Sport Concussions: Recognition and Return-to-Play Criteria by Stephen Domzalski, MPT, ATC, CSCS

With school starting back up, sports are in full swing again for the returning students. Two sports in particular, football and soccer will see an occurrence of concussions. It is important for us to know the basics about concussions, so that we may recognize when there may be one present and what can be done to manage it safely.

A concussion can be thought of quite simply as a contusion or bruising to the brain. This most commonly occurs from a direct blow, such as two players colliding heads, a player’s head hitting the ground or a player’s head being hit by a ball. Some concussions can be caused from an indirect blow, such as forces transmitted through a blow to the jaw or spine, or a hit to the thorax that creates a whiplash-type force to the head and neck region. Sometimes the cause will be obvious, sometimes not.

The symptoms of a concussion will vary, but here are some of the most common. The athlete will usually complain of some sort of headache or neck pain. If you are familiar with the athlete’s personality, you may notice that they are not acting like “themselves”, or “out of sorts.”

Recently, in regards to concussions there has been some dispute about the grading of severity of the concussion. Saying one concussion is mild and another is severe is starting to lose influence. More often, experts in neuroscience are saying that the terms “simple” and “complex” concussions should be abandoned, saying that the majority (80-90%) resolve in a 7-10 day period. What is more important than trying to decide whether or not a concussion was minor or severe, is the number and history of previous concussions suffered by any particular individual. This should be a huge factor in the return to play decision making for the athlete. Multiple concussions can cause irreversible damage that last a lifetime.

When trying to decide about the safety of returning to play for someone that has had a concussion, there are some serious things to consider in making this decision and it is important to educate yourself on the process. Any concussion is going to take about 7-10 days to heal. They will need much rest, both physically and mentally until their symptoms resolve.

One of the most serious concussive injuries that can occur and ultimately lead to death is known as “second impact” syndrome, occurring when a previously concussed brain is not given adequate time to recover and a second blow to the head is received. In this scenario, a healing brain is going through a chemical process to recover and has a reversal of this process, causing extremely sudden and large amounts of swelling to occur in the brain, resulting in possible shut down of respiratory centers and ultimately brain death. There are well-documented cases of eager coaches, parents and kids allowing concussed athletes to play before they are ready, and these individuals unfortunately end up paying the ultimate price- their life. A simple rule to follow in regards to concussions and return to play is “when in doubt, sit ‘em out”.

Prevention is achieved through education—proper technique in hitting is key. No equipment can eliminate a concussion from occurring, but if properly fitted it can reduce exposure. If concussion is suspected, seek medical care.

 Stephen Domzalski, MPT, ATC, CSCS is an Assistant Athletic Trainer with Wayne State University in Detroit, MI

Overtraining Syndrome in Cross Country Athletes by Colin Kolosky, ATC

Over training is often seen in the beginning of the cross country season. This often presents itself as foot pain, shin pain, sore hips, muscle soreness, fatigue and illness. Too often young athletes do not condition enough prior to their competitive season. This results in a lack of flexibility, endurance, tolerance to the weather and strength.

When an athlete embarks on a competitive season they must be prepared and take care of the small injuries before they become major. Athletic Trainers often see athletes who have shoes that have been worn in another sport, as well as for recreation, and then run the cross country season in the same shoes. There are shoes for a specific sport and/or foot type. If there is a lot of running to be done on the track, road or hard surface, a certain shoe will be chosen. If running in the grass, crossing water, dirt and hills then another shoe may be in order. These are important topics in which to speak with the coach of a cross country or a track team before making your purchase. Often they can save you money and get you the best shoe for the job.

Stretching is one of the quickest and most disrespected parts of a practice. Too often when athletes are late, they’ll catch up with the group by shortening the stretching time or will go through the motions. Proper stretching allows an athlete to maintain better body mechanics, improve stride length and decrease chance of injuries.

When stretching for cross country-the hips, lower back, knees and ankles are all important because these are the load bearing joints. An improper loading on these joints contributes to joint pain. Stretching of the calf musculature is critical to reduce the strain or amount of work needed to bring the toes upward, which in turn can reduce shin pain. Stretching of the hamstrings will allow for a longer stride length and a smoother run. Stretching hips and outer thighs decreases the tight hip or snapping hip syndrome. Remember this rule: A stretched muscle will contract more forcefully than an un-stretched muscle.

Improper loading or focused pressure comes in the form of muscle imbalances, and poor body mechanics. Running on uneven surfaces consistently and wearing improper footwear are just a few contributors. When training for long periods of time during the beginning of the season, joint structures can become very irritated or damaged, creating a painful environment in which the athlete may compensate to avoid the pain they are feeling in the injured joint.

Reduce these overuse injuries by ensuring a proper stretch before and after a workout, as well as proper cool downs. Appropriate running shoes, training on different patterns/surfaces, icing and taking care of minor injuries before they become major will benefit athletes in reducing the chances of overtraining, as well as increase his or her performance.

Prevention of Overtraining Syndrome:

 

Do not perform the same workout routine for two or more days in a row

Alternate your course daily; for example, run clockwise on the track one day, and counter-clockwise the next.

Listen to your body; pain is the body’s way of telling you something is wrong

Schedule rest days in order for the body to recover from the stress placed upon it during training

Alternate high intensity speed training with lower intensity endurance training

Have proper sleeping habits—get at least 7-8 hours of sleep per night

Consult with a professional to ensure your caloric intake is balanced with energy output

Colin Kolosky, ATC is the Head Athletic Trainer for Wayne Memorial HS in Wayne, MI

The Effects of Energy Drinks on Performance by Lisa Swetz, ATC

Energy drinks are appealing for young athletes who have to juggle practices, school, work, and family lives. They perceive gulping down an energy drink as a quick way to consume extra energy to get through the day, take in some vitamins and minerals, expedite recovery from exercise, or fight “energy drain” and fatigue. Unfortunately, most energy drinks don’t deliver on such high expectations.

Most energy drinks are loaded with carbohydrate 18g/8oz to more than 25g/oz. Such high concentrations of carbohydrate will impede rehydration during exercise by slowing the rate at which fluid is absorbed. Therefore, energy drinks should not be consumed when rapid fluid replacement from sweat loss is important. A well formulated sports drink would be preferable, with carbohydrate and electrolytes, which may reduce muscle cramping.

Energy drinks are also loaded with caffeine, which is a central nervous system stimulant, and makes a person feel more “energized”. Average doses of caffeine (85-250 mg, the equivalent of 1-3 cups of coffee), may result in a feeling of alertness, and decreased fatigue. High doses of caffeine (250-500mg) can result in restlessness, nervousness, insomnia, and tremors, which can lead to seizures and cardiovascular instability. Athletes who consume high doses of caffeine complain of light-headedness, and if ingested too far in advance of exercise, caffeine can have a laxative and diuretic effect, which impairs performance. Daily doses of caffeine should not exceed 500 mg.

Studies on energy drinks/caffeine and exercise performance are varied. One study (Graham, 2001), showed caffeine doses of 6 mg/kg of body weight, has proven effective to enhance performance lasting up to 120 min. Another study tested Red Bull and found no effect on performance (Dalleck 2007). Greer et al found that caffeine supplementation actually decreased peak performance and power.

Athletes will always be attracted to products that claim to have performance enhancing effects. Energy drinks are not adequate substitutions for time, training, recovery and fueling required for sports. In addition, the dose of caffeine contained in energy drinks is not always apparent on the label, but may be high enough to put an athlete at risk for failing a doping test for caffeine. Athletes need to be responsible and educated about products for their health, safety, and sport performance. The following table shows the carbohydrate and caffeine content in many of the popular energy drinks:

Product	Carbohydrate(grams/8 ounces)	Caffeine(mg as bottled)
Arizona Extreme Energy Shot	32	100
Battery Energy Drink	27	106
Red Bull	27	80
Red Devil Energy Drink	21	160
Sobe Energy	30	80

Lisa Swetz, ATC is the Head Athletic Trainer for Westland John Glenn HS in Westland, MI.

19th Annual Oakwood Red October Run is Here!

SATURDAY, OCTOBER 3, 2009
10K RUN • 5K RUN • 5K WALK • 1 MILE JR. OCTOBER
Oakwood Annapolis Hospital, 33155 Annapolis St., Wayne, MI 48184

Featuring . . .

• Oakwood Sports Medicine staff will be on hand to answer questions and provide basic services. Stop by and visit!
• Long sleeve shirts 
• Unique glass awards in running & walking events by Furnace Design Studio
• Great prize drawing
• Custom pins awarded to all finisher at finish line
• Outstanding refreshements
• New D-Tag disposable chip timing
• Race photographs
• Free kids’ run with extra activities and tee shirt design contest

http://www.oakwood.org/redoctoberrun

Rotator Cuff is to Blame for Majority of Shoulder Pain

By Marc Milia, MD

(This article originally appeared in The News Herald on September 22, 2009)

Whether you swing a hammer or a tennis racket, the shoulder can become a source of pain by the end of the day. The majority of complaints involving the shoulder are actually related to the rotator cuff.

Anatomically, the shoulder is a ball and socket that is held together by ligaments and tendons. The rotator cuff tendons are a group of four muscles that come from the wing blade to form a cuff of tendinous tissue that inserts into the humeral bone (the ball). The rotator cuff resides below the acromion bone (from the wing blade).

Overhead athletes and manual laborers can develop irritation below the acromion bone from repetitive use or acute trauma. Consequently, rotator cuff problems can frequently arise.

In most cases, physical therapy or corticosteroid injections can solve the problem. However, on occasion, surgery might be necessary.

A program has been developed where the physician can utilize minimally invasive techniques to arthroscopically repair the rotator cuff in an efficient manner. The recovery phase’s discomforts can be alleviated by local nerve blocks that allow the patient to tolerate pain two to three days into the early postoperative phase.

With the benefit of new technology, the experienced orthopedic surgical team at Oakwood Southshore Surgery Center and physical therapy at Oakwood Southshore Medical Center, we have been fortunate to return many athletes and laborers back to their previous levels of activity.

Contact Dr. Marc Milia at 1-313-277-6700. He is affiliated with the Michigan Bone & Joint Center in Trenton, Oakwood Heritage Hospital in Taylor and Oakwood Hospital & Medical Center in Dearborn.

Arizona defeats Aruba in JLWS Championship Game, 9-1

 

Arizona, the Southwest Region representative from Scottsdale, AZ defeated the Latin  American Region team from Aruba tonight, 9-1, in the JLWS Championship game in Taylor, MI.

Arizona, which plays in the Mountain View Little League, scored early and often, taking a 4-1 lead after just two innings. Jimmy DiTroia put the ball over the fence for a 3-run slam in the second. Aruba didn’t help their cause either, commiting two errors (4 total for the game) and hitting a batter in the first two innings. Despite that,  Aruba was poised to make an effort until Grant Martinez threw four innings of shut-out ball.

Arizona added to their lead when Michael Salazar put the ball in the seats for a two-run homer in the 5th.

Congratulations to all the teams in the 2009 Junior League World Series for a fine display of baseball.

Congratulations to Arizona Manager Steve Erickson, Coaches Darrin Trotta and James DiTroia and the entire team! Well done.

Oakwood Heritage Hospital and Oakwood Sports Medicine are proud of their affiliation with the Junior League World Series, the City of Taylor, tournament organizers and the many other volunteers that make this a superb week of baseball.  Through the efforts of OHH volunteers, athletic trainers and administration, Oakwood is able to provide high quality healthcare to the players, coaches and visitors of the tournament.

Teams Travel The Distance for JLWS

The teams in the 2009 Junior League World Series have won and played many games in order to advance to this week’s tournament. They have also traveled many miles to play at Heritage Park in Taylor, MI.

The tournament is divided into the International and USA pools. Teams advance based on traditional pool play methodology. The Junior League in the U.S. is divided into five regions (Southwest, Southeast, Central, Eastern and Southern). Internationally, there are five regions, which this year include Asia-Pacific, Puerto Rico, Europe/Middle East/Africa, Canada and Latin America.

The 2009 teams are:

Yabucoa, PR, Aruba, Venezia Giulia Italy, Coquitlam British Columbia Canada, Saipan, Scottsdale Arizona, Albuquerque New Mexico, Easley South Carolina, Jackson New Jersey and Middlebury Indiana.

Congratulations for each team is a champion in their own right. Good luck in the 2009 Junior League World Series!

2009 Junior League World Series

                      

The 29th annual Junior League World Series of baseball will be played August 16-22, 2009, at World Series Field in beautiful Heritage Park in Taylor, Michigan – the only place the prestigious event has been held.

The Junior League World Series is a spectacular week long international tournament for the best teams of 13- and 14-year-old baseball players from around the world. Founded in 1981, the Junior League World Series is the “older brother” of the Little League World Series held annually in Williamsport, Pennsylvania, for the best teams of 12-year-olds.

Oakwood Heritage Hospital and Oakwood Sports Medicine are proud of their affiliation with the Junior League World Series, the City of Taylor, tournament organizers and the many other volunteers that make this a superb week of baseball.  Through the efforts of OHH volunteers, athletic trainers and administration, Oakwood is able to provide high quality healthcare to the players, coaches and visitors of the tournament.

Hydration and Heat Illness

 Heat illness is a concern for people of all ages.  Risk factors that can cause someone to be more susceptible to heat illness are previous dehydration, obesity and lack of acclimatization.

Hydration is an important factor in preventing heat illness.  It is imperative to drink fluids before, during and after physical activity.  Two hours prior to activity at least 16 ounces of non-carbonated, caffeine free beverages (water, sports drinks) should be consumed. The ideal fluid replacement beverage depends on the duration and intensity of exercise, environmental temperature and personal preference.

Thirst is not an accurate predictor of hydration, so it is important to drink before feeling thirsty.  Every 15-20 minutes during activity 6-8 ounces of fluid should be consumed.  The goal is to replenish what is lost through sweat.  After activity 16 ounces of fluid should be consumed for every pound lost during activity. 

                               

 

Whether you are working in the yard or at spending the day at the beach you should get out of the heat for a 5-10 minutes every hour. Frequent rest breaks in the shade or air conditioning will help to reduce body temperature.

 The three classifications of heat illness are described below.

 Heat Cramps Signs and Symptoms: 

*Muscle spasms in the extremities

*Heavy sweating

*Slightly elevated or normal core temperature

 Heat Exhaustion Signs and Symptoms:

*Cool, moist, pale or flushed skin

*Headache, dizziness, confusion and fatigue

*Strong slow pulse

*Core temperature between 102ºF and 104ºF

 Heat Stroke Signs and Symptoms:

*Hot, dry, flushed skin

*Rapid weak pulse

*Core temperature greater than 104ºF

*Heavy sweating and thirst

The Torn ACL: How Should It Be Fixed?

When a knee injury occurs to an athlete, the greatest concern is the stability of the knee.  Although most injuries are minor, the one that worries us the most is a torn anterior cruciate ligament (ACL).  The ACL provides the knee with rotational stability during pivoting or ballistic type sports activities. It is the major structure that protects the knee from damage. If the ACL is torn, the knee loses stability which causes additional damage to the surrounding structures, particularly the medial (inner) side of the knee. If recurrent episodes of instability occur and the knee suffers additional damage to the medial meniscus or articular cartilage, premature degeneration of the joint can occur.  Arthritis can subsequently can result from an ACL tear.

 

To combat this premature degeneration, the last 25 years of orthopedic sports medicine has seen an explosion in techniques to reconstruct (replace) the ACL. Scientific evidence suggests, if you can protect the knee from additional episodes of instability, premature degeneration and arthritis can be delayed or prevented.

Since the torn ACL is in the center of the knee joint and experiences high forces of stress, it can not be simply repaired in a traditional sense. We cannot “sew it back together” like most other torn structures in the human body.  In order to restore its proper function, the ACL has to be “replaced” (otherwise known as reconstruction).  

In order to replace the ACL with a new ligament, we have to find a suitable substitute.  Tendons have been found to be the easiest source for the new “grafted” ligament.  We either use a tendon from the patient (autograft) or from another person (allograft or cadaveric tissue).  

The most common sources of autograft are the patellar tendon and the hamstring tendon.  Each graft has pro’s and con’s. In general, that patellar tendon autograft is felt to be the most reliable because it has the longest track record and results in predictable outcomes. It has the downside of increased postoperative pain and prolonged recovery. These two problems have led to the development of the hamstring autograft as an option.  The hamstring graft (semitendinosis and gracilis tendons) has less pain, is more appealing cosmetically and clinically has equal outcomes in many studies. Some surgeons feel the autograft patellar tendon is the gold standard despite the studies that claim hamstrings and patellar tendons are equal.

My beliefs lie in the middle.  I feel a hamstring graft is an excellent option and generally prefer it.  For elite athletes who have access to therapy on a daily basis, I believe the patellar tendon is a better option. For the non-athlete who suffered an unusual injury resulting in an ACL tear, I utilize the allograft tendons (tibialis,patellar, peroneals).  Allograft tissue has proven to be safe from accredited tissue banks.  It results in a quicker return to activities of daily living and less post operative pain.

The latest development in ACL surgery is the use of two grafts in a double bundle configuration.  Although this method is enticing because it reproduces “normal” anatomy, it is still in the developmental phases. I consider it another option in the armamentarium above.  The surgery for two bundles is more complicated and more costly for a procedure that is already highly successful. The use of the double bundle ACL reconstruction will eventually either become mainstream or used for selected cases. Only time will tell.

If you have an ACL tear, and would like to discuss your options please contact me, or call my office at 313-277-6700.

Marc Milia MD 

MIOrtho.com