Dr. Eddy Echols, Returning to Play After Injury

I’m Dr. Echols and you guys are definitely warriors. You’re here to the end. All right. Well over the next 20 minutes or so I’m gonna discuss game time decisions on the field management of injuries and return to play decisions with reference triathletes. Now obviously that’s a very broad topic. I could stand here and talk for over an hour on this topic but obviously I only have 20 minutes.
OK. What was the big reason. You’re. In the middle. Oh. OK. All right.
So the way I want to approach this is that initially we’ll discuss some of the broad concepts associated with medical management of an athletic association. And we’ll also discuss on a more broad concepts regarding return to play decisions. I’ll try to get to that then we’ll look at some of the more specific instances in which we apply. These principles. All right. So first slide I have up here is the team approach and why not put that up. Well obviously the team physician does not operate within a vacuum. He has a medical staff and depending on the size of the organization to deal with. That will kind of determine the structure of your staff. If you’re dealing with say high school, you may just have your trainer and it’s you. Conversely if we had a collegiate level, chances are you have multiple trainers a head trainer probably a primary care sports medicine doc and then your team surgeon obviously at a professional level you have more layers than that.
The key thing that I’m trying to get though is that obviously the size of the organizations are going to determine the structure of your medical team and that has to be defined. Everyone needs to know the hierarchy of the organization so that communication can be clear timely and concise and then everyone has to be on the same street. And as long as you have that then you can communicate with the other parties that are involved. That’s important because obviously if everybody does not appear organized sometimes you can get coaching staff that kind of go rogue if they don’t feel you know what you’re doing or they don’t feel you have the best interest they can start making decisions on their own. Which is obviously not good. You tell they only see that more so at a high school level not so much at the collegiate and professional level.
But that’s important. And you see here I got the principal parties that are involved here the medical team vibe his reasons then I’ve got the coaching staff as I said before. If in fact you’ve got clear timely concise communication and everybody is saying the same thing then that coaching staff has more confidence in what you’re saying and therefore they’re likely to agree with you and give you less pushback. Next to have the parents listed down here and once again depending on what level you’re dealing with the parents may be that second party. Of course, the key thing here is if Mama don’t believe in what you’re saying. If mom is not happy with the plan that you propose, the plan stops. Right. Now. Obviously had to call each level not so much that professional. Now we also have to add in the agent and that sort of thing. But the key thing here is is that as you see at the bottom of the pecking order is the athlete. Now obviously we’re doing all this for the athlete but a lot of us this is the athlete is at the low end of the pecking order.
But at the end of the day we’re here to do what’s best for the athlete. Now interestingly enough the medical injury the diagnosis doesn’t necessarily drive what we’re gonna do. There are a number of other factors that come into play. We’re treating these athletes and I’ve got them listed up here. There are a lot of factors to consider. Obviously if you deal with a professional athlete is this a contract year because it is a contract year and I’m proposing something is gonna basically keep him out this season. Nine times out of 10 he’s looking at me like I got two heads. All right. So now obviously if he’s after he’s gotten his new contract. OK we’re more open to potentially having the surgery doing extensive rehab things like that college.
Once again, he got look at eight years of eligibility. If you’re dealing with a freshman and sophomore, they still got the red shirt. Once again, they’re more likely to go along with say surgical intervention prolonged rehab things of that nature. Conversely though if they’re going into their last year of eligibility and this is the last time they get it looks then once again they’re not just likely to have some type of big procedure.
Same type happens with high school. If you got your freshman and sophomore, they’ve got time. All right. And once again sometimes you’d be surprised we had to fight mom you know to get them sorted out. I’ve had mom sitting in office calling me kids wimps you know get back on the field and sometimes have to have them pump the brakes. But a lot of things go into these decisions that we make and obviously the time and the season whether it be preseason mid-season postseason this all plays a role and at the end of the day the severity of the injury is going to kind of come into play as well. If you’ve got more to ligament it’s unstable knee. OK well chemicals are saying you just can’t go on that but these are some of the factors that come into play when we’re looking at return to play decisions and how we’re managing these athletes and getting them through this maze.
Now what I’ve done is I want to look at a couple of specific Hot Topic items that bring some of these concepts into play. And obviously if any of us listen to the news you know that concussions have become forefront now with our athletes as far as management.
You know we’re obviously kind of learning more and more but we realize some of the devastating potential long term effects that come into play when dealing with concussions. And so therefore appropriate identification.
Timely management of concussions obviously is paramount at this point. So. With the treatment of concussions ideally we want to start treatment before this season starts. And what I mean by that is we want to get cognitive baseline studies before season if possible. You know obviously everybody doesn’t deal in giving the same deck of cards. And so some may have better cognitive function than others and we need to know what the baseline is. So should there be an injury during the season we then have information to refer to as we monitor this patient as they make their way back. Now obviously doing the season while we have the competition if in fact there is an injury at that point then we have to do on the field or on the sideline assessment. We call it scat testing the sports concussion assessment test. And there is like a little version that can go on the sideline if in fact the patient is down. On the field. Are they out. Well obviously we know there been a significant injury there. And we’re going to go out on the field we’re going to do our ABC is back because all those sorts of things not really that’s easy. But that patient is easily identifiable the patient that tends to be more of a problem is their patient that kind of took a hit and they run off the field what times and not the guys I’m not just gonna come to you and tell you hey hey hey doc.
I took this hit man I don’t feel right there’s usually not the case you know it’s kind of ingrained in those athletes to be tough you know so they want to get back on the field they don’t stop. So you have to have a high index of suspicion that something’s happened and obviously you got other people around you that had to be on the lookout as well because you may not catch every injury. But if in fact you suspect that this individual has taken a hit and he’s somewhat compromised and you have to seek that individual out and go and evaluate.
Some of the things that you will do, obviously you know ,we ask him you know hey you know what’s going on. What happened. Do you know what happened. If you may remember that one commercial. Forget those like for fast food chain and that guy goes out and you’re asking a guy Hey what happened. Hey guys I got have a number to you know put it with a big man no joke. You know, you had to make sure that the patients are oriented as to what happened. You want to check that balance. You know we can do the different coordinates and testing whether it be finger nose, finger handles things like that. One of things definitely check also. Are there short term and intermediate memory.
Because once again a lot of times these guys are gonna try to kind of have things they can try to get back out and play. So one of things I’ll do. Is as I’m evaluating them I say hey look I’m going repeat four words to you for five words or to call them back to me now and a little bit I’m gonna ask those words which you call them back to me and so I’ll do that and I’ll go on to do some other evaluations and then I’m gonna come back. So can I. What were those words I ask you before. The key thing there is a day that they’ve taken this difficult hit they can’t fake that you know they can’t do it you know their memory will be affected.
So that’s one of the things that you can do. Obviously we want to look at their pupils. Want to test a muscle strength things like that and then ultimately if you’re not sure. Sit. Them.
Come back re-evaluate them a little bit later. And that’s great because nothing else sometimes they made it too late. The symptoms may become more prominent. A subsequent evaluation. I may go back and you know the guy may really be sound. You may let him go but the key thing here is that if you’re in doubt. You pull them out all right. You take the helmet and you let the coaching staff know hey this guy’s out all right. That’s important. And we also know the value of going back and rechecking because epidural hematoma is they can have that lucid interval and then later on you can have catastrophic deterioration. So you have to be diligent. You had to go back. You had to re-evaluate him and once again if in fact we’re doubtful we hold him up now at that initial on field evaluation the incomes the subsequent evaluation that’s where the cognitive testing comes into play.
And on a high school level you have to kind of be diligent because sometimes these kids they’re going to have the best resources and so sometimes they can fall through the cracks. And so that subsequent follow what their subsequent evaluation sometimes may not happen. Now in that situation we’ve got sports medicine primary care providers that handle concussion testing. And that’s important depending on what level of organization you’re dealing with. Then you may have some other specialties at your disposal obviously collegiate level. You may have them follow up neurology neuro psych depending on some of the symptoms. But in general, at the lower level use is going to be a primary care sports med guy that’s going to go back and re-evaluate them. All right. In general a lot of these things were resolved within two or three weeks sometimes people can get back on the field within a week.
That’s in general but everybody does not progress that way. And you’ve heard of post-concussion syndrome where individuals can have just recurrent chronic headaches chronic fatigue mood disturbances things of that nature so these things occur and we have to be vigilant. We had to be on lookout for these things so we can make sure that we treat these patients appropriately. All right. There are some people that are more prone for getting concussions and the main risk factor for getting a concussion is having had a previous concussion. All right. Basically, somebody the axons and the membranes and the brain get disrupted. Big chain of events that takes place. But it makes those individuals more susceptible for other concussions. So you had to be on the lookout for that. Younger athletes tend to be more at risk for concussions and some are older athletes or seasoned athletes as I say.
Obviously those individuals that participate in high impact sports are at more risk whether it be American football hockey soccer things of that nature. And then interestingly enough our females are more prone for concussions than the males particularly they’re participating in the same sports with the same rules. All right. Here you can see I have listed these criteria for a graded return to play these protocols. The key thing to remember here is that we start this return to play protocol. Once the patient is asymptomatic. All right. So once the headaches are resolved you know the fatigue all these things once they get resolved then we’ll start them on a gradual graduated return to play protocol. You can see we’ve got these different activities listed here and we have the different criteria to be met at these various stages. The key thing here is is to progress through this protocol.
The patient has to remain asymptomatic at each stage. If in fact they then develop symptoms again we pull them out. We set them. And then once they’re asymptomatic we restarted. But we we started at the last level that they were able to complete once they were able to get through this. Then we can return them back to sport. And we just kind of watch him and we go through this this process and hopefully. They don’t have recurrent injuries. Now. I say that and they asked the usual protocol but sometimes we need to give considerations to either into the season potentially end in the patient’s career of athletes career. Those individuals that have prolonged post-concussion syndrome a lot of times you might say hey you know what. Maybe you ought to think about this kind of terminate the season this year and let’s try this again next season. Those individuals that have had at least two concussions within this season. Once again you know you might want to have that conversation.
We may need to go ahead and kind of to stop this season. You know let your brain recover. Let’s reset and try again. If you see the athlete that’s got decreased academic performance now are decrease athletic performance at that point. Once again we might need to go ahead and kind of pump the brakes right now. Let’s take a step back. Let’s get you healthy and let’s try this again. Those individuals that we have recurrent concussions with lowered energy gas problem because that obviously indicates now that there are concussion threshold has been lowered which makes them feel that there are some structural changes taking place here. And those individuals need to give serious consideration to potentially ending their career if you pay attention to the news now is interesting I hear more and more people that are retiring now at a younger age particularly NFL players and things like that and you used to not see that but more and more people are starting to kind of you know pull back here. Obviously those are the vitals that have structural abnormalities on imaging are now resolving deficits. Once again consideration needs to be given that top needs to be had about potentially ending the career.
All right all right. Next hot topic issue here item.
Cervical spine injuries in football players but obviously can take place in multiple sports but football is one of those sports that we obviously have had a lot of problems with cervical spine injuries. And as you know there have been some devastating injuries from neck injuries in football players. The key thing here is that we want to try to identify some of things that make us prone for these injuries and correct them. We’ve had a lot of initiatives come up with tackling clinics and things like that to try to avoid some of these issues. All right. So the first issue that we’ll see most commonly are the Stingers stingers burners. Ultimately what these are these are tracks and injuries to the cervical roots or they break your Plexus. Oftentimes a patient comes in the tackle they leave the shoulder lean or head away and you get this stretch injury to those structures.
Oftentimes they hit it will mean the opposite side and sometimes rotate back around to the fact the side which once again puts more of a stretch on those structures.
Typically the patient will come off. They’ve got their whole arm at their side kind of dangling it. They’ve got this burning tingling and they’ve got this weakness in the arm. All right. usually these are transient you know. Usually the diseases will resolve in say 10 to 15 minutes. A lot of times the paresis will too. Although sometimes it can last up to 24 hours. The key thing here though is that as long as it’s not in both arms would it be more so indicative of spinal cord injury as long as it’s not in both arms in there. Their symptoms completely resolve. They’ve got a pain free range of motion no focal tenderness no focal deficits. Those individuals can return to play.
All right.
Next issue is the acute cervical strain right now. This has to be a ligament essentially injury that can have the potential for instability in this injury. The patient complains of pain in the neck. Limited range of motion. There’s usually focal tenderness which would obviously indicate there is danger to either soft tissue or bony structures. However they’re not complaining of symptoms in the arms. All right. Now what I have to pick it on screen here to the left. I have a picture of a spear tackle. All right. Where he’s lowered his head And he’s trying to strike the opponent. This is significant because the cervical spine can withstand load in part from contact through the paracervical musculature. The intervertebral disc as well as the normal cervical low doses. Once you flex the spine more than 30 degrees the neck lordosis is removed. And now these forces are being in part it into a straight six-minute column. And at that point then the neck is no longer able to dissipate those forces as readily as those forces continue to increase. You can then get compressive deformity that takes place. And if enough force is imparted you can get angler deformity in buckling which can lead to fractures and instability and some catastrophic issues. What I have listed here on the right this is what we call spear tackle or spine and see here. And how do we what’s the.
Highlight to get it. All right.
So here you can see where the normal low doses now has been lost. All right. And this is something that happens when you have individuals that have repetitively tackled in this manner. You can see diminished this basis in arthritic changes that take place at the uncovertebral and facet joints ultimately this buying now becomes less capable of absorbing impact. And with this you can get acquired stenosis which then sets those patients up for catastrophic injuries going forward. So it’s important that we try to avoid these tackling tag tackling techniques to avoid the formation of this type of spine. All right. So with the acute cervical spring once again the patients have decreased cervical most and they’ve got focal tenderness reproducible. What do we do. Once again at this point we’re going to feel we’re going to do our spy precautions. The whole nine yards and we’re gonna to take those individuals and we’re going to have them imaged. The key thing is once again though they don’t have this DS or weakness or produces into the extremities. They’ve got localized pain so we’ll get initial imaging AP less so don’t toy views. And as long as those are negative then we can treat the patient with a collar.
And analgesics until those symptoms resolve.
Once those symptoms have resolved then we can get flex and extensive use and if those and negative meaning that they don’t have say 35 millimeters translation an increase in relation between adjacent segments as long as those are negative then we can proceed with trying to get those patients back to playing. All right. So in general. What do the cervical collar analgesics physical therapy. And once those individuals are asymptomatic no pain for range of motion good strength. No focal tinnitus. Thy allow those in the videos to return to play. Conversely if they have.