Bread and Butter


Bread, butter……and food for thought!

Fall sports in the USA  — sometimes in my clinics at this time of year I feel like I am swamped in concussions.  There will be stretches in a morning that I go from room to room, each one a different variant of this all-too-common injury.

But overall, in truth, the bulk of my patient encounters this time of year are of the musculoskeletal (MSK) variety.  It may not ‘feel’ that way, but when my hospital ‘numbers gal’ crunches the data, we’re still running at > 50 % MSK for patient visits.

And ankle sprains are definitely in that mix.

Ankle injuries, like knee injuries, concussions, and fractures, are part of the ‘bread and butter’ of my practice at the Division of Sports Medicine at Nationwide Children’s Hospital (NCH).  And one of the things I love about the Clinical Journal of Sport Medicine are the multiple original research articles the journal publishes that give me insight into the management of these common injuries.

I recently wrote a blog post about the four original research articles focused on concussion in our just-published September 2016 issue.  In this current post, I want to draw your attention to some more original research being published ‘ahead of print’: “Current Trends in the Management of Lateral Ankle Sprains in the United States.”

I found this to be a very interesting read using a “Big Data” approach to look at how this common injury, lateral ankle sprain (LAS), is managed in the USA.  The authors queried a database of national health insurance records for 2007 to 2011 and identified 825,718 patients with the diagnosis of LAS.  After applying select exclusion criteria (e.g. those with associated fractures,), they analyzed 725,927 isolated patients with LAS.

The authors found that 36% of all LAS occurred in patients < 20 years old (my patient mix at NCH), and that the number of patients with LAS decreased ‘exponentially’ with age (the 60+ crowd represented < 5% of the total).  Some of the more notable findings:  fully 2/3 (67.8%) received radiographs, and for treatment — 9% received a brace, and only 6.8% received physical therapy (PT) within 30 days of their diagnosis.

the end

Ankle bracing was looked at in the study, but not taping.

I think these two findings in particular should challenge us as clinicians.

First, though we cannot know in detail what the physical examination status was for the 700K LAS patients at time of initial evaluation, it strains credulity, I think, to consider that 67.8% of them met Ottawa Ankle Rules criteria.  Talk about a knowledge translation gap!  I believe the rules have been around for a good 20+ years [I did a Google scholar search on that, anyone is welcome to comment on this and let me know what they consider to be the first, the ‘Ur’ reference for the rules].  The rules have a very high sensitivity (approaching 100%).  Does anyone remember the mnemonic SnOUT? [ SnOUT = a negative finding in a highly sensitive test rules ‘out’ the problem].  I think this result reinforces for me what I need to be thinking about in my evaluations of LAS on the sideline and in the training room — apply those rules, and I’ll surely minimize my use of radiographs, saving cost and radiation exposure.

Second, the authors make a great case for the residual functional deficits that can linger for some time after a LAS. They specifically mention the evidence “…that patients with LAS are less physically active throughout their lifetime and (have) decreased health-related quality of life.”  LAS are not the benign injury we may always think them to be, and it is arguable they need some form of rehab.  I would note, again, that we cannot know in detail what access these patients had to PT, but to think that less than 7% received PT within the first month of injury……

In my own clinics, we often prescribe home rehab, and do a brief tutorial and give a handout to patients with LAS; we also prescribe PT to many.  I am not so sure how compliant my patients are with their home rehab, and I know that I get a lot of ‘no-shows’ for my prescribed PT.  Perhaps if I ‘put the hammer down’ a bit as a clinician–emphasized a bit more of the consequences of a poorly rehabbed LAS–I might get more patient ‘buy in’ to the concept of the necessity for PT/rehab to achieve a fully recovery.

LAS — bread and butter injuries, no doubt.  And this new research article — food for thought, indeed.


Concussions — looked at from multiple perspectives


With one of the great ones — Dr. Greg Myer, leading concussion and ACL prevention researcher

It should come as no surprise that there has been a lot of ‘discussion’ recently about the topic of concussions in our world of sports medicine. That subject has been a ‘hot button’ issue for a decade.

Whether the issue is one of Cam Newton playing on through an injury that may have warranted immediate evaluation or whether it’s the topic of concussion reporting at the youth level, there is an on-going conversation in the media, social media, medical literature and conferences on sports-related concussions (SRCs) in all their many facets.

I was given an entirely new view on SRCs today. I had the great pleasure of attending a lecture on concussion prevention given by my friend (and frequent CJSM contributor) Greg Myer, PhD, who was visiting my home institution of Nationwide Children’s Hospital.  He delivered a talk entitled, “Concussion Prevention:  Has Nature Already Provided the Solution?”

It was a fascinating exploration of biomimetics influencing primary sports medicine research.  Dr. Myer and his team saw in nature a paradox:  species of woodpeckers knock their heads against hard objects thousands of times,  generating up to 1500 g-force units with each hit, all the while avoiding getting concussed. They then looked at the biology of how the bird manages this  and developed a device that players can wear in their sport to, potentially, reduce their own risk of SRCs.

The lecture was compelling, both for the details of the device and the research, and for the overall brilliance of the concept.  Talk about thinking ‘outside the box’:  looking at a woodpecker, and seeing a way of making athletes safer on the playing field.  Fascinating stuff.

I finished off the day with more of Dr. Myer and more of concussions, by picking up the September CJSM. In this issue, we have four original research studies focused on sport-related concussions (SRCs). Three come from Boston, a ‘hub’ of research on SRCs, and one comes from South Africa, which I was able to review  in the last CJSM blog post.  One of the Boston studies includes Dr. Myer as a contributing author:  Young Athletes’ Concerns About Sports-Related Concussions:  The Patient’s Perspective.  Another reports results of a survey of American Medical Society for Sports Medicine (AMSSM) Physicians on concussion management practices.  And the third looks at SRCs from the perspective of another set of stakeholders, coaches: Content, Delivery, and Effectiveness of Concussion Education for US College Coaches.

In this issue, therefore, we look at SRCs from the perspective of the patient, the doctor, and the coach.  We look at SRCs ‘spanning the globe,’ from Boston to Cape Town.

And though Dr. Myer’s work on concussion injury prevention is not published in our pages, please use the links I have provided above to read (and see) more of what’s behind the idea that woodpeckers may help provide part of the solution to SRCs.

The animal perspective, so to speak.

Enjoy all the different views of this common injury, and, as ever, let us know what you think in the comments section of this blog.



Dreams of South Africa


With Wayne Viljoen (@BokSmart), one of the authors of new rugby research in CJSM

It was just a year ago that I was preparing to travel to South Africa on an American Medical Society for Sports Medicine (AMSSM) Travelling Fellowship — dreams of Cape Town and safaris danced in my mind [see post reblogged below].

I haven’t stopped dreaming of South Africa. Should I ever have a mental lapse and not think of the Rainbow Nation for a day or two, I have only to turn to my Twitter feed or my medical journals to be reminded — the country punches well above its weight in both sports and sports medicine. I enjoy reading of the exploits of current South African Sports Medicine Association (SASMA) President Phathokuhle Zondi as she takes care of Paralympic athletes in Rio, for instance — she is a definite follow on Twitter….

And I most certainly enjoyed reading some recent rugby research just published in our September 2016 CJSM: Incidence and Factors Associated With Concussion Injuries at the 2011 to 2014 South African Rugby Union Youth Week Tournaments.  It was a delight to read this epidemiological study, whose authors include good friends Sharief Hendricks, Clint Redhead, and Wayne Viljoen — researchers all of whom most definitely have made their mark internationally.


Partying with Sharief Hendricks (@Sharief_H), author of new rugby research in CJSM, in Johannesburg

In the authors’ words, the “….study provides the first published incidence of concussion, per player-match-hours, in South African youth rugby union and falls well within what was previously published elsewhere for youth rugby.”  They found the incidence of concussion in youth rugby to be 6.8/1000 player match-hours.  Importantly, and what for me was new information, was that under-13s and under-16s had higher incidence rates than under-18s.  The younger kids were at greater risk for concussion.  This may have important implications for rules and policy making in youth rugby.

For anyone with an interest in rugby, or South African sports and sports medicine, the study, in our newest edition of CJSM, is a definite read.  And it’s never too early to start dreaming of the 2017 SASMA biennial congress, which will take place in Cape Town 2017.  To stay ‘in the know’ for the timing and details of that pre-eminent conference, follow President Phathokuhle Zondi and SASMA itself on Twitter.

Clinical Journal of Sport Medicine Blog

IMG_1630Every so often, sports takes a back seat to other world events. So too for sports medicine.

We all know this, whether in our personal lives or in our interactions with the world at large.  There is the NFL player who is torn between performance on Sunday and ‘being there’ for his young daughter with leukemia.  There are cases where the athlete him- or herself is felled with illness–think of Lou Gehrig and amyotrophic sclerosis.  The issues of who won the last game, the intricacies of a salary negotiation, or the season missed from a knee injury pale in comparison with such ‘real world’ contingencies.

In sports medicine we sometimes experience directly the intersection between serious illness and athletics.  I think immediately of the young gymnast I saw with anterior knee pain that turned out not to be Osgood-Schlatter’s but osteogenic sarcoma of the tibia…….a ‘game changing’ event…

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ECG for the PPE? A conversation with Dr. Jonathan Drezner


Dr. Jonathan Drezner in South Africa. Photo courtesy Alison Brooks.

Highlighting the just-published issue of CJSM is the new American Medical Society for Sports Medicine (AMSSM) position statement on cardiovascular preparticipation screening in young athletes.  The position statement is an invaluable contribution to the ongoing discussion over the pros and cons of adding the ECG to the preparticipation evaluation/examination (PPE) to prevent sudden cardiac death/arrest (SCD/SCA).

Those familiar with this debate will be familiar as well with the lead author of the statement, Dr. Jonathan Drezner. Dr. Drezner is a Professor in the Department of Family Medicine at the University of Washington and a team physician for the Seattle Seahawks of the NFL.  Dr. Drezner has published frequently in our pages, most often on the subjects of the PPE and screening for SCD/SCA.

The debate over the role of ECG in the PPE is one of the more contentious in sports medicine.  We look forward to seeing how the AMSSM statement will contribute to the direction that debate will take.  jsm-podcast-bg-1

You can gain added perspective on the statement and the controversy by listening to our newest podcast — a conversation with Dr. Drezner himself.  You can access the podcast both on iTunes and you can find it on our CJSM website as well.

Enjoy the discussion, and be sure to check out the statement itself, freely available in the 2016 September CJSM.


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