Spondylolysis — when to begin PT?

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).

We recently published an original research article on the subject of when to begin PT in these athletes:  The Timing of Physical Therapy in Adolescent Athletes with Acute Spondylolysis

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! 

Super Bowl Aftermath


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).

The Russell Wilson interception obviously turned out badly for Seattle, and sent all of New England into a frenzied state of joy (though a snowstorm in the region is causing the fans there to hold off one more day from a celebratory parade through Boston).

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.

I’m sure a lot of us in the sports medicine world had a sense of deja vu when we saw Edelman stay in the game after what many viewers thought was a concussion:  in the 2014 FIFA World Cup there were several similar incidents, when several players had suspicious head injuries whose management was questionable.  In the aftermath of that tournament, we had a podcast with guests Matthew Gammons and Cindy Chang , physicians of the American Medical Society of Sports Medicine (AMSSM), exploring the issues involved with management of possible concussions in real time, in the setting of a highly visible sporting event…like the Super Bowl.

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:



[1] The Super Bowl’s Concussion Calculation, The New Yorker, Ian Crouch.

http://www.newyorker.com/news/sporting-scene/super-bowls-concussion-calculation, accessed 2/3/15


Gender Issues in Sport: the case of Dutee Chand


Berlin Olympia Stadium: site of the 12th IAAF Athletics Championship

It’s time for a poll.

Issues of gender in sport are a regular feature in the pages of the CJSM journal and this blog.

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!

Take Our Poll

Clinical Journal of Sport Medicine Blog

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.

20090819_Caster_Semenya_polished 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…

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Reducing a Shoulder

anterior shoulder dislocation

A common sequela of football

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.

There are so many aspects to the treatment of this injury, which occurs so frequently on the playing field.  First time dislocators: surgery or no?  What to do about recurrent dislocations?  If an apparent anterior shoulder dislocation shows up in your urgent care, do you take the time to image prior to reduction? Do you use anesthesia or sedation?  When do you return them to play?

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.



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