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STAY IN THE GAME Tips and information for coaches, athletes and parents, brought to you by the orthopaedics and sports medicine experts at Mercy Health | FALL 2016 We’re Mercy Health — caring for more than 70 high schools, clubs, colleges and professional athletes including Miami University and the Cincinnati Bengals. IN THIS ISSUE • Seasonal tips: -T reatment of traumatic shoulder injuries - Upper extremity program helps athletes safely return to play - Understanding concussions - A focus on the knee •M ercy Health Orthopaedics and Sports Medicine cares for student athletes and supports their coaches • First aid kit check list Treatment of traumatic shoulder injuries BY MARC GALLOWAY, MD Shoulder injuries commonly occur in sports that involve contact or require overhead use of the arm. Over the last several years, arthroscopic shoulder surgery has replaced ACL reconstruction as the procedure that is most frequently reported by participants at the NFL Combine. Among the most common shoulder injuries are subluxations and dislocations. The shoulder is a ball and socket joint in which the ball (humeral head) glides in a socket (the glenoid) much as a golf ball sits on a tee. Marc Galloway, MD Because the ball is so much larger than the socket, the stability of the shoulder is provided entirely by a combination of ligaments (rope-like structures that connect the bones to one another), the labrum (a washer-like structure that helps to deepen the socket side of the joint and provide an anchor point for the ligaments) and, to a lesser extent, the muscles surrounding the shoulder joint. Subluxations occur when the humeral head partially slips out of the glenoid then spontaneously returns to its normal position. A dislocation connotes a complete separation of the ball from the socket and requires that a healthcare provider perform a maneuver that returns the bones to their normal resting position. continued on next page continued from cover Either of these injuries can result in partial or complete tearing of the ligaments, the labrum or both. In extreme cases, a fracture can also occur. X-rays are usually useful as a screening tool for fractures. However, an MRI is the most accurate diagnostic test for determining the extent of structural injury in these patients and can guide the decisions regarding the most appropriate treatment. ANTERIOR SHOULDER INSTABILITY Instability of the shoulder is classified by the direction in which the humeral head shifts during the injury. In anterior instability, the head is forced out the front of the socket. Tears of the anterior labrum and the associated ligaments will frequently occur. These injuries usually happen when the arm being levered away from the body, either out to the side or over the head. In football, these most commonly happen when a player is making a tackle or falls on an outstretched arm. These injuries can also occur in patients who do not play sports as a result of accidents or falls. Anterior shoulder subluxations and dislocations are the most common pattern of instability that are seen in athletes and can carry a high risk of recurrent injury in certain groups. Older or less athletic individuals can be successfully managed with a brief period of rest followed by rehabilitation. Surgical repair of the damaged structures is more appropriate for younger individuals and especially for those participating in organized sports. Depending on the severity of the injury and the number of dislocation episodes, surgery can be performed utilizing either arthroscopic or open techniques. Arthroscopic techniques offer the benefit of less pain and easier rehabilitation and can provide a successful outcome for the majority of patients. Open surgical techniques are indicated for patients who have sustained significant bony injuries. TREATMENT CONSIDERATIONS While surgery represents the most definitive management for athletes involved in contact sports, the timing of the procedure can vary depending on the severity of injury, the degree of instability, and at what point during the season the dislocation occurred. For those desiring to complete their sports season, the treatment is to support the injured limb in a sling until comfortable then institute a rehabilitation program designed to restore range of motion and strength to normal levels. Athletes can typically be expected to return to their sport at about three weeks following injury. Braces are available that can help prevent recurrent injury upon return, but they are not foolproof and can restrict shoulder motion and impair athletic performance. The risk of recurrent injury is generally felt to be acceptable after an initial dislocation; however, since multiple repeat dislocations can jeopardize the outcome after surgery, I usually do not recommend that athletes who sustain a second dislocation return to play until after the shoulder is stabilized. Surgery is successful in returning patients to their desired activity level in more than 90% of cases. POSTERIOR INSTABILITY Posterior instability occurs when the humeral head is forced out of the back of the shoulder and usually results in a posterior labral tear. This pattern of injury is most often seen during blocking type activities in which the hands are in front of the body and the patient is pushing against another player. I most commonly see these injuries in linebackers and offensive linemen. A patient’s outcome depends on the severity of ligament and labral injury. Initial treatment for these injuries is rehabilitation with the goal of restoring muscle strength. TREATMENT CONSIDERATIONS Bracing is largely ineffective for posterior instability of the shoulder. For patients who remain symptomatic following non-surgical treatment, arthroscopy with posterior labral repair is an effective treatment. Patients can expect to return to full athletics at six months following their surgical procedure. Dr. Marc Galloway is a Sports Medicine Surgeon who specializes in knees and shoulders. Dr. Galloway is the Head Team Physician for the Cincinnati Bengals and has office hours in Mason, OH and Crestview Hills, KY. To schedule an appointment with Dr. Galloway, call 513-347-9999. FA L L | 2 Upper extremity program helps athletes safely return to play BY CHAD SMITH, PT Student athletes of the past were likely to participate in a variety of sports over the course of a year. Today, it’s not unusual for athletes to specialize in one sport, focusing on it year round. Not surprisingly, over the past two decades, we’ve seen significant increases in upper extremity injuries among athletes who dedicate themselves to “overhead” sports. In some overhead sports, such as football, the most common cause of injury to the upper extremity is direct trauma to the involved area, while in others, such as volleyball, baseball and softball, the most common causes are inadequate pre-season preparation and overuse. When upper extremity injuries are left untreated or not treated properly, athletes may spend days, weeks or months away from their sports. To help student athletes stay in the game, Mercy Health Orthopaedics and Sports Medicine has established an evidence-based and comprehensive return-to-play program designed specifically for “overhead” athletes. The program is designed for athletes recovering from upper extremity injuries who have completed rehabilitation with their therapists or athletic trainers but have not reached a point where they can safely return to their sports and compete at the highest level possible. Mercy Health’s upper extremity program consists of four phases that address the entire spectrum of issues that the recovering athlete must face, including strength deficits, muscle imbalances, sport-specific functional deficits and the athlete’s fear of returning to the activity associated with their injury. While the first two phases of the program focus primarily on isolated and dynamic strengthening of the lower extremity, core and upper extremity, the final two stages focus on performing activities specific to their sport and a graded return to competitive play. The program utilizes a series of computer-based strength testing, dynamic activity testing and athlete-reported questionnaires to help determine when identified goals are met. Progression from one stage to the next is criterion-based: athletes transition when their goals for the current stage are achieved. Mercy Health’s upper extremity program is designed to assure a safe and confident return to sport for athletes that allows them to play at their highest ability, while providing a stable foundation for preventing future injuries. To learn more, please email [email protected] Chad Smith is a physical therapist with Mercy Health. He specializes in treating a variety of sports medicine and orthopaedic problems with a focus on knees and shoulders. Mercy Health Orthopaedics and Sports Medicine cares for student athletes and supports their coaches Mercy Health Orthopaedics and Sports Medicine staff have been busy throughout the summer preparing athletes and coaches for the 2016-2017 school year. A variety of activities were conducted, including Sports Physicals, Pupil Activity Coaches Courses, Sports Combines and Sportsmetrics Training. The Mercy team of Sports Medicine physicians, primary care physicians, physical therapists and athletic trainers provided more than 2,100 pre-participation physicals, conducted presentations to more than 100 coaches on basic first aid and the importance of recognizing concussions, tested more than 600 athletes during Sports Combines to collect valuable data, and trained more than 100 athletes in Sportsmetrics, an ACL injury prevention program. Mercy Health Orthopaedics and Sports Medicine is committed to providing exemplary care to athletes of all ages. With more orthopaedic physicians, physical therapists, athletic trainers and convenient locations throughout Greater Cincinnati than any other provider, you can be assured of being seen by experts in a timely manner. Understanding concussions BY EDWARD MARCHESCHI, MD With student athletes now training and competing, coaches and parents are focused on helping them stay safe. A key concern, especially related to contact sports, are concussions. The brain floats inside the skull. When the head takes a hard hit or is violently jostled, the brain bounces Edward back and forth off the skull. This may Marcheschi, MD mechanically stretch nerve fibers abnormally, triggering a chemical reaction in the brain at a cellular level. This injury is what we call a concussion. An athlete’s vulnerability to a concussion is dynamic and there are many factors other than traumatic force that contribute to this vulnerability. The most common symptoms of concussion may include headache, dizziness and memory impairment. The symptoms of concussion can worsen over 24 to 48 hours. The good news is that the ill effects of concussion will resolve in most athletes if the injury is managed appropriately. Rest, both physical and mental, is recommended treatment for concussion early on. A student athlete diagnosed with a concussion should avoid physical exertion and decrease mental concentration by limiting sensory input by refraining from using computers, texting, watching TV and playing video games. Baseline testing is recommended for all athletes in contact and collision sports. Using a computer-based neuropsychological test called ImPACT, athletes age 10 and older can be proactively tested. ImPACT creates a baseline of what’s normal for the individual, documenting several aspects of the athlete’s brain function. If the student sustains a head injury, the test is then re-administered. By comparing new results against the baseline, physicians are able to determine the severity of the concussion, predict recovery time and monitor recovery. Mercy Health provides ImPACT testing for concussions at all of our partner schools. When concussions are managed appropriately, student athletes can make full recoveries and eventually resume their sports. Dr. Edward Marcheschi is a Primary Care Sports Medicine Specialist trained in musculoskeletal ultrasound. He treats patients at offices in Mason, West Chester and Oxford. To schedule an appointment, call 513-981-6784. First aid kit check list Most high schools are fortunate to have a certified athletic trainer on-site should an injury occur, but with so many events taking place, the athletic trainer may not always be there. Coaches should have a first aid kit, especially when traveling to away games. Below is a sample of items to include in the kit: Athletic Tape — 2-3 rolls of 1½” athletic tape: Purpose: To be used for not only injury protection, but also assist with uniforms/equipment. re-Wrap — 1-2 rolls P Purpose: To protect the skin when using athletic tape. Some athletes use it to pull back their hair. Antibiotic ointment Purpose: To prevent infection of a wound or cut. mall mirror or compact case S Purpose: For an athlete to see their reflection (i.e., putting in contacts) atex and/or latex-free gloves L Purpose: Protection from blood/body fluids is critical. PR mask/microshield C Purpose: To be used for personal protection/limiting transmission of infection. terile gauze S Purpose: To be used for cleaning or controlling blood/ body fluids while limiting the risk of infection. cissors/nail clippers, preferably medical scissors S Purpose: To be used for tape removal or other cuttings (i.e., bandages or other packages). ssortment of Bandages A Purpose: To be used for stoppage of blood from minor cuts/scrapes and act as a barrier from infection. Ice bags Purpose: For the obvious reason to ice an injury. ose plugs or small tampons N Purpose: To be used for bleeding control of the nose. ubbing alcohol or hydrogen peroxide R Purpose: To be used for cleaning an injury site as well as uniforms, etc. otepad and pen N Purpose: To be used to write down description of the event, names, etc. hone list for parents, hospitals, athletic trainer, P athletic director Purpose: In the event of injury, notify these people if necessary. FA L L | 4 A focus on the knee BY SURESH NAYAK, MD Athletes in a variety of sports are prone to common overuse injuries of the knee. Many of these occur in the anterior or front part of the knee around and including the knee cap (patella). Before looking at common injuries, let’s look at the complex physiology of the knee. Suresh Nayak, MD STRUCTURE OF THE KNEE The four quadriceps muscles meet just above the patella to form the quadriceps tendon, which attaches the quadriceps muscle to the patella. The patella is attached to the shinbone tibia by the patellar tendon. Working together, the quadriceps muscle, quadriceps tendon and patellar tendon straighten the knee. With repetitive pulling on the patella or explosive jumping, overuse injuries are common. COMMON KNEE INJURIES • Quadriceps tendinitis occurs when there is an inflammation of the tendon where it attaches to the top of the patella. It is very common in athletes who participate in running and jumping sports. When the tendon is weakened, tearing or rupture of the tendon may occur. •P atellar tendinitis is a common overuse injury to the tendon connecting the patella to the tibia. Patellar tendonitis, also known as “jumper’s knee,” is common in athletes whose sports involve frequent jumping, such as basketball and volleyball. • Osgood Schlatter disease is also known as apophysitis of the tibial tubercle. It is an inflammation of the patellar tendon as it attaches to the growth plate around tibial tubercle. It is characterized by a painful bump just below the knee and most often is seen in young adolescents. Risk factors include overuse and adolescent growth spurts. The above conditions often respond to conservative management, which includes a period of rest, oral inflammatory medications, icing and stretching exercises. Organized physical therapy is frequently used to stretch and strengthen weakened muscles. Braces can be helpful in the short term as well. Surgery is used as a last resort for those rare cases that do not improve with conservative care, for tendon tears or for athletes with anatomical problems predisposing them to injury. Play can be resumed when the athlete is pain free. To reduce the likelihood of knee injuries, it is important that athletes focus on proper conditioning, especially in the off-season. Dr. Suresh Nayak is an orthopaedic surgeon who specializes in a variety of sports medicine and orthopaedic injuries, including knees, shoulders, hips and joint replacement. Dr. Nayak treats patients at Wellington Orthopaedic and Sports Medicine in Anderson. To schedule an appointment call 513-232-2663. • Chondromalacia patella or patellofemoral pain syndrome is a broad term used to describe pain in the front of the knee and between the kneecap and thighbone (patellofemoral joint). Chondromalacia patella refers to inflammation or softening of the cartilage behind the kneecap. The pain and stiffness it causes can make it difficult to climb stairs, kneel down and perform other every day activities. Many things may contribute to the development of patellofemoral pain syndrome. Problems with the alignment of the kneecap and overuse from vigorous athletics or training are often significant factors. SUMMER | 5 After hours, extended hours and Saturday morning Sports Injury Clinics We’re here to help after hours. No appointment necessary unless noted. Anderson 7575 Five Mile Rd. Cincinnati, OH 45230 513-624-4100 | Hours: M–F 5–9 p.m. | Sat. 9 a.m.–1 p.m. Crestview Hills (KY) 328 Thomas More Pkwy. Crestview Hills, KY 41017 513-347-9999 | Hours: T/W 5–7:30 p.m. (Appointment required) | Sat. Sports Injury Clinic (Aug.–Dec.) Fairfield (HealthPlex) 3050 Mack Rd., Suite #200 Fairfield, OH 45014 513-924-8220 | Hours: M–F 5–9 p.m. | Sat. 9 a.m.–1 p.m. Mason/Deerfield 5236 Socialville Foster Rd. Mason, OH 45040 513-347-9999 | M–F extended hours available, (Appointment required) | Sat. Sports Injury Clinic (Aug.–Dec.) Western Hills 6350 Glenway Ave., Suite 415 Cincinnati, OH 45211 513-347-9999 | Sat. Sports Injury Clinic 8–10 a.m. Outstanding orthopaedic and sports medicine care, conveniently located ORTHOPAEDICS AND SPINE 513-981-ORTHO (981-6784) Anderson 7575 Five Mile Rd. Cincinnati, OH 45230 Eastgate 4440 Glen Este-Withamsville Rd. Cincinnati, OH 45245 Fairfield 3050 Mack Rd., Suite 200 Fairfield, OH 45014 Harrison 10450 New Haven Rd. Harrison, OH 45030 Kenwood 4750 E. Galbraith Rd., Suite 105 Cincinnati, OH 45236 West 3301 Mercy Health Blvd. Suite 450 Cincinnati, OH 45211 ORTHOPAEDICS AND SPORTS MEDICINE Cincinnati SportsMedicine & Orthopaedic Center Crestview Hills 328 Thomas More Pkwy. Crestview Hills, KY 41017 513-347-9999 Mason 5236 Socialville Foster Rd. Mason, OH 45040 513-347-9999 Blue Ash 4701 Creek Rd., Suite 110 Cincinnati, OH 45242 513-733-8894 Montgomery 10663 Montgomery Rd. Cincinnati, OH 45242 513-347-9999 Eastgate 4440 Glen-Este Withamsville Rd. Cincinnati, OH 45245 513-753-7488 Rookwood 4101 Edwards Rd. Second Floor Cincinnati, OH 45209 513-347-9999 Oxford 270 S. Locust St. Oxford, OH 45056 513-524-1018 Tri-County 12115 Sheraton Ln. Cincinnati, OH 45246 513-347-9999 Western Hills 6350 Glenway Ave. Suite 415 Cincinnati, OH 45211 513-347-9999 WELLINGTON ORTHOPAEDIC AND SPORTS MEDICINE A partner of Mercy Health Adams County 230 Medical Center Dr. Seaman, OH 45679 937-386-3420 Anderson 7575 Five Mile Rd. Cincinnati, OH 45230 513-232-6677 We’d like to hear your thoughts on this issue of Stay in the Game and topics you’d like covered in future issues. Please send your suggestions and thoughts to [email protected]. 7542CINNWL (9/16) Sardinia 7109 Bachman Rd. Sardinia, OH 45171 513-753-7488 West Chester 8737 Union Centre Blvd. West Chester, OH 45069 513-645-2220 West 3301 Mercy Health Blvd., Suite 450 Cincinnati, OH 45211 513-232-6677 Health information on the web At MercyMovesYou.com, you’ll find information and videos that help athletes protect their health and avoid injury.