. Likewise there is no scientific evidence that platelet rich plasma (PRP) or stem cell injections will speed recovery. That is why these are difficult injuries for the athletes and the fans that follow them. It is hard to be patient.

Ankle Sprains Can Be More Than They Appear

Ankle sprains represent one of the most common reasons people present to Emergency Rooms for musculoskeletal complaints. While nearly everyone has sustained a sprain in their lives if ignored they can present significant disability. Ankle sprains as depicted in this picture are tears of the ligaments around the ankle. The most common type is depicted here as an inversion sprain with the ankle rolling in on itself.

Typically significant swelling is noted and there may be dramatic bruising.

Frequently when seen in the Emergency Room patients are given crutches, instructed to ice and elevate and little else is done. In reality all ankle sprains severe enough to go to the ER should undergo physical therapy for range of motion, strengthening and balance training. Additionally, the patient may need to braces during recovery.

Upon returning to sports it may be a good idea to wear a functional brace which may be as effective or more effective than taping.

A significant ankle sprain may continue to ache with activity for several weeks. Read HERE for several more facts regarding ankle sprains. Always take these seriously.

ACL Reconstruction Rehabilitation Part 2

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the systematic review evidence we based the protocol on in 3 separate studies. in Part 1 I reviewed the findings in our first publication. The second publication can be found HERE. Findings in this study included a review of open (isokinetic) vs. closed chain exercises. Closed chain exercises occur when the foot is planted on the floor or on a firm surface such as a leg press machine. These type of exercises may be more protective for the healing ACL graft,  but it appears open chain exercises are safe 6 weeks after ACL reconstruction.

Neuromuscular stimulation has been extensively studied utilizing a variety of parameters and has not been shown to be critically important. It is safe and can be utilized at the therapist's discretion most commonly when the patient is struggling to recruit the quadriceps muscle for strengthening.

Accelerated rehabilitation has gained much attention, but there remains little evidence that it can be truly lowered below the 4 month time frame safely. One randomized study looked at 8 vs. 5 months and found no problems with this length of rehabilitation, but to many of us this doesn't represent significant acceleration. Future research will be necessary to address this further.

Water exercise may decrease swelling and appears to be safe. Slide board exercises can be incorporated at 6 weeks without harm. Stair climber is as safe as stationary cycling at 4 weeks.

Additional principles will be reviewed in Part 3 reviewing our 3rd study evaluating ACL rehab PT

Nutrition Gaining Importance Even For High School Athletes

Nutrition is critical for maximizing athletic performance at all levels including the high school athlete. Read the New York Times article on this HERE

ACL Reconstruction Rehabilitation Part 1

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the principles that it was based upon in a series of evidence based systematic reviews. The study can be found HERE  I will summarize our findings in this and subsequent blogs. Continuous passive motion CPM has been anecdotally advocated as a way to improve range of motion (ROM) following ACL reconstruction. It has become increasingly difficult to get insurance to pay for this and fortunately 6 randomized controlled trials demonstrated no advantage for the use of CPM. Based on this we did not utilize or advocate for its use in our protocol.

Immediate weight bearing and early ROM has been shown to improve outcome with less patellofemoral pain postoperatively. More than 15 randomized trials have evaluated using braces during the recovery phase following ACL reconstruction. No study demonstrated an advantage for safety, swelling, graft function or ROM with the use of the brace. Given the cost and inconvenience of braces we do not require or advocate bracing after ACL reconstruction.

Home based vs. outpatient rehabilitation has been evaluated in several studies. In the motivated patient appropriate outcomes can be achieved with minimal outpatient therapist guidance. This should be individualized for each patient.

Read future blogs for a review of further studies guiding our protocol’s development.

Shoulder Instability Treatment

Watch this video to learn about management for a dislocated shoulder

Dislocated Shoulder Treatment

The 7 most common Sports Injuries

Sports Injuries are common every day occurrences in the general population. Follow this link to read a review of the 7 most common.
The 7 most common Sports Injuries

ACL Injury Video

Watch this video to learn more about ACL injuries

ACL Injury Video