Guided practice was the theme for Chris Greenleaf and Mary Williams as they joined Ben and Jeremy at the Sports Medicine Update. Being a preceptor is a growing experience, and the best way I know to grow is to ask experts how they do it.
Learn about facial injury red flags, CSF identification, EAP essentials, and return-to-play guidelines for athletes from Dr. Rehal Bhojani.
Q: What are the red flags for hematomas?
A: Protocols from SCAT6 and other guidelines for hematomas or hemorrhages emphasize watching for loss of consciousness (LOC), altered mental status, and vomiting. Quickly identify these signs to avoid missing late concussions or other critical issues. Ensure the mechanism of injury (MOI) aligns with the trauma; diagnosis is challenging if it doesn't.
Q: How can CSF be identified, and what is the “halo sign” red flag?
A: The halo sign, also known as the ring sign, remains the best indicator for identifying cerebrospinal fluid (CSF). CSF is distinct: it has a clear-to-mucous color, is super thin, lighter than water, and does not mix with other fluids. For instance, a soccer player initially diagnosed with a concussion showed a bloody nose and consistent halo sign post-game, necessitating immediate emergency room referral.
Q: What essential elements should be added to an Emergency Action Plan (EAP)?
A: EAPs are becoming more comprehensive, focusing on three key areas. First, ensure resource accessibility by including contacts for ENTs, dentists, and eye doctors. Second, review the EAP regularly, two to three times a year, rather than just annually, using past injury knowledge to proactively improve it. Third, if using AI to draft EAPs, meticulously verify all listed resources.
Q: What items should be included in kits for eye and tooth injuries?
A: For eye and tooth injuries, kits should include 4×4 gauzes, an otoscope, a “Save a Tooth” system, eyedrops, nasal tampons, and Afrin. Physician-approved medications should also be added, along with an ENT kit, which is available online.
Q: What are the risks and benefits of athletic trainers performing sutures on the field?
A: On-field suturing depends on the location and type of laceration, with the cause (e.g., metal object) being crucial due to potential tetanus considerations. Athletes often return to play the same day with sutures. For facial lacerations, specific types and sizes of sutures are used, but caution is advised near the eye. Eyebrows and the skull are generally suitable for suturing if no underlying fracture exists. Control bleeding and inform athletes of the risks associated with playing with sutures; safety is paramount.
Q: When can athletes return to play after tooth injuries?
A: For primary (baby) teeth, if no secondary tooth injury is suspected, return to play (RTP) is generally straightforward. However, secondary tooth injuries involving complex factors can lead to lasting effects. It is important to document whether the injury involves primary versus permanent teeth. For younger children, involve parents to understand the mechanism of injury and the potential for future crown and root fractures.
Q: What current sports medicine trends should recent graduates be aware of or learn in the classroom?
A: Sports medicine is constantly evolving, with increased pressure for accurate decision-making. Recent graduates need to be proficient in current literature and comfortable with shared decision-making and escalating care. As athletic trainers often serve as primary sports medicine providers, they require broad skills across various domains.
Q: How can these emerging sports medicine competencies be effectively taught?
A: Teaching these competencies is challenging due to the need for comprehensive exposure. Educational methods vary by setting, and the field has expanded significantly. Training provides a broad scope, so it's important not to be narrow-minded. Past experiences remain relevant, and post-training, continuous reading and skill refinement are crucial. In a controlled educational environment, students should learn as much as possible, as quickly as possible, to prepare for real-world practice.
Q: What topics are covered in today's breakout session?
A: Today's breakout session focuses on facial injuries, incorporating practical eye, ear, and nasal examinations. The session emphasizes that history-taking accounts for 80% of a diagnosis, with the physical examination comprising the remaining 20%.
Dr. Dominic Maneen shares insights on OMT in sports medicine, covering his AT to DO transition and OMT applications for common conditions.
Q: How did you transition from an Athletic Trainer (ATC) to a Doctor of Osteopathic Medicine (DO)?
A: I transitioned to practicing sports medicine without surgery, as that field didn't align with my interests. I explored osteopathic medicine, identifying the core difference between DOs and MDs as a dedicated course in osteopathic principles. I maintained my athletic training certification to foster understanding and collaboration with ATCs, and a second course focusing on the musculoskeletal system further ignited my passion. During medical school, I also pursued an MBA, gaining insights into medical billing.
Q: Can you describe your athletic training (AT) experience at HBU?
A: I completed my undergraduate studies at UT, then worked as an ATC for baseball and softball at HBU. I entered the profession serendipitously, drawn by the phrase “sports medicine.” It required rapid maturation, as I assumed an adult role despite being only slightly older than the athletes. I collaborated with Richy Valdez and several GAs, and student athletic trainers were indispensable since it was impossible to simultaneously oversee both baseball and softball. I recall an incident involving twin softball players: one sister not playing, the other on deck, with an accidental practice swing hitting the sister, necessitating a golf cart ride to the adjacent facility.
Q: Why is low back pain a significant health concern, and how is it related to depression and lifestyle?
A: Low back pain is the second most common reason people visit the doctor, with depression being the first. Patients typically present with symptoms that indirectly lead to a depression diagnosis, rather than overtly stating “depression.” A sedentary lifestyle is often termed “the new smoking” in medicine, leading to tight, unused muscles. Hands-on manipulation therapy can be beneficial, and simple exercises like push-ups can improve posture by strengthening the neck muscles that support the head. Many individuals struggle with core muscle activation; focusing on proper technique and guiding them to engage their core will lead to increased strength over time.
Q: How do you address flat feet in patients?
A: Patients often present with concurrent back and knee pain. Structural analysis can reveal the cause, leading to recommendations for inserts or corrective devices for arch support, rather than immediate surgical intervention. Subsequent efforts focus on improving knee mechanics to alleviate symptoms.
Q: What is your approach to concussion management?
A: Myofascial release may sometimes require trigger point injections. However, most concussion cases can be effectively managed with muscle energy techniques. In older patients, some form of osteopathic manipulation may be necessary.
Q: What are the key anatomy considerations for the neck?
A: It is crucial to understand that the neck's complexity extends beyond superficial muscles like the scalenes and deltoids; smaller, deeper muscles also play a significant role in neck function.
Q: What are your tips for the Athletic Training Room?
A: Prioritize hands-on manipulation therapy and muscle energy techniques with athletes, rather than solely relying on stationary bikes or treadmills for warm-up.
Learn how to optimize hamstring recovery for peak performance with insights and key Q&A from Brian Duncan, PT, DPT, OCS, SCS.
Q: Is fascial length more critical than strength for hamstring recovery?
A: Fascial length is not necessarily more important than strength, but the body adapts from training, loading, and sprinting. However, sprinting alone is insufficient for optimal hamstring recovery.
Q: How can fascial length be tested in athletic training (ATR)?
A: Currently, there is no way to palpate fascial length. It can only be observed on MRI or ultrasound as imaging techniques improve. An NFL-funded trial is ongoing, examining hamstring injuries and investigating various factors with imaging across several colleges.
Q: How does adjusting knee positioning impact hamstring rehabilitation?
A: Varying the amount of knee flexion or extension can increase hamstring length and load depending on the specific area of the hamstring. Training hip extension can place more load on the proximal hamstring tendon. Most hamstring injuries occur at the myotendinous junction (proximal), while injuries within the muscle belly tend to heal better.
Q: What are the challenges in hamstring rehabilitation for high-level athletes?
A: The higher the level of competition, the more complex the situation becomes, often involving “more cooks in the kitchen.” This raises questions about collaboration between different coaches and the athletic trainer. Communication and planning can be challenging in these scenarios, impacting hamstring recovery.
Q: Is high-intensity sprinting the most important aspect of hamstring recovery, and what are the considerations for progression?
A: High-intensity sprinting is considered most important, but a lack of planning may be an issue. There is a significant load difference between an 80% sprint and a 100% sprint, with a substantial increase in eccentric load at maximum effort. The length the hamstring travels between 80% and 100% sprint is no different. A gradual progression back into previous activities is often necessary for effective hamstring recovery. Running more than nine sprints in a session can lead to further hamstring injury.
Q: Can AI, such as ChatGPT, replace athletic trainers?
A: AI is only as effective as the user and the questions asked. For example, it can build a maintenance program. When asked to include high-speed running and eccentric loading, it then asked if a weekly microcycle was needed. Hopefully, it will not replace athletic trainers' jobs but instead help them to excel at them, especially in optimizing hamstring recovery.
Q: What are the key takeaways for athletic trainers from this presentation on hamstring recovery?
A: Athletic trainers should start eccentric training early (at a pain level less than 4/10) and incorporate sprinting (running) as soon as possible. It is also crucial to communicate with coaches to target at-risk position groups with maintenance plans throughout the season and to incorporate banded Nordic hamstring curls to maximize range of motion.
Q: What is the role of maintenance programs in athletic training, especially concerning hamstring injuries throughout a season?
A: Maintenance programs are vital throughout the season to prevent recurrences and soft tissue injuries. During SAC camps, the key is to prevent overtraining and identify athletes who don't self-regulate. Sprint training should occur early in SAC camp or during the day's workout before lifting. For in-season maintenance, hamstring work should be incorporated on match day and two days after, ideally 3-4 days before the next match day.
Limb Alignment & Leg Length Discrepancies: Key Takeaways
Guest: Brennan Roper, MD
Discussion Points:
Magnet-Based Leg Lengthening: Explore cutting-edge technology utilizing rods implanted in bone and an at-home magnet for non-invasive leg lengthening. This innovative approach allows for daily progress monitoring by providers, offering a minimally invasive alternative to traditional manual methods.
Precision in Magnet Use: Understand the critical importance of using the correct magnet, placement, and parameters for effective leg lengthening outcomes.
Understanding Leg Asymmetry: Learn that some degree of leg length asymmetry is normal. However, significant discrepancies warrant prompt medical attention, as early intervention can lead to less invasive treatment options.
When to Seek Medical Advice: Recognize the importance of consulting a physician for any concerns regarding limb alignment, especially if a discrepancy exceeds 5mm or 1 cm.
Specialized Care for Discrepancies: Discover why seeking a specialist for limb length discrepancies is crucial, rather than relying on general clinics or ready clinics.
Supplementation for Teens: Discuss the role of Vitamin D supplementation, particularly for teenagers, due to potential dietary deficiencies. Calcium supplementation may also be considered based on laboratory findings.
Long-Term Prognosis: Examine how the long-term impact of limb length discrepancies is influenced by the degree of the discrepancy and treatment goals. Even small differences, like 2mm, can allow for a quick return to sports after incision healing, with “guided growth” being a viable option for minor discrepancies.
Miserable Malalignment Syndrome: Gain insight into this condition, characterized by knee or hip pain and a feeling of being “off,” despite a seemingly neutral external appearance. This syndrome often involves internal rotation of the femur, knee valgus (knock-knee), and external rotation of the tibia.
Tolerance for Differences: Understand that small leg length differences (2, 3, or 4mm) are generally well-tolerated, while angular discrepancies tend to be less so.
Advancements in Cartilage Repair: Insights from Dr. Raj Shani
Cartilage damage is a common issue, particularly among athletes. Understanding the latest repair and preservation techniques is crucial for both medical professionals and those in sports medicine. We recently had the opportunity to discuss these topics with Dr. Raj Shani, a leading expert in the field.Favorite Technique: ACI (MACI)
Dr. Shani highlighted Autologous Chondrocyte Implantation (ACI), specifically MACI, as his preferred technique due to its immediate positive impact on patients. This procedure offers a faster, easier, and less burdensome recovery for the patient. Looking ahead, advancements may allow for cartilage harvesting and growth to occur in a single setting, eliminating the current two-stage procedure.Why Athletic Trainers (ATs) Need to Know
For athletic trainers, a general understanding of these techniques is invaluable. ATs are often the first point of contact for athletes and see them daily. Their knowledge fosters comfort and trust, allowing for more effective discussions about injuries and treatment options with athletes.Exosomes vs. Gene Therapy: The Future of Growth
When considering future growth, Dr. Shani believes exosomes hold more immediate promise. The ability to directly introduce exosomes into the knee makes them a more practical option than gene therapy, which presents significant challenges in modulation.Cartiheal: A Natural Solution
Cartiheal, derived from coral, is a fascinating naturally occurring and biologically inductive material. Bone can grow into it, making it a valuable substitute for allografts, which can be expensive or unavailable.The Meniscus: Protecting Cartilage
It's important to differentiate the meniscus from the articular cartilage that deteriorates with arthritis. The meniscus plays a vital role in protecting the articular cartilage by increasing the surface area for weight-bearing. Without a healthy meniscus, the cartilage on the bone experiences less surface area for load distribution, making it more susceptible to damage and issues.
Cartilage Lesions in Athletes: Sports at Risk
Approximately 30% of athletes experience cartilage lesions. Sports involving cutting and contact, such as basketball, are particularly prone to these injuries. While data may be biased due to a higher male participation rate in sports, male athletes generally show a higher incidence of these lesions.
Joseph Eberhardt and Dawson Sports Medicine were preparing for a 3-peat at the time of this recording. Spoiler alert they placed 3rd in the 2025 state championships.
For those of us who may not know what is GHATS? And what is it all about?
Chris Shaddock brought me into Sports Medicine as an eighth grader
GHATS hosts a workshop for student Athletic Trainer Aides.
The workshop is to educate and expose students to the profession.
Numerous courses and rotations provide students with opportunities to learn and explore their interests.
I was uncoordinated and unathletic, and I needed people who understood me.
My sophomore year was the first year of the QuizBowl in GHATS.
Chris told them: Do not embarrass me, watch the quiz bowl, and learn.
Learn it, love it, win it.
My senior year, I wanted to keep competing and so we were doing speed drills, we acquired a quiz bowl buzzer, we did scrimmages…And we finally won.
I went on to college and came back to GHATS to recruit the student AT aides from Houston.
We won 5 championships and have been in the finals 7 times.
I began developing the program so that we as a staff, are involved.
We start studying for them in August.
As part of our student AT workshop, before school starts.
If we win this year, we will be the leading state title holders in our entire district.
We study one 30-minute session each week starting from week one.
13 students were at each of these sessions
I write 200 new questions each year so the students can not just memorize them. I introduce them only at the scrimmage.
Region 6 has created a clause that requires the question to be fully read before the students can buzz in.
The quality of competition has increased
What did that look like through college?
1 year at Texas A&M Corpus Christi we competed.
It was a different style quiz bowl that was more like Kahoot.
What does the state quiz bowl competition look like?
The last two years was at Tarelton State. We came in early Sunday to settle in
Then they host the AT Olympics.
Monday morning they start the state competition like a track meet. Multiple events and your points total place you.
This year there is a rubric that enables the student to learn exactly what is being required.
After lunch was the quiz bowl just like GHATS.
Tournament style with buzzers, head to head.
They have a skills requirement list that they must learn and have signed off on by the professionals.
How do you keep kids motivated and engaged? Are they intrinsically motivated?
Both
I push hard but it’s because they show up and want to be there.
Give us your tips for success.
ENJOY IT – the whole process
Ernest Shackleton – Difficulties are obstacles to be overcome
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