All right. Hello, everyone. Welcome to AAP virtual didactics today. My name is Amos Song, and I am a third-year resident from Vanderbilt, and I will be your host today. Your usual host, Sterling Herring, is off taking board exams, so I will be filling in in the meantime. And before we get started, I would like to take a moment to recognize those that have been both professionally and personally affected by this current pandemic, and we realize that not all of us have been affected equally in this matter. The goals for these talks are to augment didactic curricula, to offload outstretched faculty, especially those that have been reassigned or have increased clinical demands. It's also to provide learning opportunities for off-schedule residents, as social distancing has made scheduling didactics difficult. It's also to develop more digital learning resources here at the AAP, and to support physiatrists during COVID-19. A couple of house rules. We're going to keep everyone's video and audio muted. This is just to preserve bandwidth, as well as to be able to give our full undivided attention to our speaker today. If you have any questions at all during this lecture, please go ahead and send me a private message on the group chat. You can just click participants and look for my name. Again, my name is Amos Song. She'd be near the top, and I'll ask that question at an appropriate time. If you have any questions, suggestions, or concerns regarding these lecture series, please email Candace Street at that email below. You can always find us on Twitter at AAPhysiatrists. I'd like to introduce today's presenter, Dr. Gerardo Miranda Comas. He is the Sports Medicine Fellowship Director at Mount Sinai in New York City. I really appreciate him taking his time to come speak with us, especially at a place such as New York City, where it's really been an epicenter of this pandemic. Dr. Miranda Comas, welcome. We're happy to have you here today. Thank you. I wish I was more useful in terms of being in New York, but I'm actually not in New York right now. How do I, do I need to share my screen by any chance? Yep. Well, we still appreciate you and just up the screen. There you go. You got it. Yeah. I am the former Sports Medicine Fellowship Director. I was not fired. I just moved because of family situation, but I am actually still part-time at Mount Sinai, so I'm still involved with our residents and fellows, especially our fellows. I'm currently in the works to start here at the University of Puerto Rico as well, to get involved with residents and fellows as well. That's where I'm at. I'm actually collaborating a little bit because at Mount Sinai, one of the big initiatives that is actually led by the rehab department is something, it's an initiative called Precision Recovery. Precision Recovery initially was an outpatient monitoring system that was developed by neurosurgery and rehab to follow up on stroke patients that were treated at Mount Sinai Hospital. Since that volume obviously went down a little bit, the priorities shifted a little bit. The initiative led by Dr. Dave Petrino, who's our Innovation Director at the Rehabilitation and Performance Department, he switched the Precision Recovery initiative towards COVID patients. Now COVID patients that recover from the hospital that are actually discharged, they have this access and they're monitored by nursing staff and by physicians to follow up on their symptoms, et cetera. These turn into a monitoring system into actually a hotline type of thing. Patients, citizens, individuals that have questions about symptoms at home and they don't want to necessarily go to an urgent care emergency room, they actually call and they can be evaluated by a nurse. Then if that has to escalate to a physician before they actually leave their house. That's actually a good initiative and that's something that I've been able to work with remotely. Anyways, we're here to talk about overuse injuries in sports, identifying and addressing risk factors. I think this is a talk that I've given in some way or another to many of the trainees that I've worked with over the years because it's something that was part of my education. The identification of these risk factors that can lead to not just treating the patient, but identifying, preventing re-injury and in the future preventing injury period. Sadly, most patients that we see come already injured. One of the reasons I like to give this talk is to try to promote, and I've given similar talks to people that are not necessarily physicians, try to promote the injury prevention concept. All right, so no financial disclosures about this topic in particular. We're going to overview the injury classification. We're going to talk about overuse injury definition, discuss the musculoskeletal injury complex and where identifying risk factors fit in. We're going to review some of the risk factors for an overuse injury. I'm going to briefly talk about a clinical evaluation and then discuss our treatment approach to this type of patient. When we talk about MSK injuries, we talk about different types. We usually divide them, two big groups, excuse me, acute versus overuse. Sometimes overuse is interchangeably used with chronic. That's up to debate, but for discussion sake, we're going to go acute and overuse. They can be divided by anatomic structure, tendon, muscle, ligament, bone, nerves, or by body area. What's an overuse injury? The definition of overuse is the imbalance between external load and tissue capacity. This can be a repetitive submaximal, single, multiple, physiological, psychological, or mechanical stressors on the musculoskeletal system without any time to recover. It can vary by time periods, seconds, minutes, hours, weeks, months, year, or by magnitude. This graph, how I did this, it's a good visualization of how our body adapts to stressors in terms of training, for example. Once you apply a load, there's reduced capacity of the tissue to withhold stressors. If there is not this period of recovery, then we're going to end up in something like this, that we never recover. So when you apply that stress, instead of having a good adaptation, you have maladaptations. And this is when you are at more risk of injury. This actually applies not just to overuse injuries. This concept applies to acute injuries. And we know that muscle fatigue can lead to biomechanical deficits that can eventually lead to acute injuries as well, not just overuse injuries. So common overuse injuries, just to have an idea of what we're talking about. When we talk about bones, they can be overuse injuries, like stress fractures. We talk about frontal pain syndrome, TCL injuries in the youth athlete, apothecial osteochondrosis in the youth athlete. When we talk about tendons, we have tendinopathies. We have, for example, common extension tendinopathy or tennis elbow lateral epigondrialgia. Different tendons, patellar achilles tendinopathy, are usually more of an overuse type injury. When we talk about ligaments, we can have, for example, UCL insufficiency in throwing athletes. I know that phantom fracture is not technically a ligament. It's a little bit more complex than that. I put it as classification as a ligament because it behaves more like a ligament than a tendon. And nerves, for example, carpal tunnel, median nerve entrapment at the wrist, unless there's specific trauma, is mostly an overuse injury. So when we talk about overuse injuries, we're not just talking about athletes. We're talking about pretty much every, most MSK patients that we see in a rehab type clinic. So why is it important? It's important to identify risk factors because it can lead to injury prevention. Again, injury prevention is not necessarily, you know, a money-making endeavor. It's something that actually can prevent people from coming to see you and you billing there. And the way our health system is set up, physicians get reimbursed for doing a lot of things that are not necessarily prevention. Hopefully that will change in the future, but as it is right now, it's, you know, that sums it up. Universal injury prevention considers injury risk factors common to all sports, such as nutrition, physical activity, mental health, sleep, protective equipment. And we're going to go a little bit deeper into that. And selected prevention considers specific individuals that are asymptomatic, that display some characteristics that may be associated with risk factors. For example, age, sex, sport, training age, and then selected prevention programs that they're doing or not doing neuromuscular training. So those are selected prevention methods. So this slide here, I use it in, I think like, it's got to be like at least half of my talks that have to do with anything that has to do with musculoskeletal injuries, because it applies to overuse injuries, but it also applies to activity injuries. But nevertheless, you should, the way I was taught and the way I believe that we should look at it, we should look at intrinsic risk factors, which are, can be modifiable or non-modifiable. And that's key. The non-modifiable ones, it's more important to identify them just to know who's at risk of injury and to actually have a better differential diagnosis when we do evaluate patients, because we'll understand which injuries are more prevalent in females than males, right? I put an asterisk in the non-modifiable intrinsic risk factors. Menstrual characteristics has a double asterisk because technically, it could be modified by external sources and it could be modified by, for example, increased activity, overtraining, et cetera, and you can have menstrual dysfunction. But, so that's why it's questionable, can you modify or non-modify it? But body composition, weight can be modified, but height cannot be modified. Bone density is also something that has a big genetic component to it, but technically we know that with certain types of exercise, we can actually strengthen bone density. Or with certain, you know, physiologic adaptations, we can actually decrease bone density. Aerobic capacity, anatomic misalignment, when I talk about misalignment, anatomic misalignment, we're talking about more bony structure, right? Then when we talk about muscle fatigue and imbalance, that's more of a dynamic, so when we talk about anatomic misalignment, we might be talking more about static misalignment, that it's not modifiable, versus the dynamic misalignment, which can be modifiable because it's very dependent on muscle fatigue and muscle imbalance. Inadequate flexibility, so people can be too flexible or people can be very tight, and that can lead to certain types of injuries. Skill level, mental health, and characteristics of mental status, that is something that has not been talked about too much, and for those of you that have been, you know, roaming around the different types of the different virtual lectures that we've had, there's been a couple on mental health and athletes, especially recently there was a prevent injury prevention symposium sponsored by the USOPC, which actually one of the best lectures in that symposium was about mental health. Extrinsic risk factors include nutritional state, training load, which is something that I've been discussing very recently with a lot of trainees and colleagues, training equipment and environment, biomechanical or specific physical demands, so meaning technique for example, rest. So rest goes hand in hand with injury, and I don't, I believe we don't talk about it enough, and external stressors like family, coaches, owners. So this is a graphic that I ran into a couple years ago. This is from the works of Tim Gabbitt, which is at the bottom here. Tim Gabbitt is, I believe, Australian, who has been studying the role of workload or load management in injury prevention, and they came up with this framework of a musculoskeletal risk factor. So we have the intrinsic risk factors of the predisposed athlete, right, we talk about age, sex, body composition, health, overall health, physical fitness, anatomy, skill level, psychological factors. Then we put the exposure to external risk factors, so such as the specific sport, coaching rules or freeze, protecting equipment, the environment, and you have a susceptible athlete to injury, right. So this is very important because we need to understand this, again, this is more, this workload injury ideology type of framework that applies to acute and overuse injuries, right, but it's something to look at and understand, and that helps a lot. And then you have the injured athlete, and here this can become very, very much complex because then you have treatment, and then you can do treatment if it's not treated accordingly, then you have re-injury. So now I'm going to go a little bit more into each of the risk factors and talk a little bit more about them, and so when we talk about age, we talk about skeletometry, that's very important as we know that the youth, the youth athlete is susceptible to overuse injury during their growth first, specifically when we talk about apoptositis, when we talk about spinal issues, so that's when they are more susceptible. They are growing and they lack of lean tissue mass, they have joint hypermobility, and sometimes there's imbalances in the growth and strength. They're most susceptible ages 12 to 18, that's when there's the highest overall injury rate, and it's highest in terms of severe injuries, and this applies to acute injuries as well. The master athlete is another population that thankfully we're talking more and more about, and they have a higher incidence of concomitant issues that may predispose them to overuse, to overload of the tissues and overuse injury. We talk about sex, we know that there's been a lot of studies that compare male and females in specific sports, and they might be a higher incidence of abdominal pain, for example, stress fractures, we talk about the female athlete triad, that term that involves metrodysfunction, low bone density, disorder eating, has been interchanged, it has been changed to relatively energy deficiency state in sports, because now we know that it can apply to males as well, but nevertheless, stress fractures are more common in females, and overall injuries are more common when we talk about the same sport and time exposure in basketball, soccer, and volleyball. Again, this accounts for acute and overuse injuries for both. When we talk about body size, so lower BMI has been strongly associated with increase of overuse injury. When we talk specifically about stress fractures, females that do have certain characteristics of the female athlete's triad, like distorted eating, or their relative energy deficiency state, they are more susceptible to stress fractures, and when they have a lower BMI, specifically a number that we should look at is when you see a BMI lower than 17, that actually has been linked to increased risk of risk factors, and higher BMI has been associated with lower limb injury in football and volleyball, and volleyball specifically in females as well. And I like this diagram for those of you that have been familiar with the female athlete's triad, and now when you look for the female athlete's triad information, you look for relatively energy deficiency state in sports, and this diagram pretty much covers why it's not just a triad, it's more of, it affects more systems than just the three that has been linked to the female specifically. Anatomic factors, like I said, extremity by alignment, it could be static or dynamic. Most of the time that we talk about extremity by alignment, we're talking about a static concept of it, and we talk about pes planus, pes cavus, femoral absorbation, knee valgus, fetal torsion, excessive number of doses, increased Q angle. When we talk about flexibility, that flexibility, we know it can be modified somewhat. We know that some people are naturally more flexible than others. You can see joint hypermobility. In the young athlete, you can see tightness in the muscle tendon unit during the growth spurt that can predispose them to capofasciitis, for example. And then you can see, for example, in runners, some of these slides I've taken from a talk that I did about running-related injuries, and tightness in the first metacarpal phalangeal joint has been linked to injury as well. Muscle weakness and imbalance. So we know that when there's weakness in the rotator cuff, muscle scapula stabilizes that predisposes to injury, to shoulder injury in overhead athletes. ACL injury has been linked to weakness in the pelvic stabilize, especially when you see it in a drop vertical jump, and pelvic disability in which pelvic drop in runners has also been associated with injury. And this picture here is another picture that, another diagram that I use very frequently in my talks. I think I used it when I was a medical student that I, during my PNR rotation, I did a talk in patellofemoral pain. This pretty much summarizes what the risk factors for patellofemoral pain syndrome, which is pelvic drop, femoral anteversion, knee vagus, tibial torsion, pes planus, or foot hyperpronation. And then when we talk about shoulder injuries, we'll talk about this diagram that I use very frequently. This is from Ben Kibler, that pretty much is talking about that the overhead athlete, the forces are started from bottoms up, and anything that disrupts this chain can lead to pain here, to symptoms here. And then when we talk about the pelvic weakness in a runner, we talk about Trendelenburg, that we learned this, you know, early on in medical school. But dynamically, we see it very frequently in our active population. And the single most, the single most important risk factor for injury is actually previous injury, especially within 12 months. That is actually, if we're going to go very scientific and go into statistics that, and I don't know if I've read meta-analysis about this, but when you go review articles, and you look to systemic reviews, this is a single, the single injury risk factor that's very consistent throughout, independent on study, design, and findings. When we talk about experiencing factors, we talk about biomechanical demands. We know that not every sport or every physical activity has the same demands on the person. So technique plays a big role. This is a diagram that I got from Google. It can be, we can talk about a lot, and we're going to talk about it a little bit, a little bit more thorough. But, you know, people that have bad running technique may be more predisposed to injuries. People that have pelvic drops have less pelvic stabilization. Maybe you're predisposed to injury. In the tennis serve, this has been very much well studied, and certain aspects of it, people that are not bending their knees properly, that are relying on hyperextension of the knee, the elbow is not, it's not lower up. There's not a straight line between the toss hand and the elbow. Hitting the ball behind versus hitting the ball in front of you, all these factors can be, can play a role in injury. This is a pelvic, a vertical drop test, and we can see when the athlete jumps and when they land, they land in knee bulges, pes plantas, a little bit of rotation of the femur. So this is a very much not healthy landing technique, and this here looks way, this here looks way more healthy, healthier than this. This one looks healthier than this one right here. And these are tests that we can do in our, in our office. You don't need very sophisticated equipment. You're going to do research on it, then you need very sophisticated equipment. But if you need to make clinical decisions and educate patients, then you don't need very much. Let's go too, too technically, too technical about it. When we talk about overhead athlete, right, this is taken from Dr. Cerenci's paper on overhead athletes. The baseball throw, a little different from cricket throw. Throw the overhead movement of a volleyball spike is a little different than, than a football throw and javelin throwers. But they all have specific demands on the shoulder and the body that, that we need to understand. You don't have to be a volleyball athlete to ask a volleyball player where the pain is, how their approach is. Now everybody has an iPhone, everybody has slow motion video. So that's something that we can actually evaluate in our office. When we talk about a gymnast, we need to understand, again, you don't need to necessarily understand the point, the point system to, to win a gold medal. If you do, good for you because you understand a lot. But understanding the mechanics of what their body goes through, right? So we know that this requires a lot of hyperextension on that back. So they're probably putting a lot of stress in that parts of interarticular area. So we know that that may predispose them to spondylolisis. And those are, those are injuries that we need to understand. By understanding the demands of the sport, you might be able to have a better idea of what mechanism can be linked to it. The type of sport. So again, this is from a running talk that I gave. So there's, within running, there's injuries that are associated with it, with different modalities of running. So sprinters are more, are more susceptible to muscle strain, low distance, and you know we're using the above long distance to foot and ankle stress injuries. And then you can divide sports to contact, linear contact, and non-contact. And you can, you can see that the overall injury frequency is higher in non-contact sports. So that means that it's, that's probably more related to overuse injuries, right? So active strains, sprains, and overuse, are common in non-contact sports versus contact sports that contusions are more common. And team versus individual sports, that understanding which type of sport in that sense can help to have an idea of what's going on. So another extrinsic factor when we talk specifically about the youth athletes, sports specialization, right? So there's a big talks about early sports specialization. Again, during this COVID, one of the, you know, if you're going to, you're going to take some of the good things that have come out of this pandemic that we're living, is how we have been interconnected way more. And we've been able to maybe exchange ideas a little bit easier through all these platforms and through all these initiatives of virtual education. So sports specialization recently, there was a Emory, some of the folks from Emory talked about it. And the concept is very simple, is that early sports specialization in a youth athlete has been linked to increased risk of injury. There are caveats because there's some sports that technically in order to a person, an athlete to be successful, they might have to to specialize early on, like the next is swimming, diving, figure skating. Nevertheless, they're at higher risk of overuse injuries. And when we talk about not necessarily sports specialization, we're talking about young and older athlete, maybe the training load plays a big, big, big role. We know that frequency of training has been linked to overuse injuries. When you talk about training, sport training sessions or organized sessions and all the training sessions, like push resistance and cardiovascular. In runners, more than 32 kilometers per week or 20 miles per week has been linked to increased risk of injury. In young athletes, more than 16 hours per week has been linked to increased risk of injury. This number 16 hours actually varies. So the recommendation is no more than 16 hours in the high school athlete, for example, that's already 16 years old. People that are 16 years or younger, actually, the recommendation is that they don't they don't train or compete more hours than their age per week. So if you're an eight year old, they should practice no more than eight hours per week, nine, etc. And, and about overhead athletes, like like pitchers, no, not throwing more than 100 inch per year has been sort of like a guideline the same way that not throwing for more than nine months. So in other words, taking three months off every year from throwing can maybe lead to less overuse injuries of a shoulder over scheduling. So year round training. So you have, and we talk about this more in kids rather than professional athletes, because professional athletes actually they have their season, they have their off season and they have they have a schedule that you know, a lot of a lot of there's a lot of investment in them. So so they're better monitor than our kids and parents want them to go to college with a scholarship and they have them playing soccer during the soccer season. And then when they are actually maybe doing cross country, they're also doing club soccer at the same time, and they're being over scheduled. So when we talk about over scheduling over training, we need to talk about the concept of maybe load monitoring that that has become very popular lately. For those of you that maybe follow the NBA couple years ago, it's been more than five, six years, it was more quiet then some of the coaches decided to sit their star players in back to back games to decrease their their load to decrease the risk of injury. Now you see it more often in in more of a high level athlete, more of the superstars actually asking themselves asking for time off themselves because they need want to decrease that that risk. So load monitoring has been a big has been a big topic in the in the last couple years. So we know that low monitoring can be can be measured in different ways. There's different ways to to to measure training low, for example, if you have a runner, they probably know how many miles per week they're running. However, now we know that that not every mile that they run somebody who's who's a serious runner is not the same intensity, right? So so there's got to be a component of of an internal load measurement and an external load measurement. So you can run miles and you can say, okay, so so there's the most of the studies that have been published, they use something called the arbitrary unit, which they take into consideration an external load, for example, mileage, or time, right? So in a soccer player, how many, how many hours they train, and RP, which is a rate of perceived exertion, you use this a lot in cardiac rehab, and you guys that going to rehab will learn about it then. So so you take that concept, and then you take the concept of the acute on chronic workload ratio, which is how much work they accumulate acutely, which is seven days versus chronic, which is 28 days, and you take a ratio of that. And those are above 1.5 are an increased risk of injury. So so that's it. This concept of load monitoring, I gave a talk at AP that was a 30 minute talk just about this. So it's a little bit more complex than that. But in a nutshell, that's a that's a way to to avoid over scheduling over training and necessarily maybe decrease the risk of injury. So a simple way to ask your patients is where are they in their training in their season, etc, how how how hard their workouts were in the last week versus the last month, and monitor that and maybe that that can give you an idea on how to to avoid injury. Another concept within this whole thing about acute on chronic workload ratio is that in order to decrease injury, you actually need to to to stress your body to similar stuff that that you're gonna that you're gonna do the similar stress that your activity is gonna take on your take take on your body, right? So so it's important to actually do have a chronic load, right? That is that that is there that you're always doing something that you don't go from zero to 1000 just to to compete, for example. So that's another concept that's do not need to take into consideration. And that goes into this whole thing about a 10% guideline, right? So So if you ask somebody, if somebody asks you, and this is jumping a little bit between topics, but it has to do with with the over training, over scheduling and training intensity and workload in general, that it is an external risk factor. So when somebody is increasing their load, they need to increase it gradually. And we don't know what gradually means. So we use this 10% guideline to keep it safe, right? But this, this graph here, what it what it shows us is that a 10% increase, right? But starting too low, it's going to be hard to go to this to this floor of safety that that you need to stress your body to have a floor of chronic load that will prevent actually that will help you perform and will help you to prevent injury, right? So if you think about it, if you have somebody who's going to run a half marathon, and they start three months out to start training three months out, and they're running 400 meters, the first the first week, the second week, they run 600 meters, they're never gonna stress their body enough to withstand 13 miles of running. So so they're never going to get to this floor of safety. So they might actually put themselves at risk if they do run 13 miles. The other the other concept goes into people that that do 10%. But they start very high, and they and they maybe that they might put too much stress in their body, and they might increase the risk of injury. So so in other words, it's it's tricky, but but if there's there's a lot a lot to it, it's very complex, and you're going to see more papers about it in the near future. We talk about equipment and environment, environmental factors, we talk about running shoes, we talk about running shoes, we talk about, you know, this is, again, a diagram that I took from Google is by no means very scientific. So so we can go again with shoes, you can talk about it a lot as well. But nevertheless, there's there's shoe recommendations for different different foot types, it's a little bit more complex than that, it has to do a lot with dynamic evaluation, it has to do a lot with comfort, which is the number one reason to buy a tennis shoe, and running technique. So what is important to ask about about, for example, a runner specifically, if they use whatever shoe they wear, usually a runner will know what type of shoe they like, actually, they don't know the brand and don't know the type. And they know if they bought it more, like several years in a row, etc. And the mileage that they had. And when you talk about a cyclist, for example, we know that proper fitting in the bike can lead to decrease injury rate in cyclists. So those are just examples of what equipment means. When we talk about a clinical evaluation, so this is going to be sort of like brief, we're mostly done, but this is in your clinical evaluation is when you're going to address those risk factors that we just discussed, some of them are going to be addressed in history, some of them are going to be addressed in physical extent. So clinical history, we talk about onset, is it acute, insidious, you can have an acute onset of symptoms and have an overuse injury, right. So that's why it's sort of like using the term chronic injury can be misleading, because chronic usually it implies time, right. And you can have a new onset of symptoms of something that is chronic, you can have a new onset of knee pain that is secondary to pathopharmal pain syndrome, which is an overuse injury, injury mechanism, location of the injury, intensity. So the intensity, we can use the pain scale, right, if you if you are actually doing clinic and for those of you that bill, the pain scale saying that's one of the elements that the billing people are looking for. But an overuse injury might not be too useful. Why? Because overuse injuries, sometimes the patient will come to you, and they'll tell you, my pain is when I start training. And when I start training, when I run five miles at the five mile mark, and that's when it hurts. If I'm training three miles, if I'm doing speed work, if I'm doing flat work, it doesn't hurt at all. So that's why the pain scale, they can come to you often, they can be zero out of 10. So, so we use this overuse injury grading system that that goes from one to five, which grade one symptoms occur at the end of activity or only initiation, then diminish, so somebody can can complete their workout versus grade five, which symptoms prevent training. And that's a good way to ask a patient when the pain is because when they come back, if they were not able to train, but they come back and they're able to do some of the activity at low intensity, you know that they're better, even if they're not 100%. And that's what that's what you want. You want, obviously, your patient to get better. Irrelevant factors, mechanical symptoms, that's important, because mechanical symptoms are more associated with maybe not just conservative, non-surgical treatment. Neuromuscular changes and red flags, like, like we always do red flags, for example, you have a young gymnast with back pain, you need to make sure you understand the red flags as well. History of previous injury, like I said before, this is the single most important risk factor. And this is important that if somebody comes to you with an ankle injury, you need to ask them if they had any musculoskeletal injury, because they might tell you I had an injury a while back on that same area, I had back pain that that affected that side. And that might be an association with the injury. Associated medical issues. Now we're talking about master athlete, I'm not talking youth athlete only. So actually specifically asking about osteoporosis or sophenia is important. Eating disorders. There's a big taboo on asking issues that have to do with mental health. I think we need to learn how to approach that topic specifically and not necessarily fall on hunches that I feel like this person might be having some issues. It's important to address it. This is not my talk, but the relatively energy deficiencies state in sport. They developed a evaluation tool that actually is online if you Google it. You'll find it that is similar to the SCAT in concussions for those of you that are familiar with the SCAT. So there's an assessment tool that actually stratifies the risk of the athlete depending on the different risk factors that they may have so that you can make a decision whether they should play, not play, or rest and what they need in terms of treatment. So it's out there, something like that. That if you're not comfortable asking certain questions, especially in this type of athlete, then having that tool and having, handing that tool or just going through it might be an easier way to dig in into those topics. Current medications, NSAIDs, steroid use. We know that steroids may be associated with tendon issues. Family history, menstrual history in the females. That's also something that we need to be comfortable asking. So we need to ask about menarche, date of last period, regular periods, whether they're pregnant or not, whether they take OCPs, things like that. Social history. And in social history, I include sleep hygiene. I'm not sure if that goes in there, but it has to do with ADLs. It has to do with something similar. And I'm asking more and more and more. And it's not just in the athlete. The patient that goes, now we know that chronic pain is strongly associated. Actually, that has been known for a while. But for example, fibromyalgia patients that I know as residents, trainees, it's always interesting to go in and actually evaluate fibromyalgia patients because once you see the first one, you actually never forget. And if you talk about sleep, you have your battle half won. Because if you get a fibromyalgia patient to sleep better, they will be better. That will be followed by exercise and overall improvement. Anyways, went off topic a little bit. Nutritional state is another thing to ask. So this is, again, I took it from a running talk that I did, but it applies to any sport. So I talk about running experience, so years running, pace and mileage per week, shoe type, miles on the shoe, whether they use orthotics or not, level of competition, distance of events, last race, upcoming races. So most people, high level athletes will have a plan and they'll know where they're at in their training. Most of us that do it for fun and to be in competition and just stay in shape and stay healthy, we need to learn how to actually select the distances that they're racing so that our training is tailored towards that specific area. Recent changes in training, which is a risk factor. You might be increasing intensity or volume and might be leading to injury. Running surface, any cross training that they do, right? And when I say cross training, it applies to any sport. So if they do multiple sports, they do multiple physical activity. And I did not include here, but occupational goes into physical activity, right? So a lot of us don't do a very strenuous occupation, but some people do. Physical examination, right? So this is a very typical physical examination. And this is why I tell students, residents, if you go in this order, you'll never miss anything, your physical exam, at least in your presentation, if you organize it like that. But in athletes, specifically, when you're looking for a specific risk factor, you have to observe. You have to observe in three different planes, front to posterior lateral, standing, how they look in double leg support, how they look in single leg support. I do a navicular height over activity, navicular drop test, miserable mild alignment syndrome. So gait analysis, lungs dry, exaggerated crouch. So something like this. And I do the bottoms up approach when they're standing to see their range of motion. It goes from actually testing their first MTP, testing their eversion on the foot, doing double leg squat to see how flexible dynamically their lower extremity are. Is double leg cross for hip flexibility, lower spine, single leg standing, right? And for strength and balance, right? For strength and balance, the minor muscle testing that we typically use. And again, for billing purposes, you're gonna write five out of five lower extremities. And I think we all do because we are taught that in order to get paid, you need to do those things that might not be as useful. But you always have to, so I usually write minor muscle testing and then I write dynamic strength, right? So, and then dynamic strength, the number one that might go to is the single leg squat. And now I'm using more and more this power pose, right? This gives you a lot of information. If you look at it from the bottom up, it will look at, you look at navicular drop, you look at hyperactivity of the foot. You might look at knee bulges, femoral anteversion, pelvic drop, right? Which is very useful to evaluate lower extremity. And then you have to examine people seated and supine, right? And you do a series of tests that help you evaluate flexibility, strength, and rule out any of the red flags, like the straight leg raise, et cetera. Knowing what to palpate is important, right? Knowing your anatomy, knowing where somebody tells you that they have posterior heel pain, where to palpate for the Achilles tendon, for the Achilles tendon insertion, where to palpate for the calcaneus, for calcaneus stress injury, for retrocalcaneal bursa. It's a little different than the Achilles tendon. It's important to know what to palpate. Now we, most of us have ultrasound and we are learning before ultrasound has helped me to make sure that I know my anatomy. And actually the ultrasound has improved the anatomy knowledge. So knowing both things and knowing where to touch within your differential diagnosis is important. And when we do dynamic testing, we should never forget about the core. The core is a little hard to test because it's very subjective. There's different objective parameters that have to do with time that they're able to hold, but there's not a real consistency in terms of how to do this test. But we can do pelvic bridge and see how much they can hold it. You can write down how much they're holding it today. And then when you get an evaluation, we can re-evaluate, set up tests to see the strength of the abdominal muscles and leg lowering tests. So you can see when their lumbar spine lifts from the exam table and measure that degree and have that written down. So you have an objective measure about it. And then you can do an extension of your physical exam. And that's why I call it an extension of my physical exam. You can do dynamic evaluation with, for example, video analysis. So I do running video analysis. Now you have a lot of technology that allows you to evaluate, slow down, and have a high quality picture of a patient. You can do this with throwers. You can do this with runners. You can do it with jumpers. Pretty much any sport, you can actually analyze their technique. And if you have enough space in your clinic, you can do that. And you evaluate cadence, foot strike pattern. So you evaluate knee flexion during stance. You evaluate hip position during stance. The hip extension, evaluate trunk lean. You evaluate whether they're over striding or not. So where their center of mass is located. You evaluate whether their center of mass is moving vertically versus moving horizontally, horizontal. How much time they're spending. It's called bounding. So moving up and down rather than moving in a horizontal plane. When you look at it from the posterior, you look at heel inversion. You look at foot progression angle. You look at the heel whips, right? Everything associated with different conditions. You look at pelvic drop. And all those things give you an information, give you a good framework. If you have somebody who you're doing a static evaluation in your office and they seem very strong, then you need to do something further, especially when they're coming to you with an injury that you may think this is more fatigue, muscle-related injury, then you need to put them to stress. You need to make them run in a treadmill and then evaluate them with muscle fatigue. I'll take a video of it. And that leads to the basic concept of treatment. So basic concept of treatment include rehabilitation, which is what we all do, right? But if we are going to talk about something that has to do with identifying injury risk factors, it's a prehab. And prehab plays a role in every patient that we see. Plays a role in the cancer patient that's going to undergo cancer treatment. It plays a role in the athlete that you do a pre-particular evaluation. You evaluate those risk factors and you need to address them in order to prevent injury. So that's the prehabitation concept. And then you need a multidisciplinary team approach. You need a physician, sports medicine. In our case, we have, you can have an orthopedic surgeon, you can have a family medicine doctor, internal medicine, emergency medicine, or PEDS, physical therapy, occupational therapy, sports psychology, nutritionist, athletic trainer. This will help you cover all the bases in terms of the risk factors that you evaluated. And then the goals of the rehabilitation program, right? And the goals are to go back to sport-specific activities. So it's important to understand everything that has led to injury in order to be very individualized and make sure that this athlete goes back, performs and is able to prevent the injuries. So when I talk about our approach, so this talk, I'm only focusing on those risk factors. And that's why I'm not going in depth in other treatment, but identifying risk factors is not the only treatment that you provide, right? So you identify those risk factors, then you get a multidisciplinary team involved. And usually we don't see this because you refer to physical therapy and that's it, but it's good to have a cohesive team. And that's how I actually grew professionally when I was exposed to this team cohesiveness and that everybody has a role, everybody has an expertise. You rehabilitate to address those modifiable risk factors and the injured tissue. And if you're not able to rehabilitate, that's when you have to learn how to use the different fancier interventions that we in sports medicines do. And then they gradually reach into sport activity and monitoring the process to get back to performance. So these are some references in addition to the ones that are in the different slides that I've used over the years. And if you have any questions, concerns, comments, thank you, I appreciate the opportunity. Thank you so much for this really thorough talk. We have a couple of questions from the audience here. Here we have one from Sam. See, is there a way that athletes can quantitatively measure recovery? Heart rate variability is a hot topic in sports wearables. Is there any rule or evidence to support the relationship between heart rate variability and recovery? All right, so Sam, right? So there's always some evidence about heart rate variability. Can we do it consistently and be able to apply that into the day-to-day so that the evidence doesn't link that so easily? So there is, right? So in terms of recovery, so there's different ways. It seems actually a subjective questionnaire seems to be very reliable. So I had the opportunity to work with the New Jersey Nets and one of the things that our department was working with them was actually in performance. And one of the aspects of performance was actually recovery, right? So it turns out that this fancier, very high elite professional organizations have access to too many tools, right? And they measure a lot of things. Among those things was heart rate variability. So, but it turns out that simple questionnaires seem to be more reliable in terms of assessing recovery, but you have multiple tools. And that's one thing right now in terms of just using that. I wouldn't recommend just using that because you have to use, for example, sleep, right? Studying sleep is part of it. And some of the wearables, what they do, if they measure your sleep through heart rate variability, and we know that that's not necessarily 100% accurate. So that's one parameter that I will look at, but it won't be the only one in isolation. I don't think that answers your question. Sure. All right, we have another question here from Toka. At what point in recovery would you recommend return to sport? All right, so that is a very complex answer because a lot of factors go into it. If you, am I able to just show him a slide of something else? Of course. All right, so give me one second. Okay, give me one second. So the answer to that is very complex, right? Because there's multiple factors that come into play, not just one. And that is because the decision is not made, the decision is not made just on tissue healing. So one thing that you think in consideration are the factors that have to do with the injury itself. So that's your medical knowledge and your medical assessment and your clinical assessment as to where the patient is in terms of tissue healing. So that's one thing, right? But then you take into consideration during the rehab process, how well they're tolerating their activity, right? And now how can I do? It's just gonna be like, yep, we can hear you just that share screen button again, and then the green arrow at the bottom. Give me a second. All right, so here, I like this framework because it explains very well when to make that return to sport, return to play decision. And this is a talk that I give, like it's a whole 30 minute talk on just that. So it's way more complex than this, but this summarizes very well. So step one, you see medical factors, right? And then you have to address specific participation risk, right? The type of sport, position, play, link dominance, competition level, ability to play, and then you have the decision modifier. So where are you in the time of the season? You might be able, you might more lenient in letting somebody return to sport before, if they're going for a gold medal versus if they're in their initial beginning of the season or pre-season type of thing. Pressure from athletes, internal pressure, masking the injury, conflict of interest and fear of litigation. And then you make your decision. So it's very complex. But in a nutshell, you have to address the risk of injury, you have this sequence of injury, rest, and you start doing rehab. And then within rehab, you have different stages. And in the stage that you are actually applying stress to the sport-specific stress to the athlete, and they're able to tolerate it, you combine that with what they've done in terms of the injury and the tissue healing, et cetera, and then you make your decision. But it's way more complex than just looking at, fracture healing and it should be healed in six weeks because it's a little more complex than that. All right. So if there isn't any more questions, I just wanted to thank everyone for joining us today at the AAP Didactics. If you want to find the full schedule, including many more talks coming next week and later this month, you can follow that URL right there for Zoom details. Also, all these lectures are recorded and you can re-watch any of them at your time. Again, www.physiatry.org slash webinars. You can find them there. If you have any questions, the Twitter handle for Dr. Miranda Comas is there, and you can find Sterling Herring, as well as AA Physiatrists below. Thank you for joining us today. Thank you.

risk factors

overuse injuries

athletes

identifying risk factors

injury prevention

performance improvement

multidisciplinary team approach

rehabilitation

prehabilitation