ACL Injury Prevention

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Dr. Timothy Hewett, in action

I had the good fortune (and space in my clinic schedule) to attend a lecture given earlier this month by Tim Hewett, PhD, FACSM.  Dr. Hewett is a man of many titles.  I know him best as the Director of Research and Director of the Sports Health & Performance Institute at Ohio State University Sports Medicine, and his talk was on “Understanding and Preventing First and Second ACL Injuries.”

If you have never heard Tim speak, you are missing out on a treat.  I learn so much from his talks: ranging from the ones I catch at the annual American College of Sports Medicine (ACSM) gatherings to the ones I occasionally can attend here in Columbus, Ohio, the city we both call home.

It stands to reason: the man has authored over 248 peer reviewed articles and has been awarded millions of dollars of grant money.  We have had the fortune here at CJSM to have published a number of his manuscripts, including one in the most recent September 2014 journal (on gender differences in hip abduction/adduction) and one in 2012 on  the incidence of ACL re-injury after primary reconstruction.

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Oh, my reconstructed ACL: Where have you gone?

The issue of primary- and secondary-prevention of ACL injury is huge. We’ve lived, for instance,  through a virtual epidemic of ACL ruptures in the NBA over the past couple years.  Derrick Rose is returning (yet again) to the hardcourt after his terrible injury in the 2012 playoffs, and that’s great news for the Bulls and fans of great basketball in general.   In his talk Dr. Hewett suggested that at least part of this statistical uptick  in ACL injuries was likely due to the NBA lockout, resulting in an abbreviated 2011 – 2012 season preceded by an ‘abnormal’ preseason.  “These teams have a very structured offseason training program where they do a lot of injury prevention-type neuromuscular training”  (NMT), Hewett has been quoted in interviews.  The absence of such pre-season NMT work, he thinks, is associated with the litany of ACL injuries seen that season, capped off by Derrick Rose’s.

ACL injury prevention is both needed and achievable.  In his lecture, Dr. Hewett stated that there is evidence to suggest that anywhere from 50% to 100% of patients who sustain an ACL rupture go on to develop osteoarthritis (OA) of the knee, even in those who go on to have an ACL reconstruction (ACLR) Read more of this post

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LeBron and Exercise-Associated Muscle Cramping

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Does this count as “Old School”? LeBron James, in his first incarnation as a Cleveland Cavalier (photo: Dave Hogg, Wikimedia)

Game 2 of the NBA finals is this weekend, and I’m sure the Miami Heat (despite their nickname) are hoping the air conditioning works.  In truth, I think most of us are hoping that we witness a straight up basketball affair determined more by athletic skill and less by Exercise-Associated Muscle Cramping (EAMC).

If you need a primer to know what I’m talking about, here’s a brief rundown of Game 1 and LeBron’s EAMC. 

‘Most of us’?  I truly have no horse in this race (speaking of that….I most definitely am rooting for California Chrome to bring home the Triple Crown later today), but outside of Texas, it seems that most of the country may be leaning toward the Heat.  At least that’s what ‘Big Data’ would suggest:  check out this great, data-driven map from the New York Times showing the breakdown of team allegiances across the United States.

Truly though, aside perhaps from a pocket deep in the heart of Texas (who may want victory, no matter what!), I think most fans of the NBA would rather see the outcome of the games determined by the players and not by a lack of AC.

As a team physician, like many of you, I have had–along with my Athletic Trainers–to deal with plenty of muscle cramping in my career.  Here in the States, I find it occurs most often in the very beginning of football season:  during August pre-season, or the early September games that may be played in temperatures approaching 90 degrees.  It seems the combination of relative deconditioning, environmental conditions, and plain foolishness (my adolescent athletes frequently forget to stay hydrated, despite constant reminders to do the same)  gives rise to any number of trips on to the field to assist a player downed with quad or abdominal cramps.  At some levels of the game, to circumvent that inability to maintain adequate oral hydration during a game, teams will turn to pre-game intravenous hydration, as has been discussed in literature published in this journal and blog.

Then again, perhaps there are other issues altogether different than these potential risk factors that give risk to EAMC. Despite the high incidence, the etiology of EAMC continues to be debated.

Yes, I am a believer in the powers of pickle juice, but EAMC remains a puzzle to me and others.  And so I turned to the CJSM website  this morning for guidance and found a great 2013 study:  Collagen genes and exercise-associated muscle cramping, from a group of South African authors.  I especially appreciated this article for its contribution to my basic science knowledge:  I learned so much about the biology behind EAMC.  I encourage you all, clinicians and non-clinicians, to check it out.

The authors begin the paper with an excellent overview of various hypotheses of EAMC, ranging from electrolyte depletion to altered neuromuscular control. They then explored the literature that points to the possibility that EAMC may be associated with a genetic predisposition to musculoskeletal soft tissue injury. Specifically, their research hypothesis was that “variants within collagen genes that code for components of the musculoskeletal system would increase susceptibility to EAMC.”  To test this, the authors conducted a ‘retrospective case-control genetic association study’. Read more of this post

Return to Play Decisions

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Though a beautiful time of year, fall is not
the most idyllic for a sports medicine clinician

Like many of the readers out there, my colleagues and I are deep in a football season, where we are managing various teams and their mounting injuries.  For a sports medicine physician, fall in America must be a bit like early spring for an accountant (tax day = April 15):  it’s the time to buckle down and crank through patients, the time, from a certain perspective, to see the volume of patients that will sustain the business through leaner times of the year.

When I’m out of the clinic and on the sidelines, I’m also doing one of the parts of my job that is the most fun, and I’m sure my colleagues out in the blog sphere will agree.  But I wouldn’t describe the work as an idyll.  I can be enjoying my team’s performance, and then called in three directions at once, treating players and making decisions on whether they can get back into the game:  decisions that can have significant consequences for the player and the team.

I thought I would write somewhat extemporaneously today, and in sharing some of the more interesting cases I have seen of late think in a more structured way about how we primary care sports medicine physicians make return to play (RTP) decisions.

RTP decisions make the headlines all the time.  In the professional leagues of North American sports, in just the last two weeks, we have seen discussions about Kobe Bryant’s return to the NBA from late spring Achilles tendon surgery; Rob Grownkowski’s ‘delayed’ return from a surgically treated forearm fracture; the much anticipated return of Derrick Rose more than a year after his ACL reconstruction; debate over RGIII and whether he has come back too soon from his own multi-ligamentous knee injury…….the list goes on!

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The end of a season?

In my own practice, I have been trying to return players back to American football while they have recovered from a kidney contusion, a posterior elbow dislocation, a complete rupture of the ulnar collateral ligament, and a demyelination injury of the axillary nerve.  Of the four, two are back playing; the elbow dislocation is still rehabbing, and i hope to return in a hinged knee brace before the end of the year; and the axillary nerve injury continues to have pain and profound weakness of his deltoid, and his recovery will extend beyond the end of this season (much to the coach’s dismay).

Despite being one of the more important aspects of our job, there is very little in the way of evidence-based medicine to guide a clinician in these decisions. Read more of this post

Achilles Tendon Ruptures and Kobe Bryant’s Injury

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Kobe Bryant, Joe Johnson Wikimedia

I woke up this morning to hear very sad news that occurred in the NBA last night:  Kobe Bryant has ruptured his Achilles tendon.

Kobe, who turns 35 this year, is one of the most recognized athletes in the world (maybe one of the few things that China and the USA can agree on). He had been leading his team to crucial victories as they were making a playoff run when he succumbed to this not uncommon injury in the middle aged athlete.

As he is quoted saying, he made a move he had executed a ‘million times’ when he felt like someone had kicked him in the leg, and he subsequently crumpled to the ground.  This is the classic history one might obtain when caring for an athlete with such an injury.  If you watch the video, you’ll see Kobe perform a classic move which can result in a ruptured tendon:   his left leg  pushes back  while he powerfully tries  to accelerate around the defensive player; this eccentric contraction is followed by a step and immediate inability to bear weight, and he falls to the ground. Read more of this post

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