The tale of two or three ligaments…

Most people have heard of the dreaded ACL (Anterior Cruciate Ligament) tear. It used to be a career ending injury, but now thanks to modern technology and the advance of sports medicine in most cases it is only a 6-9 month road block and athletes can sometimes comeback even stronger. There are 4 major ligaments the comprise the knee joint; ACL, PCL, MCL, & LCL. The ACL prevents anterior translation of the tibia helps with rotational stability of the knee.

Over recent years there has been an emerging debate on what is the best way to reconstruct the torn ligament. The patient has three main choices; hamstring autograft, patella tendon autograft, or a cadaver graft. Each have their own pros and cons. For the sake of this post I am going to eliminate the cadaver ligament as it is mainly only chosen as for patients over 40 as a second or third choice. The pros and cons of the hamstring and patella grafts are relative to each and patient and there is just a difference of a couple of percentage points in regards to the re-rupture rate between the hamstring and patella tendon grafts. This blog post also is not to debate if the hamstring is better than the patella. It is about the “discovery” of a new-found knee ligament.

In 2013 an article in the Journal of Anatomy (1) made comments and brought to light the potential impact of a widely unknown ligament called the Anterolateral ligament. At first the media portrayed that this was a new discovery but this ligament has indeed been documented since the 19th century.

(http://www.sydneyknee.com.au/wp-content/themes/ypo-theme/images/anterolateral-ligament-knee.jpg)

The ligament is on the outside part of the knee, tanish in color.

Another article came out a couple of weeks ago in Bottom Line (2) alerting consumers to orthopedic surgeons who have started repairing the anterolateral ligament along with the reconstruction of the ACL. This is alarming and should be definitely be brought up with your surgeon if you are having ACL surgery. It is alarming because there is no evidence that supports it is beneficial to the patient to repair the anterolateral ligament. Research is on going and it will be interesting what conclusions they will find and if it’ll have any benefit in eventually repairing it along with the ACL ligament. This is also a controversial surgery because there is no info on how to exactly perform the surgery! Make sure you are talking with your surgeon to get all the details possible and do your own research to make sure you make an educated decision in regards to the reconstruction of your ACL. My best advice is just to have an open and honest conversation with your doctor.

1.Claes, S., Vereecke, E., Maes, M., Victor, J., Verdonk, P., & Bellemans, J. (2013). Anatomy of the anterolateral ligament of the knee. Journal of anatomy, 223(4), 321-328.

2. Bottom Line Link

AT’s Have your Back…Literally

I am a huge fan of college football and love watching games all day on Saturdays. Watch enough football and you’ll unfortunately be a witness to some rather gruesome injuries. For example this past Saturday Seth Russel (QB for Baylor) dislocated his ankle and was carted off the field (praying for a speedy recovery bud). Other times you’ll see a player be spine boarded when there is a suspected cervical spine injury. Usually this is done for precaution and it is always good to be prepared for this type of injury. With that being said there has been some recent debates over the best way to spine board someone or even to spine board someone at all with a suspected cervical injury. The National Association of EMS Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma (ACS-COT) have published a new position paper on “EMS Spinal Precautions and the Use of the Long Backboard.”

The change in protocol comes from lack of research support for using the long backboard technique. The position statement outlines the benefits and risks for using a spine board. The side effects for using the spine board include increasing pain, pressure ulcers, patient agitation and comprised respiratory system. People who are recommended to be spine boarded include someone with:

  • Blunt trauma and altered level of consciousness
  •  Spinal pain or tenderness
  • Neurologic complaint (e.g., numbness or motor weakness)
  • Anatomic deformity of the spine
  • High-energy mechanism of injury and any of the following:
    • Drug or alcohol intoxication
    • Inability to communicate
    • Distracting injury

People who are no longer needing to be spine boarded include someone with:

  • Normal level of consciousness (Glasgow Coma Score [GCS] 15)
  • No spine tenderness or anatomic abnormality
  • No neurologic findings or complaints
  • No distracting injury
  • No intoxication
  • Patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard

(EMS Spine Boarding Position Statement)

The National Athletic Trainer’s Association (NATA) has also done some research into spine boarding techniques. A study published in the Journal of Athletic Training compared the different spine boarding techniques with the amount of spine movement. The lifts the study looked at include the traditional Log Roll, Lift and Slide technique, and the  6+ Person Lift. Researchers measured axial rotation, flexion-extension, lateral flexion, anteroposterior displacement, distraction, and medial-lateral translation at the C5-C6 spinal segment.The results from this study concluded that the there is ultimately going to be some spinal movement regardless of the lift technique. The researchers also concluded that the 6+ Person technique minimized the extent of motion generated across a globally unstable spinal segment (1). There was also significantly more lateral flexion and axial rotation during the log roll technique when compared with the two others.

Sport medicine is constantly changing and more research is occurring daily to help make sure the best possible care is available for athletes. The new spine boarding techniques should start being visible within the next year if they haven’t been seen already. As an athletic trainer I am going to do everything I can to help make sure the athlete is cared for safely. Spine boarding is an intense situation for everyone involved and ultimately can save someones’ life and/or limbs! AT’s have your back…literally!

This is only one of many life and limb saving stories! Tommy was indeed back boarded and had a full recovery. His story could have ended very differently had the right protocol not been taken by his athletic trainer!

*Disclaimer: Please use this information only for personal use and only perform actions within your scope of practice*

  1. Del Rossi, G., Horodyski, M. H., Conrad, B. P., Di Paola, C. P., Di Paola, M. J., & Rechtine, G. R. (2008). The 6-Plus–Person Lift Transfer Technique Compared With Other Methods of Spine Boarding. Journal of Athletic Training, 43(1), 6–13.

Scary Sickle Cell

Living at altitude there are some things that you become hyper aware about. One of the more obvious things is the lack of oxygen in the air. When it comes to athletics there are a few advantages but many disadvantages to the limited O2. Having played and watched sports at the mile high level for many years you start to become in tune to ailments or conditions that might worsen because of the high altitude. One of those conditions that you definitely need to be aware of is Sickle Cell Anemia and Sickle Cell Anemia Trait. The National Athletic Trainer’s Association defines Sickle Cell Anemia Trait in their position statement as the inheritance of one gene for sickle hemoglobin and one for normal hemoglobin. Hemoglobin is a protein in the red blood cells that transports oxygen. In times of extreme exertion or exercise the sickle hemoglobin will cause the red blood cell to shrink into a quarter or half-moon shape. This greatly affects the body’s oxygen levels. The sickle cells also causes blockages in vessels because the cells catch on each other and cannot move freely.

shutterstock14313925

Sickle cell is a genetic adaptation and  it is common in people whose origin is from areas where malaria is widespread. Just carrying one of the sickle-cell genes could defend off malaria (NATA Position Statement). 1 in 12 African-Americans posses the trait. It is good to take note that the trait is also seen in Mediterranean, Middle Eastern, Indian, Caribbean and South and Central American descendents.

Some startling stats about sickle-cell:

  • In the past four decades, exertional sickling has killed at least 15 football players.
  • In the past seven years alone, sickling has killed nine athletes:
    • Five college football players in training,
    • Two high school athletes
    • Two 12-year-old boys training for football
  • Of 136 sudden, non-traumatic sports deaths in high school and college athletes over a decade, seven (5%) were from exertional sickling

(http://ksi.uconn.edu/emergency-conditions/exertional-sickling/)

So what are some signs and symptoms of a sickle-cell attack:

  • Cramping muscle weakness that exceeds muscle pain 
  • Athlete “slumps” to the ground rather than a sudden collapse (Rules out cardiac)
  • Able to speak (Rules out cardiac)
  • Muscles look and feel normal (rules out heat cramps)
  • Rapid breathing, but pulmonary exam reveals normal air movement (rules out asthma)
  • Rectal temperature less than 103oF (rule out heat stroke)

(http://ksi.uconn.edu/emergency-conditions/exertional-sickling/)

Ways to avoid a sickle-cell attack:

  • Build up slowly in training with paced progressions,
  • Allow longer periods of rest and recovery between repetitions.
  •  Encourage participation in preseason strength and conditioning programs
  • Athletes with sickle-cell trait should be excluded from participation in performance tests such as mile runs, serial sprints, etc., as several deaths have occurred from participation in this setting.
  • Stop any activity with onset of symptoms [muscle ‘cramping’, pain, swelling, weakness, tenderness; inability to “catch breath”, fatigue].
  •  Athletes with sickle-cell trait who perform repetitive high-speed sprints and/or interval training that induces high levels of lactic acid should be allowed extended recovery between repetitions
  • Ambient heat stress, dehydration, asthma, illness, and altitude predispose the athlete with sickle trait to an onset of crisis in physical exertion.
  •  Emphasize hydration
  • Control asthma
  • No workout if an athlete with sickle trait is ill
  • Watch closely the athlete with sickle-cell trait who is new to altitude.
  • Modify training and have supplemental oxygen available for competitions
  • Educate to create an environment that encourages athletes with sickle-cell trait to report any symptoms immediately;
  • Any signs or symptoms such as fatigue, difficulty breathing, leg or low back pain, or leg or low back cramping in an athlete with sickle-cell trait should be assumed to be sickling

(http://ksi.uconn.edu/emergency-conditions/exertional-sickling/)

** THIS IS A MEDICAL EMERGENCY!**

How to treat a sickle-cell attack:

  • Check vital signs.
  • Administer high-flow oxygen, 15 lpm (if available),
  • Cool the athlete, if necessary.
  • Call 911, attach an AED, start an IV, and get the athlete to the hospital fast.
  • Tell the doctors to expect explosive rhabdomyolysis and grave metabolic complications.
  • Proactively prepare by having an Emergency Action Plan and appropriate emergency equipment for all practices and competitions.

Sickle cell anemia is a very serious condition and needs to be treated as soon as possible! The good thing about this disease is that it is easily screened for and once the proper people are aware of the condition it can definitely be well managed! Be aware and get screened!

Orange Crushing Cam

NFL: Carolina Panthers at Denver Broncos

I am a Colorado native and have grown up cheering hard for the Denver Broncos. The NFL season opener kicked off last Thursday night (9/8/16) with a rematch of last year’s Superbowl contenders; the world champion Denver Broncos vs. the Carolina Panthers! It was a great season opener as each team battled back and forth for the lead. Ultimately the Broncos prevailed to a 21-20 victory! Go team!

However the much anticipated win was soon flooded with controversy concerning the barbaric punishment Cam Newton (Carolina’s Quarterback) faced from Denver’s defense, and the lack of medical attention he received throughout the game concerning the head to head blows. Numerous questions were and still are being raised about not only Carolina’s medical staff but how the trained NFL spotter (whose only job is to watch for players who might have sustained a concussion) failed to act accordingly! Was the team’s potential victory worth more than the health and safety of one their athletes?

A concussion is considered to be a traumatic brain injury. It can greatly alter someone’s orientation and they do not have to lose consciousness in order for it to be diagnosed as a concussion. One of the main mechanisms of injury for a concussion includes a direct impact or blow to the head. Concussions have been an extremely hot topic over the past 15 years. The medical world has learned so much in regards to diagnosing, treating, and the lifelong impacts of multiple sustained concussions.

A study conducted by Kevin Guskiewicz who is renown concussion expert from the University of North Carolina looked at thousands of retired professional NFL players who sustained concussions during their career and their quality of life after retiring. Of the 2,000+ players he researched he concluded that 61% had sustained at least one concussion and 24%  had sustained 3 or more concussions! He also noted that in the players who had 3 or more concussions they reported 5 times as higher as being diagnosed with mild cognitive impairment.They also had a 3 times higher incidence of self reported memory problems compared those players who did not sustain concussions. Guskiewicz concluded that an early on set of dementia symptoms might be initiated by repeated concussions sustained in the National Football League.

For more information here is a LINK to Guskiewicz’s article from Neurosurgery 

Concussions are an extremely hot topic right now and I am glad the NFL is beginning to take steps to protect their players. However, I believe it is inexcusable to allow a players health to be compromised because of who they are or how close the game is when a victory is on the line. I am glad the NFL is taking action to review these hits and Go Broncos!

UPDATE: Since the conclusion of the game Thursday night numerous media outlets and articles have been composed calling out the lack of medical attention Cam Newton received in regards to all of the head hits he sustained. An article from The Denver Post states that “both the NFL and the NFL players association are going to investigate the implementation of the concussion protocol” (http://www.denverpost.com/2016/09/11/panthers-cam-newton-hits-broncos-investigate/). There were four hits that were aimed at Newton’s head, and only one hit was penalized. The NFL has since determined that two of those hits were bad enough to sustain fines. Brandon Marshall was fined $24,000 where as Darian Stewart received an  $18,000 fine.