SNL’s Jane Curtain and Dan Ackroyd may have found spondylolysis an interesting subject for debate!
One of the perennial ‘hot topics’ in pediatric sports medicine has to do with the diagnosis of spondylolysis — specifically, adolescent isthmic spondylolysis [an acquired stress injury of the pars interarticularis]. As with many controversies, people who treat this condition are often passionate about the specific issues under debate.
Among the more burning issues are to brace or not; what imaging modality to use (plain film, CT scan, SPECT scan, MRI); how long to ‘rest’ a patient before re-introducing a level of physical activity or instituting physical therapy (PT); and how to determine treatment success (clinical measures such as PROMs, or imaging to verify bony union of the pars interarticularis).
I am happy to report I was part of the team that conducted this study, and we found that in patients who began PT early, recovery to sport was faster: ‘early PT’ athletes returned to their sport a mean of 25 days earlier than their counterparts who initially rested from all activity. Moreover, there were significant differences in adverse reactions between the groups studied.
How do you approach the initiation of PT in your adolescent athletes with spondylolysis? Take the poll and share your thoughts!
Julian Edelman, New England Patriots pic: Jeffrey Beall
It’s a Tuesday as I write, so literally (and figuratively) I do not propose to do any “Monday Morning Quarterbacking.” I’ll leave it to others to deconstruct Pete Carroll’s decision at the end of the game (though I don’t think it was that crazy of a call, and was in keeping with other contrarian decisions he has made that actually got the Seahawks into the Super Bowl–like the fake field goal call against Green Bay in the NFC Championships).
No, I’m here to focus on sports medicine–specifically the management of Julian Edelman’s apparent concussion in the big game–and encourage you, the reader, to take a poll to stimulate conversation about the issue.
The NFL has, in the wake of much criticism, introduced new concussion protocols. It is my understanding that “….. the NFL assigns an independent physician to each team to monitor head injuries, and there is another independent ‘spotter’ who watches players on both teams from a booth above the field and can radio to the sidelines if there is evidence of an on-field concussion.” [1] Additionally, each team has its own medical personnel to monitor the situation as well as do any necessary evaluations.
It is not clear to me, however, that there is an independent physician who is empowered to remove a player from the field of play; to mandate removal if necessary, and not just ‘monitor.’ Should there be a clinician who i) has no conflict of interest [as exists intrinsically in any dynamic that involves medical personnel employed by a team: player safety comes first, but there are, inarguably, biases that can creep into our decisions when player performance, especially in the setting of the World Cup or the Super Bowl, is at a premium]; and ii) who has the power, and the backing from the league, to disregard the player’s opinion, the coaches’ opinions, etc. and can mandate even the removal of a key player like, say, Tom Brady, for suspicion of a concussion, on the biggest stage of their sport.
And so, today’s poll:
References
[1] The Super Bowl’s Concussion Calculation, The New Yorker, Ian Crouch.
I wanted to share with you, again, a poll that got a lot of traffic earlier this year when I wrote about the IAAF policy on gender testing in sport. The issue continues to be relevant: just this week, the New York Times published an excellent article on the subject of the Indian sprinter Dutee Chand. She is the Indian 100m women’s U18 champion, and she cannot currently compete for her country because of her naturally high testosterone levels. She faces the decision, as several female athletes have before her, of whether to retire or compete…..but the latter option is contingent on medical interventions aimed at lowering her testosterone.
The issue is highly charged, and I think both the pro and the con side of such testing and intervention make some sense in the field of competitive athletics. At the end of the day, however, I find the IAAF policy to be highly flawed. I think it is largely discriminatory, sexist, and reductionist: too high of testosterone = you cannot compete as a woman.
Read the rest of this post and take the poll. At CJSM, we’re interested to know what you think!
I was taken by an editorial that I read in the New York Times this weekend: The Trouble With Too Much T. If you didn’t have the chance to see it yourself already, by all means click on the link and read this piece.
Caster Semanya, South African Olympian
The authors, Katrina Karkazis and Rebecca Jordan-Young, give a broad overview of how current sports governing bodies determine if an athlete is ‘really’ female. Of note, Karkazis and Jordan-Young are also the principal authors of The American Journal of Bioethics critique of the current gender-testing policies of the IOC, IAAF and other governing bodies.
They lead with the well-known story of Caster Semanya, the South African woman who, in 2009, was barred from international competition and was compelled to undergo testing after the Berlin World Championships (she has subsequently been reinstated, and in the 2012 London Olympics was…
Football, American style: the season for anterior shoulder dislocations.
My specialty group and I manage this condition throughout the year, of course, but the numbers surge in the fall. Pre-reduction on the sideline, or post- in the clinic, the dislocated shoulder is an entity that loves this time of year.
One aspect of this issue I especially like to discuss: What’s your favorite method for reduction? Hippocratic? Spaso? Slump method?
A lot of us use what we were taught; and if it works, then that’s our go to procedure.
I had the good fortune of spending a month working with Dr. William MacAusland, Jr., an orthopedist from Boston who spent years working at Harvard. He sponsored a medical student rotation at the Carlos Otis Ski Clinic at Stratton mountain, in Vermont, and I spent a month in medical school skiing the slopes and treating the injured with Dr. MacAusland. He favored the ‘modified Kocher method,’ and that is what I have used ever since.
I should say, as well, that Dr. MacAusland took great pride in reducing a shoulder with no anesthesia; he favored a slow, gentle approach that essentially relied on hypnotic techniques. He believed the ‘humerus wanted to get back in place,’ and any significant effort on the practitioner’s part (e.g. traction) was more apt to get in the way of rather than aid the reduction. Certainly, I have found that if I can see a shoulder within the first hour or so of the injury, before significant spasm has set in, that Dr. MacAusland’s approach in toto works like a charm. I was taught as a general principle to have two techniques at the ready, in case the first method was ineffective for a particular patient. The Spaso method is my second method.
So, what’s your favorite method? Take the poll below and tell us in the comments section why you prefer it.
James MacDonald, M.D., M.P.H. Clinical Journal of Sport Medicine (CJSM) Deputy Editor
"The CJSM blog offers the opportunity for clinicians with a primary interest in sports medicine practice to discuss current issues in the world of sport and exercise medicine. The blog acts as a community platform for knowledge sharing; its goals are the promotion and dissemination of best clinical practices for our patients."
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