We're just about at that 802 mark, so let's get rocking. So welcome everyone to the Association of Academic Physiatrists Medical Student Council Monthly Journal Club. This month we got a good sports med theme. We're pleased to have Dr. Brian Suterer, current sports med fellow out of the Mayo Clinic, completed his med school training at Indiana University, his physiatry residency out of the Mayo Clinic, has a fascinating YouTube channel where you can catch him reviewing sports injuries in an effort to explain them in a digestible manner to the casual sports fans and for us physiatrists to nerd out about as well. And we got a bunch of great presenters tonight, so let's get rocking. So first off, we have Kristen Clark, our fourth year med student at Renaissance School of Medicine at the Stony Brook University. She'll be talking about the effectiveness of progressive tendon loading exercise therapy in patients with patellar tendinopathy, a randomized control child. So take it away, Kristen. Sounds good. Okay, here we go. Just like you mentioned, the article is Effectiveness of Progressive Tendon Loading Exercise Therapy in Patients with Patellar Tendinopathy, a Randomized Control Trial. A little bit of a mouthful, but here we go. So the objective of this exercise is really to look at patients with patellar tendinopathy and then comparing progressive tendon loading exercise therapy to eccentric exercise therapy, which is kind of, was determined one of the main states of current treatment. So just a little bit about patellar tendinopathy, this is also known as jumper's knee. So we see this as an overuse injury of the patellar tendon at the distal portion of the patella. And it's really most commonly caused by repetitive jumping or loading onto the patellar tendon. And actually it's fairly common in these athletes. So up to 45% of elite athletes involved in jumping sports will present with some signs and symptoms of patellar tendinopathy. And your classic presentation is some anterior knee pain is often worse with running, walking uphill, moving after prolonged sitting or standing. And on exam, you notice some tenderness to palpation, usually over where the patellar tendon attaches on the inferior patellar, rather than the tibial tuberosity, but anywhere along the tendon could be, could be noted. One thing to notice that it was previously called patellar tendonitis, however, this was kind of changed the patellar tendinopathy because they noticed that it was rather than being an inflammatory process, it was more degenerative changes were being seen. So a little bit about who's included in the study. So they basically included any patient from 18 to 35 years old, who had a history of knee pain over the patellar tendon. And it was involved in that had the injury had incurred from training or competition. And so these patients had to compete in sports at least three times a week. They had to have some structural changes seen on ultrasound. And they looked at something called the visa P score, which is basically I'll go into a little bit more later on, but it looks at kind of pain limitations from sports and kind of overall functionality associated with the sport. A score of 100 means that no pain and no limitations. And so they had to have a score less than 80 in order to be eligible for the study. And then the exclusion criteria was anyone who has some acute knee or patellar tendon injuries, previous surgery without full rehab, inflammatory joint disease, history of kind of familial hypercholesterolemia, all these kind of other things that could be confounding factors. And then any use of like fluoroquinolones or things that negatively affects tendons, steroid injections, history of rupture, and then they had to be able to perform the exercise program. So I accidentally skipped a slide, so I'm going to go back to the methods of randomization. So this is called the jumper study, which makes sense because it's commonly seen in jumper's knee. And so this was considered a stratified investigator blinded block randomized control trial. So what is that? Basically a computer placed patients in blocks of four to 10 patients into either the intervention group or the control group in a one-to-one fashion. They also tried to stratify patients based on whether it was kind of an early patellar tendinopathy deemed less than six weeks of symptoms versus a longstanding patellar tendinopathy. And they wanted to do that because there was kind of suggested that an earlier early stage of patellar tendinopathy had a better prognosis. So then just getting into eccentric exercise, what is it? So this is kind of a form of exercise where the muscles being loaded while you're lengthening the muscle compared to contract concentric exercise, which is the opposite. So the muscles being loaded kind of while you're contracting and shortening the muscle fibers. And one of the big differences between eccentric exercise therapy and the progressive loading therapy was that this one is pain provoking. So the patients were instructed that they should be performing the movements while they're experiencing some pain. And this is actually was one of the main kind of mainstays of treatment and was supported by certain guidelines, like the NICE guidelines as noted on the slide. And so then just going a little bit into what they did for the treatment. So they started in, they had two stages for the eccentric exercise therapy. The stage one was kind of doing things like a single leg decline squat. They would do these exercises two times a day for about 12 weeks, and then they would move on to the sports specific exercise. Once they had kind of completed these exercises, then they could return to sport. But the key thing was that they should be have some pain while doing these exercises. This contrasts with progressive tendon loading exercise. So for this, this was kind of an alternative to the eccentric exercise therapy. And the idea behind it is basically to limit the pain and slowly increase the load on the tendon over time. And so they did some kind of loading modifications based on reducing these high load energy storage activities like jumping and running in order to kind of progressively increase the strength of the tendon and the supporting muscles. So they don't have as many symptoms and are able to return to sport. So for this branch, which was the intervention branch of the group, there was four stages. The stages started with the isometric static exercise, like isometric holds and things like a single leg press, but they weren't actually pushing the plate. And once they kind of completed this phase, then they moved on to the dynamic exercises. And they still kind of continued the exercises from the previous stage, if that makes sense. After completing the isotonic dynamic exercises, then we moved on to this phase three, which was the energy storage, explosive plyometric exercises, like running, jumping, where they could really load the tendon. And they had to kind of complete this phase in order to reach the sport specific exercises before returning to sport. So this is just kind of one of the figures, and it kind of goes through what we had mentioned on the past two slides, how they randomized, and then there was the two different arms. And these are kind of some of the exercises which they would do for the eccentric exercise therapy, the squats, and then in order to increase the load, they would increase some of the weight before entering the sport specific exercises compared with the more slower progression as seen in the patellar tendon loading therapy. So then just looking a little bit at the outcomes, the primary outcome was based on the VISA-P questionnaire. So VISA-P stands for Victorian Institute for Sports Assessment, and the P is referring to the patellar tendinopathy. And so this is a validated injury specific questionnaire, which I kind of alluded to incorporates pain, function, and then ability to play sports altogether. And so they did a baseline, and then they also administered at 12 and 24 weeks as well to kind of see the progression after the therapy, but they also looked at some secondary outcomes such as returning to sports at a pre-injury level, satisfaction, and then adherence to the exercise because these exercises they were doing on their own, they weren't supervised. Briefly on statistical methods. So this was a followed an intention to treat protocol. When looking at the VISA-P scores, they were trying to determine a minimally clinically important difference or MCID, which was basically determined to be a change in the VISA-P scores of 13 or greater in order to be kind of an important difference. They did know that if patients who had dropped out of the study were in the intervention arm, they would determine like the worst case scenario for those patients and alternatively have a best case scenario for patients who were in the control arm as far as when the statistics were being calculated. In order to look at some of the secondary variables, they dichotomized the variables to make the analysis a little bit simpler, looking at either the return to sport at pre-injury level versus no return to sport, and then satisfaction, which was if they had an excellent or good for satisfied, it was considered satisfied and moderate and poor was considered dissatisfied. And then they just did a weekly online questionnaire in order to assess for adherence to the exercise program. So our results. So first on the right hand side, we see figure three, so this is just kind of a breakdown of their screening and kind of breaking down into the two groups. So kind of as noted, they started with 272 patients and they ended up with 76 being randomized, 37 included in the experimental group and 30 included into the control group. The median duration symptoms was for about two years, but kind of ranged mostly from about one to four years with only one patient experiencing more of the acute symptoms. And so their stratification that they were planning on doing really didn't make that big of a difference just because most of the patients had chronic patellar tendinopathy. Of the patients included, 42% had bilateral symptoms for these patients. They only considered the data who on the worst knee and then 82% had a previous kind of treatment without full recovery. And this, these 82% of patients were distributed evenly amongst the two groups. One thing to note that the intervention group with the patients who received the progressive tendon loading exercises had a little bit of more like chronic symptoms and they all had more erosions found on ultrasound. They noted that these patients had symptoms on average for 119 weeks compared to eight weeks in the control group. And they had about 45% of erosions is what they said compared to 18% on the control group. So a little bit difference in the groups there. And then I told them nine patients were last to follow up. So for our results, their main, the main outcome, as we like mentioned, was the vis-a-vis results. And so we saw a significant increase in the scores from baseline to 24 weeks out in both groups. And there's also statistically significant difference between the two groups and the PTLE groups compared to the control group after 24 weeks. For the other outcomes when they were looking at kind of improved. Thank you. Okay. Thank you. We're looking at the other groups. They noticed improvements in that people were reaching this clinically significant kind of difference. However, there was no difference between the groups, at least not statistically. Then going quickly into the kind of return to sport and the satisfaction, as you can see after about half of the patients almost returned to sport after 24 weeks from the progressive tendon loading exercise group and about 27% in the control group, same thing. There was no significant difference between the two groups there. As far as satisfaction, both are about equally satisfied by the end of the trial. One thing that they did do is they looked at people who said excellent as far as their satisfaction and these patients, there was a significant statistically significant difference in kind of satisfaction for like an excellent rating. In favor of the progressive tendon loading exercise group. One other thing which they did also look at was just kind of like a general pain scale across the time period. And there was a significant reduction in pain in the tendon loading group, progressive tendon loading exercise group. And so just a little bit about kind of the discussion. So progressive tendon loading exercise did show a greater percentage of improvement in the mean vis-a-vis scores, which was our primary outcome throughout the study, especially during the late phase of recovery. And so this was suggested to be really because of the inflammation of the phase three, which was those like dynamic loading exercises, the running, the jumping prior to initiating the specific sport specific exercises. And so it really kind of showed that this is an effective treatment and an effective alternative to the eccentric exercise therapy, which was kind of the mainstay of practice. And so that's one reason why this was an important study for us as future physiatrists and physiatrists. The only, there are some limitations though, there's kind of a lack of generalizability for the study. They looked at a very kind of small segment of population. They looked at athletes who were young, basically 18 to 35. So it doesn't really necessarily, you can't draw conclusions about older athletes. You can't draw conclusions about kind of acute patellar tendinopathy because there's only one patient who had the symptoms less than six weeks. And there's also a big mix of population of athletes. There are some recreational athletes, there were some elite competitive athletes. So it's hard to say if one group maybe had more elite competitive athletes and they maybe did things differently or pushed themselves harder or had different kind of criteria of what their pre-injury level, because a lot of this was subjective. So that kind of muddies the water a little bit, in my opinion. And then the other big thing for me is that the exercises were unsupervised. And so it's hard to tell were people doing things correctly, were people sticking to what was considered the appropriate level of pain they should be performing the exercises at. And so these are kind of some questions that, and maybe kind of concerns I had about study that could be followed up with the future studies. And so then just in conclusion, this trial basically showed patients mostly with chronic patellar tendinopathy and that the treatment of patellar progressive tendon loading exercise was superior to eccentric exercise therapy after 24 weeks, despite kind of the presence of these patients having chronic symptoms and previous conservative treatment for the majority of the patients. And so they support the use of progressive tendon loading exercise as a part of the conservative therapy for patellar tendinopathy. Thank you. Awesome. Thank you, Kirsten. So we'll let Brian weigh in first, and then we can just open up to our audience for questions for Brian, our clinician expert or our speaker, Kirsten. Thanks. Really nice job, Kirsten, on that study. There was a lot of stuff that they did. I thought you did a really great job of going through some of the kind of weaknesses and the strengths of the study. I think the weaknesses almost stand out just as much to me as the strengths, and I think it really is the patient population, like you were saying. There was so much variety in terms of the people in these studies that you're right. It's very hard to sort of make a blanket statement about treatment of chronic patellar tendinopathy just based on this study, especially when you're talking about things like return to sport. I mean, for a 35-year-old recreational weightlifter, that's very different than your elite 21-year-old college athlete. And so it's really hard to get a sense of really what that meant in terms of return to sport. I think that's definitely one of the biggest limitations of the study. I think overall, the way that I kind of look at this is there's a lot of different ways to skin the cat, so to speak. I don't think there's like one specific exercise program that's better than all the others. The best therapy is the therapy that patient will do effectively and tolerate. And so whether that's heavy, slow resistance training, which some of you guys might have seen come out in some recent papers, whether that's eccentric or that's this progressive tendon loading, I don't really care what my patient does. I want them to do the program that they're going to be consistent with, and also that the treating physical therapist is comfortable instructing them on. It's great to see studies like this though, because let's say somebody is really struggling with their eccentric program and just not making any progress, but we have good evidence to say, hey, let's try this other approach. Let's try progressive tendon loading. Maybe that will kind of be the one thing that gets them over the hump, or it could be vice versa. Maybe someone does progressive tendon loading for a few months and this is getting nowhere. Well, switch them to eccentric. So I think it just gives us some confidence in having another tool in our tool bag and should make you think, okay, if I'm seeing a patient with chronic patellar tendinopathy, what have they been doing for their therapy? It's easy to just say, have you done therapy? Yes, no, and check the box, but really saying, okay, show me what you're doing, trying to dive into what type of program they've had, and then maybe make a change based on what they haven't tried yet. So, but really great job on a pretty complex study. Thank you. Questions from our audience members. Hello, Alex Chor right here. I was wondering why both exercise prescriptions, as it was stated, required some level of pain. And if so, what was like the level of pain? How was that measured? Thank you. Go for it, Kristen. Yeah. Okay. So I believe for, so the progressive tendon loading exercise was not supposed to be painful. It was supposed to be on like a scale of one to 10. They said, I think level three or less, whereas the eccentric exercise therapy was supposed to be a pain level of five or great, about five, I believe. Maybe Dr. Sutter can like weigh in on kind of why they wanted to make it painful. He might have like a better idea of kind of the physiology behind that. Yeah. I think that's a really good question. I'm trying to find specifically, I remember, yeah, it looks like eccentric's five, you're right. And then progressive tendon loading less than or equal to three. So there's, there's a tough balance when you're doing physical therapy of like having people in pain because when they're in pain, that's somewhat a sign that you're, you're trying to like stimulate the tissue. So tendons and they, tendons respond to like mechanical stimulus. And so if you're not giving them enough mechanical stimulus, they're not going to respond to what you're doing. And oftentimes when you have like a chronic tendinopathy, you get all these, we call them like neo vessels, like new blood vessels, new little nerves that sort of form particularly on kind of the underside of the tendon that we think is kind of what causes a lot of this pain. And so the bottom line is when you stimulate the tendon, it's going to be painful, but you need to stimulate the tendon in order to try to induce that reorganization of the tendon fibers. Cause in a chronic tendinopathy, everything is just like very haphazard and kind of mush together and you're trying to give mechanical stimulus to help kind of realign and properly position those fibers. And so the pain is basically a sign that you're providing mechanical stimulus to help with that tendon reorganization. Okay, so it has to be painful to some extent to see like a clinical relevant? Yeah, to some extent, you just don't want, and this is part of the skill of a good physical therapist, you just don't want it to be, oftentimes you'll hear in general PT, like pain of about a three as kind of a good threshold. Eccentrics are different because eccentrics naturally kind of induce more lower tissues, so you're gonna have to like apply more load, but you want some discomfort, but you don't want, you know, seven, eight, nine out of 10, where now you're in pain for two or three days. So it's the job of the therapist to say, okay, what's kind of the appropriate pain threshold that you can tolerate, that's not going to cause you to have a setback and fail the subsequent days with your exercise. Thank you. All right, and then just so we have, for the sake of time, so we got other presenters going here, and if we have questions that kind of linger from this study, you guys can throw them in the chat and we can see if we can have time for them at the tail end of things, but just so I can keep us on track. So we got Thomas Roach, our fourth year med student out of the Midwestern University, CCOM, sorry, I'm blanking on what that abbreviation for, there's too many abbreviations these days, where Thomas will be talking about the relationship of overuse injuries and extra scholastic sports participation in high school athletes from 2009 to 2010, through 2015 to 2016. Go ahead, Thomas. So it's Chicago College of Osteopathic Medicine. There we go, just blanking hard on it, thank you. Hi, so I am Tom. So my article is over what Nathan just said. It was from the AAPMNR journal from September of 2020. The objective of the study was to compare overuse injuries across several sports among high school athletes who participated in school sanctioned sports and athletes who participated in school and outside school sanctioned, classified as extra scholastic athletes. This was basically they're just trying to get those specific terms because there are studies through the same kind of dataset used that they found other, but they didn't really, no one really compared the two. So there's the definition of overuse. So the dataset that was used is from the National High School Sports Related Injury Surveillance System. It's where athletic trainers or physicians plug an injury into a database with four or five different things. So injury type, season they're playing, stuff like that. So then the three inclusion criteria for an injury is something that occurred during high school competition, practice performance, required medical attention by athletic trainer or physician, resulted in restriction of athlete's participation by one or more days. And then the fourth point, any fracture, concussion, dental injury or exertional heat event was actually removed because the study did not believe that they could be caused by an overuse injury pathology. So just an overview of the study is it's a descriptive cross-sectional secondary analysis of injury data collected on high school athletes from 22 sports from the 2009, 2010 season to 2015, 2016 academic years. So it covered 100 randomly selected high schools in the Northeast, Midwest, South and West and the sports here. So the boys ones, so each of these are one, one and this is two for boys and girls. So they're classified as two. So the audience, can anyone think of any specific overuse injuries that we can think of? I guess chat or unmuting would be great. Yeah, one stress fracture is another. Rotator cuff. So I think it's a little bit too specific but it is kind of overarching. So I'll just go into it. So some of them, apophysitis, bursitis, blister, hyperextension, ligament sprain, muscle strain, inflammation, stress fracture, tendonitis, plantar fasciitis, shin splints and spondylolisis. So then the athletic trainer put in these six things. So for athlete demographics, it'd be year in school and gender. Injury characteristics would be new injury or current injury or other. A level of play is varsity, JV, freshmen combined or other. Injury is pre-season, regular season, post-season injury events would be a sport in which the athlete is participating and setting of injury. And then each individual injury is classified as a unique injury. So they can determine which of each injury, of more than one, sorry. So with this database, they were not able to collect data on injured athletes. And because athlete exposures were not captured separately for athletes who do and do not participate in extra scholastic sports, it's not possible in the study to directly calculate the injury rates and rate ratios. So instead, a chi-square ratio is used to approximate the injury rate ratio of interest, which includes three equations. So the results overall, there are over 56,000 injuries, individual injuries, and then they removed around 13,000 based on the fourth criteria or if the injury data was incomplete. So if they didn't specify what type of injury. So overall, there were 32,000 individual athletes. So there were 10,000 athletes or multiple injuries. 3,500 are qualified as overuse with the highest proportion of injury, overuse injuries being girls track and field and boys track and field, which are down here. So 29% of all the injuries were overused, 36. The lowest overuse injuries is boys hockey and then boys wrestling. So boys wrestling, 66 and then eight. And then the eight will come back later. So boys football had the highest number of total injuries, which was, I believe it was 43% or something. It was incredibly high, like 18,000 out of 42,000. And only 550 were overuse. So it just kind of shows you how much like acute pathology happens in football. So these are the four most commonly reported overuse injuries. And then this is another of the tables that showed extra-scholastic versus scholastic by sport. So these had a higher number of overuse in extra-scholastic and they basically did numbers, not proportions or percentages, so 100 over 64. So the injury patterns. So overuse injury in scholastic athletes most likely to occur in seniors. Also overuse injuries in scholastic, only athletes were most likely to occur in freshmen. Female extra-scholastic athletes were more likely to have an overuse injury, whereas scholastic only female athletes were likely to have non-overuse injury. And all of these demographic were statistically significant with the exception of timing of injury. So in addition to this, in seniors, most overuse injuries were at varsity level for both extra-scholastic and scholastic, but were actually 10% higher likelihood of injury with the extra-scholastic. And extra-scholastic had recurrent injuries 8% more often than scholastic. So another question to the crowd, assuming these are risk ratios, which are statistically significant. All of them that don't include one. Yep, exactly. With the exception of, they did not mention ice hockey. I think it was because there's only like eight injuries, which accounted to like 0.1% of their injuries. So yeah, so boys football, girls, sorry, boys baseball and girls softball. And then one quirk was that they removed football from the IPR and it showed that it was actually a negative statistically significant lower than one IPR, indicating a lower portion of overuse injuries and extra-scholastic athletes compared to scholastic only athletes. And then there was another table not included by PowerPoint showed that overuse injuries more likely to be playing the same sport outside of school and that extra-scholastic athletes were more likely to have time loss with overuse. Discussion, so extra-scholastic experienced statistically significant higher proportion of overuse injuries overall. And boys football is the main driver of combined IPR. And then they discussed with the decreased IPR when football was removed is believed to be a miscalculation with more than one sport athletes. So they just put that one. So playing for, I'm sorry. So no individual sport has statistically significant lower proportion of overuse injuries in extra-scholastic athletes compared to scholastic only athletes. Playing for two leagues concurrently for the same sport showed higher likelihood of overuse, which is most likely due to more athlete exposures and more specific repetitive motion, which is a risk factor for overuse. And it would also increase training load. So some of the limitations in the data set is it's based off of one athletic trainer with no one looking over their kind of mechanisms. And also each athletic trainer is individual could over-report, under-report overuse injuries or others. And then the study most likely under-reports because of multiple athlete. Some examples would be athletes who continue to play despite their overuse injuries that were not captured. If an athlete who participated in extra-scholastic play sustained an injury and then was healthy during the school season without any reportable injuries, that injury that occurred outside of the school setting would not be collected. And then also not able to record or report athletes. And then since this data was a subset of injured athletes, it's not about the general public. Also each injury sustained by an athlete was recorded separately. So capturing data by athlete was not possible. This limited the ability to discuss athletes who participated in more than one school-sanctioned sports. And lastly, non-time loss injuries, which commonly include injuries of an overuse mechanism were not quantified. So here's some future research that would be helpful. For the dose response, it would be- Five minute warning here, Tom. Okay, thank you. You could analyze thresholds of training load, number of days off, number of days on, and compare all of that. And obviously more years of data would be helpful for any study. So some take-home points. Close monitoring may be warranted for extra scholastic overuse injury in the boys football, girls softball, boys baseball. However, with this, any conclusion drawn has to be tempered with the limitations of the data sets. The last take-home point is students potentially at increased risk for overuse include varsity players, females more than males, athletes playing more than one sport, sorry, playing scholastic sport and an extra scholastic sport in the same season, previously injured extra scholastic injuries. Yeah, thank you. Tom, that was a lot of data to go through. Yeah, yeah, it was. There's a lot of numbers and thousands and tables and stuff in this paper, but great job trying to kind of sift through some of it to hit just the high points. I think this study, I think what they're trying to get at and address, but I feel like they don't really kind of hit home on it is this idea of sports specialization, which is a big hot topic in youth sports right now. This idea of eight, nine, 10-year-olds that are playing 10 months of soccer a year and they're practicing six days a week and they're just way too specialized in their sport and all the both physical and kind of psychosocial risk factors that can come with this. And so when I first kind of saw this study and was starting to read it, I thought, oh, they're gonna like really kind of get at this idea of sports specialization and see how that kind of plays into this. But I feel like they didn't really address that at all. I think it would have been really interesting to know. I mean, for one, any of these exposure studies or like injury surveillance studies are extremely hard to do. And the biggest challenge with them is capturing exposure. So on all of these athletes, you don't know how many games, how many practices, how many miles, if they were a mile runner in track or if they were a shot putter in track. Like there are endless variables in these papers that unless you're very proactive ahead of time are impossible to tease out and oftentimes play a big role in them. I think also, I don't know of any extra scholastic football. And so I'm not sure how in the world they were able to include football players because I don't know of any like 10-year high schoolers that play football outside of their football. So that alone tells me that they potentially missed some huge, like huge error in this paper. And I'm guessing that a lot of those questions of like, were you an extra scholastic football athlete or probably multi-sport athletes who like also played basketball or baseball and then played travel baseball in the summer or something and like totally confounded this football out, like not even college athletes like play club football. It doesn't exist. So I think there's some really big holes to be very honest in what they're trying to look at. But when you see all the data, it sounds like very impressive. I think the bottom line is, we know that sports specialization in terms of your risk of injury, the more you play your sports, the more at risk you are of getting hurt in terms of these overuse types of injuries. Now for like acute serious injuries, it's actually kind of the opposite. Like the more experienced you are at your sports, the more you play it, the less prone you are to these bad like ACL tears, fractures, et cetera. And so I think we can still take out, if you're trying to convince the parents of a 10 year old who plays year round baseball and pitches that they're putting their child at risk of getting hurt, I think you can use this a little bit to kind of just look at, okay, there's some data that's been done, kids who are doing year round sports outside of their main sport are at risk. And that's kind of one of the fundamental properties of how to guide parents with limiting kind of sports early specialization is to not be competing in both your like team sport and your club sport, especially at the same time. And so I think there's still some good things to tease out of it from there, but I can't get past the whole football extra scholastic piece of it. And when that's like 80% of the kids they had on the study, it's so hard to take the rest of it seriously, unfortunately, you know, it's worth understanding just the concepts of like sports specialization and kind of how we define it and sort of some rough criteria. If you guys search the National Athletic Trainers Association recommendations on like sports specialization safety, they've got a nice little infographic where basically, you know, the recommendation is no more hours per week than your age in years. So if you're a 10 year old, you shouldn't be practicing or playing more than 10 hours a week. If you're an eight year old, it should be no more than eight hours a week. You should have two days off per week from your sport, less than eight months a year in your sport and ideally delay specialization as long as possible, like into your kind of early teen, 13, 14, 15 kind of years. All of this idea of like 10,000 hours came from the world of musicians, which has all kinds of irrelevant to like sports specialization. And so there's definitely some things, check out that infographic. It's really helpful and kind of just gives you some high points. So I'll stop rambling so other people can ask questions, but great job, Tom. There was a ton of data in there. And so just for you to be able to like be your head around big picker, I thought you did a really great job of just highlighting the relevant stuff and kind of giving a good oversight of it. So thank you. Thank you. I actually, I went into the HS Rio thing and you could actually like do demo and they now, you can specifically put in like how many practices, how many injuries, it's like expanded from back when they started it. So hopefully that will help at least the data a little bit, but that's good. Questions from the crew. And then we'll give, raise the shout out for nail on that stats question. Yeah, I'm Eric. I'm a fourth year at California North State University. Thanks Tom for going over all that really comprehensive. I guess my question maybe is a little more for Dr. Suter. So in terms of like this athlete specialization, I've definitely like gotten word of this and heard some things, but is there any like kind of public health like realm or any like interventions kind of being made by the sports medic community to like get this info out to like parents and athletes? Yeah, that's a great question. I think there has been more recently, I would say in the last, I don't know, in the last like five to 10 years is when a lot of this research has started to come out. And so, all that stuff is gonna take some time to trickle down. The only things I know of are like the different associations like making these position statements. So like, I believe like the American Academy of Pediatrics has like a position statement for their pediatricians about sports specialization. The like National Athletic Trainers Association has one. And so that's a lot of what it is, is more targeted at like the organizations that are gonna be seeing these kids. And then unfortunately, other than that, the only time we really get to talk about it is if we see them in clinic with an injury. I mean, that's one of the unfortunate sides of it is you see them with little league shoulder and you're like, oh, how much are you pitching? Oh, six days a week, like nine months a year. Okay, stop. And so, unfortunately, we are kind of like behind the eight ball on some of this stuff. It's a resource thing. Like, when you've got hundreds, thousands of kids in your town that are going out for Little League and like coach doesn't know about any of this and there's no athletic trainer there and the parents don't know, it's hard to just get the information out there. So hopefully as more comes out, we figure out a way to do it. But yeah, I don't know of any, you know, public outreach programs, like hockey's getting better about some stuff with like hitting and checking and getting the coaches more on board. And so hopefully we'll kind of be able to translate that to other stuff. But yeah, it's definitely a limitation in sports right now, especially since that young age where they don't have, there's no like t-ball athletic trainer, you know, like there is at the high school level. And usually by the high school level, you know, they're generally okay to start being more specialized in their sport, but. Awesome. Well, thanks again, Tom out of Chicago College of Osteopathic Medicine. My apologies again. These abbreviations get me, man. All right. So next up we got Samuel Sicconetti, our third year med student out of the Ohio University Heritage College of Osteopathic Medicine. He'll be talking about the clinical research of comprehensive rehabilitation and treating brachial plexus injury patients. So take it away, Sam. And it's a chicken that he probably pronounce it. Am I able to see the chat? Do you know? If not, I can just read them out to you when they come out, Sam. If you scroll up, you can. All right. I'll just get it when it's time. So I have like just three questions, interactive questions for you all once I get to that. So yeah, I'm Sam Sicconetti, I'm a third year from OUHCOM, Athens campus. Thanks for coming to the sports medicine talk tonight, everyone. So just a general outline of how this is going to go. I'll give you some background and relevance to this study and how it relates to sports injuries going on today. I'll give you the pathophysiology of brachial plexus injuries, talk a little bit about the article, and then I'll also have time for some questions. So just a little bit of background, is your guys' like bar of faces on the side right here, is that, can you see that or no? You can minimize it if you click on it. There we go. Cool. So I'm sure you all have heard of like a stinger or a burner. It commonly occurs in football and it's usually related to a brachial plexus traction injury. It's one of the most common injuries of the cervical spine and peripheral nerves in football and actually Dr. Brian Sutterer has a video on it on YouTube, which I would recommend you all to go check out. He stumbled upon that when I was creating his PowerPoint. So it can result in a constellation of pain such as, you know, burning and other types of paresthesias that radiate down the arm after contact. It can be, it can last from just a few seconds to minutes or even hours. And if it's severe enough, it can turn into days or significant injury. So here's one of those questions. What percent, if you had to guess, of high school and college players experience a stinger at least once in their career? So if you can just throw up any percentage in the chat, if you feel like. John Lasko, high with the 50. So about 50% of football players will experience that at least once in their career. Just an overview of the pathophys. So this is, I mean, this is a pretty good animation of what it looks like, you know, a strain on the brachial plexus. I think most commonly occurs due to traction, which is shown here in A. It can also occur from a direct blow or, or compression. If your head turns to that side and there's enough force to generate compressive injury. So just a little bit of more pathophys continued. Like I said, if, if it is, if there is enough force, it can lead to permanent neurological commonly through either stretching a rupture, which is second, worse, or a complete evulsion off the spinal cord, which is absolutely the worst. And just, I don't know if anyone's ever heard of Inky Johnson. He was a quarterback for the university of Tennessee. He had plans on making it to the NFL until he made a tackle that made a helmet to helmet collision with a career ending tackle in 2006. So he was taken off off the field and was immediately taken to the emergency room for some emergency procedures, but had no, no motor control of his arm or anything at that time. He went on to actually be a motivable motivational speaker to talk about that and to talk about other things that he experienced in his life. And here's a photo of him doing that. And I just wanted to bring this up here because you can see on his right arm and the picture on the right, it has that kind of clinical stereotypes, stereotypical waiter's tip that we all learned about. Y'all remember that. So here's just a picture of the brachial plexus and going off the waiter's tip. Can y'all throw in the chat? If you remember what two spinal roots are affected or where the injury would occur in, in the brachial plexus in order to see the waiter's tip, the classic waiter's tip. There's two levels. I'll give you, I'll give you a hint. Like an upper trunk. Yeah. Upper trunk. So basically it's yeah, C5, C6. Oh, there we go. Yeah. C5, C6. Cool. Yeah. C5, C6. And here's another picture of a player who had the same injury in high school. And you can see all the atrophy in the pectoral area, the deltoid biceps, all that. You can actually see the, you can see the wing scapula, the picture on the right. So last, last quiz question, which nerve is damaged in order to cause a wing scapula? Long thoracic. Here we go. You guys are ready for your boards. All right. So this study, it was a randomized controlled trial, and it was based out of Hoshan Hospital, Fudan University in Shanghai, China. The objective was to observe the clinical therapeutic effect of comprehensive therapy on the patient's brain. The objective was to observe the clinical therapeutic effect of comprehensive rehab and treating dysfunction after brachial plexus injury. So this whole study involves all injuries that are beyond the burners and the stingers that I kind of introduced you to at the beginning. They're more rare than the burners and the stingers, but they do happen. So it is one of the many difficult medical problems in the world. And after many decades of efforts and innovations, they finally figured out how to surgically repair these, you know, significant injuries. In 1970, the idea of a phrenic nerve transfer procedure was created. And then in the 1980s, they actually executed that doing a contralateral C7 transfer and multi-nerve transfer. So even after doing those surgeries and having successful surgery, they still found that there was poor recovery without any, without any real rehab done on them. So this study is looking at rehabilitation in order to recover function of the joint in terms of range of motion, muscle force, prevent atrophy and promote nerve regeneration. So just the inclusion criteria, they obviously had to be diagnosed with the brachial plexus injury clinically. And they also had to have a microsurgical treatment, such as neurolysis or the like multi-nerve transfer procedures, as I talked about in the last slide. And that can involve a phrenic nerve transfer, a C7 transfer intercostal nerve transfer. And there's many more with I'll show you in just a moment, but here's a photo of what a nerve transfer taking the, you can see the accessory nerve right here going out of the trapezius. And during the surgery, they basically snip it and swing it over and sew it or glue it to the suprascapular nerve in order to give function to the supraspinatus and infraspinatus muscles. So the methods, treatment group consisted of 21 cases in the control group of 22. There was 43 patients total from the hand rehab section of the Hoshawan hospital in Fudon. And then of the treatment group, 14 had a total brachial plexus injury. So basically like a almost total avulsion and then seven had a branch injury. So obviously the treatment group went through comprehensive rehab, control group, no comprehensive rehab. And just talking about some of the rehab that the treatment group went through. There was four 30 day courses that they went through and four criteria in order to fit that rehab. So the first one was transcutaneous, transcutaneous, electro nerve stimulation and that was used primarily to promote nerve regeneration. And they had mid frequency electoral stimulation and that was to prevent muscular atrophy and then occupational therapy, which was used to retrain neurological intent. So basically the principle of that was to complete the auxiliary motions of the, where the donor nerve originally controlled, and then imagine that simultaneously by completing the expected motion with the recipient nerve and where the recipient nerve controlled. And the fourth was a tween up therapy and that involved a lot of like meeting, rolling, pressing, pinching vibration, in order to improve circulation and adhesions following, following the surgical procedures. So the control group didn't really have any comprehensive rehab. They did have at home, low frequency, electrical stimulators and then they had some independent PT and OT at home, which they completed. And they were, they were instructed on how to do all of that. It was just up to them to complete that independently. In terms of the, the electrical, electrical stimulation, you can see in table two below kind of the placement of the negative electrodes. So these are the surgery types along the left side where they would take part of the phrenic nerve and basically glue it to the anterior division of the upper trunk. They would place the, the electrode on the biceps brachii and then the expected motion after recovery of the nerve was the elbow flexion. You can see the same thing with the accessory nerve and suprascapular, which I showed in some of the pictures previously. And then as for the occupational therapy, depending on the type of surgery they got, they would attempt to, you know, do a deep inspiration. So they would do a deep inspiration. They would do a deep inspiration. They would do a deep inspiration via the phrenic nerve, but also imagine themselves and doing elbow flexion in order to kind of retrain the brain to gain that function back and, and furthermore with the rest of the procedures. So the, the evaluation of function was done before and after the surgeries. They use a upper extremity functional evaluation, which is one example is shown of it right here. I'm just checking the time real quick. So they would look at the, they would look at the angle of range of motion and also the muscle strength in order to judge its recovery. And then they would grade that based on the joint and give it a, give it a total grade both before and after. And they also did an EMG examination during the surgery and then after the full four courses. So looking at the results, the treatment group, it did have a significant difference in scores for both the total and branch injuries. You can see right here that the, the summation of their, their function levels increased pretty significantly, especially in the branch injury from like 7.7 to 11.2, basically three and a half, three and a half full points compared to the control, which didn't really go through any of that comprehensive rehab the EMG examination. So it did show regeneration potential and it, of the treatment group by dominated muscles of recipient nerve. And it was earlier, much earlier than that of the control group. And you can see that below. So it doesn't really show much data here. It just kind of says has occurred, has not occurred. So in terms of the discussion, the recomposition after injury and surgery can reflect the flexibility of the nervous system. I feel like we're used to thinking that the nervous system doesn't have quite as much adaptability as, you know, other tissues of our body, which is true, but it does still have some. So in terms of nerve injury, muscular atrophy, joint stiffness, adhesions, and pain, the study demonstrates how patients will not get the expected effect of after some years without the rehabilitative help, both at home and in the hospital or clinic, even if the surgeries are successful. I think the big take home message from this is that the comprehensive rehab done in the study, you know, by combining both the physical, physiotherapy and occupational therapy with the Tweena massage helps both patients, their shoulder, elbow, and wrists, and all recover. So the schematic of the comprehensive rehabilitation that the patients in the study went through. So conclusion, comprehensive rehab was much more effective than the non-standard rehab. And some of the limitations I saw in the study is that just the functional ratings are somewhat subjective in terms of the strength range of motion, I'd say is a little bit more subjective. And some of the limitations I saw in the study is that just the functional ratings are somewhat subjective in terms of the strength range of motion, I'd say is a little bit more objective, but the strength, that's always subjective. They did examine the extrinsic muscles, but none of the intrinsic muscles and it wasn't, you know, double blind placebo or anything like that. And we only did see 43 patients. So in terms of physiatry, as I talked about before, I think that the nervous system is a little bit more flexible than we thought. It can gain a better understanding of comprehensive rehab programs and can help build confidence in both. I think the clinicians and the patients that they, you know, see studies like this and see that going through this therapy, that it might not, it might not feel like it's working at that time. In the longterm, you might see some pretty positive benefits in terms of outcome. So, you know, brachial plexus injuries, they do commonly occur in sports, especially in football. And depending on the severity, I think just being aware of these different ways and this kind of well-rounded approach to rehab would benefit us strongly. Another reason why I felt like this study was important, at least to me, is Nathan told me to find something that, you know, I really wanted to write about is because this is me and that happened to me in high school. And I went through a very comprehensive rehabilitation for several years, occupational physical therapy, all of that, even acupuncture and all sorts of stuff that might not have actually helped, but who knows. So I've, I found that it, it does work. And this is something that, you know, I feel passionate about. So any questions? Thanks for listening. Great work. I really appreciate the blend of kind of a concept we can see in sports and stuff that's more consistent with physiatry. I'll admit when I first saw the paper, I was kind of like, that's interesting. I wonder why he chose that. And then I hear about kind of your, that correlation with, you know, the I kind of forget about some of the plexus injuries we can see in sports. And I thought it was a really nice reminder of the overlaps because at the end of the day, while this is a sports medicine journal club, we are all interested in becoming physiatrists and we'll always have that basic foundation. If we go on to be sports medicine physicians of, you know, the rehab piece of things. And I thought too, your kind of personal story with it really also is very great to hear about because I know that's a lot of why a lot of us go into this field. So thank you for sharing that. I think the thing to remember with a lot of these nerve injuries in sports or otherwise is kind of what the pathophysiology of the specific injury is. So when you think of like level of severity with nerve injuries, kind of the most mild, which by far and away the majority of stingers, if we bring it back to the sports thing are going to be just like a neuropraxia. So like a very transient like compression or stretching of the nerve where you might have some damage to like the myelin or some compression of the myelin around nerve, but no actual injury to like the epineurium. It kind of surrounds the nerve or the axon itself. And then you get onto what we call like axonotimesis, which is the next level where if you think about like your, your electrical wire with insulation around it, this is like the metal is cut, but the outer insulation is still intact. And so the pathway is still there for that axon to regenerate. But then kind of the most severe is just going to be your neurotimesis where basically it's like taking a pair of scissors and just cutting the whole thing. And so I think a lot of the patients in the study that we talked about here were probably more that neurotimesis type of injury pattern since they're talking about doing like nerve transfers and, and that sort of thing in your kind of just run of the mill stinger. You don't really do any therapy for it. Basically the whole kind of definition of a burner stinger is transient unilateral symptoms that resolve. Most of them are going to be within a couple of minutes. Some of them will last a day or two, but if you have somebody who has a stinger and it's progressed, it's persisting for like multiple days. That's when you think about these more severe plexus injuries where there could be like a root avulsion from the neck and you're going to have to do more investigation and potentially more intensive therapy. So it's really important to remember these because yeah, I mean, that, that story of Inky Johnson, I should talk about that at some point on a video because it's, it brings in a lot of kind of fundamental concepts to sports and you think, gosh, this stuff would never happen. And it like ended this guy's career. If you get into residency and stuff, you'll see, I mean, between the tendon transfers, nerve transfers, especially if you're at a big academic medical center, like the stuff that our neurosurgeons and hand surgeons are doing here at Mayo just like blows my mind, like with where they'll reroute nerves and reroute tendons and just like take a essentially non-functioning arm and suddenly like give it some basic, you know, elbow flexion or things to do like basic daily activities. So it's exciting for the field that all this stuff is out there and it's nice that this paper highlights just, yeah, like our comprehensive rehab works because it's hard to get good evidence sometimes in PM and R and it's always nice to see like, yes, there is clear value in sort of our multidisciplinary comprehensive approach to help patients. So nice study to give a good reminder of that. Questions for Sam. Chicken. There you go. I guess just to speak to your study and how it just sort of like successful rehab outcomes. I guess how are you doing like personally with your, your own injury now. Good. So I actually had two separate double nerve transfer procedures. The one that I talked about with like the, the accessory nerve to the, basically to like supraspinatus infraspinatus. I had that surgery done and a few others to basically give me like elbow flexion. So, I mean, I'm in med school and I'm in my third year, so I'm doing pretty well. I just had to be adaptive. And I mean, if it weren't for, you know, the treatment and the management that I had gone through, I don't know if I'd be able to say the same thing sitting here in medical school. So yeah, like what Dr. Sutter was talking about, just the incredible work that they're doing with like nerve surgeries is it's pretty crazy. I know it's only getting better. So, but yeah, I'm doing fine. Thanks for asking. All right, y'all. There's no more questions. So I'll let y'all get out of here because we're getting late on the East coast. So I thank everyone for coming out. Thanks again to Dr. Sutter, Kristen, Tom, and Sam for being our speakers tonight. Our next journal club is October 19th. That'll focus on pain management. So feel free to tune in for that. Excited for that one. And thanks everyone for your time and hope you all have a good night. I left my email there in the chat. Feel free to reach out, message anybody, questions about residency applications, sports, like whatever the case. Send me an email. If I don't respond right away, send me another email. I don't mind it at all. I know sometimes as students, you're like, I don't want to bug people. So, but for real, if you have questions about stuff, whatever the case may be, let me know. And I'm happy to try to help if I can. Thank you very much for the invitation. I love being able to do stuff like this. It's a pleasure of the YouTube side to be able to get more involved with these things. So I applaud you guys for putting this work in and doing this. It shows a lot of great initiative and interest in the field. So keep it up. It's all very impressive. And I'm sure you all have excellent futures ahead of you as physiatrists or else other things. Thank you so much. Thank you. All right. Thank you. Bye, everybody.

progressive tendon loading exercise therapy

patellar tendinopathy

eccentric exercise therapy

pain

functionality

overuse injuries

high school athletes

comprehensive rehabilitation

brachial plexus injuries

nerve regeneration