Hamstring Injuries, second most common injury in the NFL

Dr Sullivan explains sports injuries

Hamstring injuries are common in athletes who have to accelerate, decelerate rapidly or just do a lot of running. The hamstrings are a group of muscles that run down the back of the leg from the pelvis to the posterior tibia and fibula. They are responsible for flexing the knee.

The 3 muscles that make up the hamstring group from inner leg to outer leg are the semimembranosus and semitendinosus which attach to the inner lower leg along the tibia after passing thru the knee and the biceps femoris which attaches to the outer fibula.

Hamstring injuries are characterized by sudden shooting pains in the back of the leg. Generally the pain makes straightening the leg fully impossible. In other words, the leg is unable to extend without pain.  Hamstring injuries are graded according to severity and associated symptoms.

With Leonard Fournette dealing with a hamstring injury, reading below may change fans’ opinion on how fast to get him back out there.

Mild (Grade 1) Injury

  • Stiffness, tightness and mild tenderness to palpation along muscle bundles in back of thigh
  • No noticeable swelling at rest and only minimal
  • Heel is raised by flexing the knee
  • Gait is normal without deficit in range of motion.
  • Mild discomfort only while walking

Moderate (Grade 2) Injury

  • Gait noticeably affected.  Limp when trying to ambulate
  • Tightness with significant twinges upon flexing the knee
  • Palpable muscle tightness in back of thigh
  • Range of motion is limited and marked pain when flexing the knee
  • Pain generally relieved or tolerable when no weight on affected leg

Severe (Grade 3) Injury

  • Posterior thigh swelling and bruising which is markedly tender even to light touch.  Occasionally hematoma develops which forms firm lumpy texture to posterior thigh.  This is related to nature of the deep bruising associated with this degree of injury.
  • Significant pain at rest which becomes markedly more severe with any ambulation
  • Ambulation is difficult without assistance either through another person or device

Recovery and Reinjury

Hamstring injuries are the 2nd most common injury in the NFL each season. Each team experiences an average of 6-7 injuries each season and reinjury occurs more often than initial injury.  In an MRI study done in 2014, despite being pain-free after an average of 15 days, evidence of sustained injury still was evident on MRIs done at the 6 week post injury point in over 50% of the athletes examined.

What exactly does this mean?  If the injury is still evident at 6 weeks on the MRI, it means that full healing has not taken place and the risk for reinjury is still significant.  In addition, Grade 2 and 3 injuries involve actual tears of the muscle which results in the formation of scar tissue that markedly changes the consistency and function of the originally injured muscle as well as interferes with the function and use of the muscles around the injured ones.

A number of treatment options have been tried to speed the recovery process including deep ultrasound therapy, cryotherapy, and platelet rich plasma. Results have been mixed and currently no one treatment option other than adequate healing time has been shown to decrease the rate of reinjury.

Another interesting study has found that the injuries that have the longest time to heal are the ones classified as low stretch injuries. These occur during stretching type exercises and activities and result from extensive stretching of the muscles.  While they don’t appear as bad initially, they actually cause more extensive deep injury to the muscles and the risk for reinjury is almost 3x that of injuries that occur during active movement like high-speed running.

Professional sports is a business, and getting athletes back on the field quickly is important, however, if the risk of reinjury is so great is that really the best thing in the long run?  Until a way to limit and treat hamstring injuries is found, adequate healing time is imperative for the athlete’s health and long-term playing future. These findings are one of the reasons more and more athletes with significant hamstring injuries find themselves on injured reserve much faster than they previously did.

“High Ankle Sprain” – Dr Sullivan Explains

Dr Sullivan explains sports injuries

When is an ankle sprain not an ankle sprain?  When it is a high ankle sprain. A high ankle sprain is actually an injury above the ankle joint occuring when excessive rotational stressors result in injury to the high ankle ligaments. The high ankle ligaments are collectively called the syndesmosis complex and consist of 3 structures responsible for holding the 2 bones in the lower leg, the tibia and fibula, in the proper position so these bones can fit properly into the foot. When this complex is injured it results in laxity in the structures holding the tibia and fibula together and therefore greater instability in the ankle joint.

The syndesmosis complex is composed of 2 ligaments and a membrane between the 2 bones. The anterior inferior tibiofibular ligament, or AITFL, which runs in front of the two bones just above the ankle, the posterior inferior tibiofibular ligament, or PITFL, which runs in the back of the 2 bones and the interosseous membrane which runs between the two bones from just below the knee all the way to the ankle. This type of injury is much harder to describe and also takes a considerable amount of time to recover.

High ankle sprains are diagnosed using a series of tests including physical examination of the lower leg immediately after the injury. This is what you see the trainers and medical staff who come on to the field do. The 2 tests they perform include the Fibular Squeeze Test which is positive when pressure over the fibula applied midway between the knee and ankle results in significant pain right above the ankle.

The second is the External Rotation Test or Kleiger’s maneuver which is positive when significant laxity in the ankle is palpated. X-rays are used to access the lower fibula and tibia for fracture as well as the determine the amount of space between the tibia and fibula. MRI and CT scans are also used to access the extent of soft tissue damage.

High ankle sprains are graded Level 1 – 3.  A Level 1 high ankle sprain is considered a stable injury and requires 5-6 weeks of conservative therapy before returning to participation.

A level 2 and level 3 sprain are determined based on the amount of laxity in the ankle joint.  This is usually related to the amount of damage to the interosseous membrane. A partial tear causes mild instability and a Level 2 Sprain and a complete disruption of this membrane or a fracture of one or both lower leg bones is a Level 3.

A Level 2 high ankle sprain generally takes 8-12 weeks to completely heal and allow a return to participation. Persistent pain or swelling after the initial rehabilitative period may require more aggressive treatment.

A level 3 High Ankle Sprain usually requires surgery to stabilize the bones of the lower extremity and allow the interosseous membrane to heal. A level 3 injury can take 6-12 months to completely heal and is usually season ending when it occurs.

Treatment of High Ankle Sprains starts out with no weight bearing and the use of a non-walking boot to prevent further injury.  NSAIDS, ice and elevation are used for inflammation. Passive ROM exercises which consist of assisted movement of the ankle by a therapist to prevent decreased range of motion. Once the inflammation has resolved and stability has been restored, the athlete can begin weight bearing and working with physical therapists toward passing the hop test.

This is used to access the healing and stability of the ankle and being able to hop on the affected 15 times without pain or swelling is the standard established before an athlete can return to the practice field. Once the athlete returns to practice, 2-4 additional weeks to continue to rehab the injury and also regain movements specific to their position will be needed before the athlete can resume playing.

Reinjury and/or further injury occur when a person suffering from a high ankle sprain tries to resume previous activity before the initial injury is completely healed. Additional injuries such as ankle dislocation, achilles tendon tears and Knee disruptive injuries including ACL/ PCL and Meniscus tears have all been reported in athletes who were returned to active participation before complete resolution of the initial injury.

In Part 1 of this series I compared the common ankle sprain to a flat tire on a car.  Using the car analogy again, a High Ankle Sprain is like a broken shock (level 1) or broken axle (level 2) or both occurring on the same wheel (Level 3). Just as most drivers know axle and shock problems take longer to repair and are more expensive to fix than a simple flat tire, the high ankle sprain requires prolonged rehabilitation and extensive time to heal.

Hopefully, this explanation of ankle sprains will help everyone be more understanding of what is meant when an athlete is reported to have sustained an ankle injury and be more tolerant of the recovery time associated with the type of injury diagnosed.  All fans want to see their favorite players on the field but trying to rush them back to the field following an injury could result in them never returning to the field. Patience is a virtue and is also a necessity sometimes when dealing with sports injuries.

Stress Fractures, how they occur, the types and the treatment.

Dr Sullivan explains sports injuries

Player X has a stress fracture or Player Y is out of practice because of persistent pain.  This type of thing is heard frequently throughout training camp, preseason and the regular season.  I thought I would explain the concept of a stress fracture before we talked about specific types of stress fractures that occur.

A stress fracture is an overuse injury. It occurs when muscles become fatigued and are unable to absorb added shock that occurs from the repetitive activity of practice and game. Eventually, the fatigued muscle transfers the overload of stress to the bone causing a tiny crack called a stress fracture. Generally stress fractures occur at sites where the muscle has been pulled away from the bone to which it is attached.

When I explain this to patients, I use the example of gluing something and inadvertently gluing your fingers together.  When you pull your fingers apart breaking the bond of the glue, you create the same type of stressors that a stress fracture does when the muscle is ripped away from the bone.  While the glue example only hurts for a second or two, a stress fracture can result in pain for 6-8 weeks while the muscle heals itself and reattaches the damaged fibers to the bone.

The simple tearing away of the muscle is a class 1 stress fracture.  With proper treatment, which is basically rest and limited stress to the area, the severity of the injury does not progress.  However, continuing to play through the pain can result in an actual microfracture of the bone itself.  Needless to say, this is a more bothersome injury.
Most stress fractures occur in the weight bearing bones of the lower leg and the foot. However, location is more associated with type of activity and certain injuries are more often associated with specific activities.

Particular locations of stress fractures are commonly associated with particular activities.  Metatarsal, Navicular, Pars Articularis, Fibular and Tibial fractures are commonly seen in football players.  Baseball players who experience Ulnar Collateral ligament injury (Tommy John) often also experience Olecranon stress fractures.  A grade 1 Lisfranc injury in the foot is associated with a stress fracture of the 1st and or 2nd metatarsal.

Pars Articularis is a stress fracture in the articulation area between the vertebrae in the spine. This could be what Derek Wolfe was suffering from, or in addition to another condition/injury.

Stress fractures are the one time a woman doesn’t want to be superior to a man.  Stress fractures in female athletes are 3 times more common in females than in males.  There are a number of theories why this is true, but the most common thought is that a lack of adequate calcium in diet can lead to an increased incidence of stress fractures. The female athlete triad: eating disorders (bulimia or anorexia), amenorrhea (infrequent menstrual cycle), and osteoporosis is a condition that has been associated with the increased rate of stress fractures in female athletes.

The most common symptom associated with stress fractures is pain exacerbated by activity and relieved with rest.  Stress fractures are difficult to diagnose because plain film x-rays are usually negative when pain first occurs.  Often times adequate treatment is delayed because appropriate diagnosis is delayed days, even weeks because the only symptom is persistent pain and sometimes mild to moderate swelling at the pain site.

Persistent pain should lead to repeat x-rays which may or may not show bone remodeling (healing), if persistent pain does not diagnose problem. MRI or nuclear bone scans maybe used to show specific localized areas of injury that may not appear on typical x-rays.

Once the diagnosis of a stress fracture is made, then comes treatment.  The most important treatment is rest. Individuals need to rest from the activity that caused the stress fracture, and engage in a pain-free activity during the six to eight weeks it takes most stress fractures to heal.  If the activity that caused the stress fracture is resumed too quickly,  harder-to-heal stress fractures can develop. Re-injury also could lead to chronic problems where the stress fracture might never heal properly, this is called persistent nonunion.

How are stress fractures prevented? Common sense is #1 – If it hurts don’t do that thing that makes it hurt.  Fans often get upset when an athlete on their favorite team is held out of a game or practice because of pain.  They think the athlete is being a wuss or is “soft” and out of condition.  This is not true.  Pain is the body’s way of telling you something is wrong.  Ignoring pain is just asking for a worse injury to occur.
Here are some tips developed by the American Academy of Orthopaedic Surgeons to help prevent stress fractures:

  • When participating in any new sports activity, set incremental goals. For example, do not immediately set out to run five miles a day; instead, gradually build up your mileage on a weekly basis.  In football players this goal is met thru the gradual build up of activity during OTA’s.  It helps explain why athletes start out with strength and conditioning before getting to on the field activities.
  • Cross-training — alternating activities that accomplish the same fitness goals — can help to prevent injuries like stress fractures. Instead of running every day to meet cardiovascular goals, run on even days and bike on odd days. Add some strength training and flexibility exercises to the mix for the most benefit.
  • Maintain a healthy diet. Make sure you incorporate calcium and Vitamin D-rich foods in your meals. Most people assume this means drinking more milk, but calcium is found in several foods you may not be ware of these include Kale, broccoli, figs, sardines, salmon,and black beans
  • Use the proper equipment.
  • Do not wear old or worn running shoes.
  • If pain or swelling occurs, immediately stop the activity and rest for a few days. If continued pain persists, seek medical evaluation.
  • It is important to remember that if you recognize the symptoms early and treat them appropriately, you can return to sports at your normal playing level.

By now everyone who reads these articles know how much I like car analogies.   A simple example of a stress fracture in a car is driving with a broken shock.  While usually the car will still roll and get you from point A to point B, it may not be the smoothest of rides.  Ignoring the busted shock long term can lead to premature tire wear, brake wear and tear and other more serious damage to the cars suspension.  The same is true in athletes.

Ignoring persistent pain can result in longer periods of nonparticipation and in some cases has resulted in premature ends to athletes competitive careers.

Ankle Sprain and the athlete: Read Part I

Dr Sullivan explains sports injuries

An ankle sprain is one of the most common injuries that sports fans hear about each season.  Some athletes are out a week or two and others are out for months  Fans start thinking a player is injury prone, soft, or some other misinformation simply because not all ankle sprains are created equal.

This post is going to be done in two separate parts to try to clarify the difference between a low or common ankle sprain and a high ankle sprain.  Hopefully, once you finish reading these posts, it will be a little easier to understand, especially before we start seeing news about ankle sprains occurring during training camp.

This type of ankle sprain is what most people have experienced at least once in their life. You step wrong, your foot comes down funky, and bam your ankle hurts and perhaps swells. 80% of all ankle sprains of this type are what is known as inversion sprains.

What does this mean? It means the foot and ankle are twisted in such a way that the bottom of the foot is facing the other leg rather than the ground.  This puts stress on the lateral ligaments of the ankle resulting in pain and swelling on the lateral (outside) of the ankle.

The other 20% of common ankle sprains result from eversion of the foot and ankle, which means the foot and ankle is twisted in such a way that the bottom of the foot is facing away from the other leg.  This motion puts stress on the medial ligaments of the ankle and results in pain and swelling in the medial (inside) of the ankle.

Low ankle sprains can occur for several reasons including walking or running on an uneven surface, falling down resulting in your body weight being unevenly distributed between your legs. It can also happen when participating in sporting activities which require rolling/twisting of the foot and ankle or rapid changes in direction and speed of the athlete.

Another way that an ankle gets sprained is when athletes are playing in close quarters with others and the athlete’s foot or ankle gets stepped or fallen on by someone else on the field.

Most ankle sprains of this type are minor and with simple treatment full function and a resolution of pain is possible in just a short time. These sprains are graded mild, moderate or severe, with most being mild or moderate in severity.
In a professional athlete, a mild sprain can often be treated simply by applying additional support through taping and the athlete can return to play.

Moderate and severe ankle sprains require more care to prevent the development of chronic instability and the risk for re-injury. Moderate and severe sprains are usually treated with braces/walking boots or short temporary casts to provide support during the initial recovery period to prevent further injury.

Treatment of common ankle sprains usually resolve with RICE. Not the stuff we eat, but Rest, Ice, Compression and Elevation.  The goal of treatment is to let the body heal the ligament damage itself and to maintain range of motion in the joint to decrease the chance of re-injury.

Most ankle sprains are better after 1-2 weeks and even the most severe ones that resulted from a complete tear of the ligaments in the ankle resolve with conservative therapy after 6-12 weeks.  Surgery is rarely needed to treat common ankle sprains and is only considered when pain and swelling have failed to resolve after months of conservative therapy.
Since I love analogies to everyday things when I am explaining medical problems to non-medical audiences, a common ankle sprain is a flat tire on your car.  As long as it is flat the car won’t roll.  Fix the flat and the car is as good as new.

In the next part of this ankle sprain discussion I will discuss high ankle sprains.  This is actually not an ankle injury despite the name and to use the car analogy again, this is like having a car with a busted axle. Not as easy to fix on your car or in an athlete. Stay tuned!

LisFranc Injuries – No it is not my French Cousin. Dr Sullivan Explains

Dr Sullivan explains sports injuries

LisFranc injuries are talked about in all sports as a season progresses, but what exactly is a LisFranc injury? The LisFranc joint complex are the bones and ligaments that form the arch in the human foot.

It is a series of bones, joints, ligaments and tendons that provide stability to the arch of the foot and bridge the region between the ankle/heel and the toes.  It is important in providing stability to to structure of the foot and stabilizing the foot during the strenuous activity of walking, running and jumping.

The LisFranc region and therefore the injuries associated with this region are named after Jacques Lisfranc de St. Martin – a surgeon in the Napoleonic army in the 1800’s who first described this particular injury.

Most people assume this injury is related to a fracture; however, it is a complex continuum of damage that is rated by the severity of the injury.  Simple strain of the ligaments to full displaced fracture of the 1st and or 2nd metatarsals.  The interesting thing about this injury is not the injury itself, but the damage that occurs to the cartilage at the ends of the midfoot bones.

This damage results in restrictions in movement of the joint and persistent pain. Cartilage is the smooth surface in each joint which allows for ease of movement of the joint region.  When this region gets injured, the joint is like a ball bearing with a nick in it.  The bearing doesn’t move smoothly and this results in binding and restrictions in the normal smooth movement.

If the injury goes untreated, or inadequately treated, the entire joint can fail which results in both collapse of the arch but early onset arthritis in the midfoot which is both painful and persistent even in the world class athlete.

How do lisFranc injuries occur?

They can occur from both non contact and direct contact stressors.  Simple twist and fall non contact injuries are common in football and soccer where a player “steps wrong” or the foot gets twisted in the turf or with other players’ legs and feet.  It commonly occurs when one player “trips” over another player’s extended foot. More severe injuries occur when a player “lands wrong” after jumping to catch a ball resulting in the full weight of the body being absorbed by the tiny region in the foot.

Direct trauma generally results in fracture of the 1st and or 2nd metatarsal and partial or full dislocation of the resulting bone fragments.  This type of injury can occur in any sport where a player is asked to jump and then land on a hard surface including football, baseball, basketball and track & field.  Without proper stabilization and treatment of this injury, excessive scar tissue as well as early arthritis can occur in the injury site resulting in persistent pain and swelling when stress is placed on this region of the foot.

The most common symptoms of Lisfranc injury include:

  • The top of foot may be swollen and painful resulting in difficulty bearing ny weight on the affected foot.
  • There may be bruising on both the top and bottom of the foot. Bruising on the bottom of the foot is highly suggestive of a Lisfranc injury.  This bruising occurs right behind the great toe and severe pain is experienced when a shoe with a high or firm arch is attempted to be worn.
  • Pain that worsens with standing, walking or attempting to push off on the affected foot. The pain can be so severe that crutches may be required to prevent further injury.

Regardless of the mechanism of injury, early diagnosis and initiation of treatment is imperative to maximize recovery from this type of injury.  The greater the amount of displacement that occurs in the joint as a result of injury, the greater the need for more aggressive  treatment including surgery to stabilize the joint.

These types of injuries are difficult to identify on regular x-rays and treatment maybe delayed as a result.  Simple strains (no fractures) are treated with none to minimal toe weight bearing for 6-12 weeks and then a gradual return to full weight bearing in a custom shoe which is molded to the persons foot to maximize stability of the affected area of the foot.

If surgery is needed to stabilize the LisFranc joint, it is commonly done 7-10  days post injury to allow time for swelling to go down.  The surgery is usually done to insert screws and or wires to hold the bones in place, to remove any bone fragments occuring when the ligament is torn off the bone and hold the bones and ligaments in place to give the body time to heal the area.

Generally 4-6 months or more after the initial surgery a minimal procedure is done to remove the screws and or wires. This is done for 2 reasons: pain, and to prevent breakage of the screws from the forces applied when the athlete returns to the practice and playing field.

Recovery from this injury can be difficult to predict.

Simple injuries that do not require surgery may have the athlete out of commision for 2-3 months minimum to allow time for adequate healing.  They will miss a significant time, but if all goes well they may be able to return during the same season in which the injury occured.  If surgery is required, generally the athlete is placed on injured reserve for the remainder of the season.  If all goes according to plan without setbacks, they should be able to  return to the playing field 6-12 months after the injury.

Trying to rush the athlete back too soon can often result in irreparable damage to the athletes performance and their career.  LisFranc injuries are not something to play around with.  The athlete needs to follow the instructions regarding immobilization and weight bearing to the letter and stop immediately if they experience any pain or swelling in the repaired foot.  Many athletes return from these injuries without detriment, but there are also many who never returned to their pre injury form.

Concussions – 7 symptoms the NFL looks for when diagnosing them

Dr Sullivan explains sports injuries

Concussions in all sports are a fact of life; however, in the NFL because of the nature of the game, several players on multiple teams are in concussion protocol at any given point in the season.  How concussions are handled by the NFL and individual teams has changed drastically in the last few years.  The current concussion protocol is a valid and useful series of evaluations done both before an injury occurs (baseline) and after diagnosis during the recovery phase.

Anyone who watched NFL games 20 or 30 years ago remember seeing  players appear badly shaken-up, taken off the field and then return to play fairly quickly.  In the current NFL, if a player is deemed to have sustained a head injury a spotter signals down to the sideline, play is stopped and the affected player or players are immediately removed from the game for further evaluation.

Concussions are difficult to diagnose immediately after the offending injury as symptoms may not manifest until several minutes to hours after the injury was incurred.  This is in of the reasons why there is a perceived increase in the number of players in concussion protocol.  Every team has an independent neurological consultant who along with the team physician are responsible for evaluating and permitting a player to return to the playing field.

Most consultants are aware of the delay possible in symptom onset, so for the sake of player safety and long term well being if there is a question as to whether a player has sustained a serious head injury, they will likely be placed into concussion protocol to provide additional time for further evaluation.

In Game Protocol – “Observable concussion symptoms”

There are seven observable symptoms used to identify players with concussions. Those are:

  1. Any loss of consciousness
  2. Slow to get up following a hit to the head.  The hit may occur when 2 players tackle one another or when one player forcefully strikes the playing field (or hitting his head on a weight bar like Philly Brown)
  3. Motor coordination/balance problems.  If a player is slow to get up, requires assistance standing or walking following a hit or stumbles when walking back to the huddle or sideline
  4. Blank or vacant look
  5. Disorientation -unsure of where he is on the field or location of his teams bench.  Unsure of game context clues such as quarter of play, or who another player on the field is.
  6. Clutching of head after contact
  7. Visible facial injury in combination with any of the above.  This can include lacerations in the head or neck region or dental injuries.

When spotters up in the booth, or other medical personnel on either sideline see any of these signs, play is stopped, the player is taken to the locker room or if necessary taken to local hospital by ambulance for further evaluation and the protocol goes into effect.  Once a player is placed into concussion protocol, the players well being is the number 1 concern.  No further information is provided to the head coach or position coaches other than where in the protocol the player is.

This protocol has been in place since 2009 and each off season as more data is available, any necessary changes are made to try to best manage player safety and well being.  There have been a few instances where a team failed to adequately enforce the concussion protocol, particularly the In Game – Observable symptom protocols and as a result, the NFL has implemented hefty fines and also the loss of draft picks when a team is felt to have tried to skirt the concussion protocol.

Return to play process

Once in the concussion protocol, the player must progress thru a series of 5 steps before they can be cleared to return to the playing field.  There is no set time table for this evaluation and recovery.  Some players progress thru the protocol fairly quickly and others take longer to be cleared to resume playing.

The full NFL Return to Play Protocol is lengthy without any set timeline for a full return from a concussion.  The link above will take you to the full detailed protocol.

In a nutshell the 5 steps are as follows:

  1. Rest and recovery:Until a player returns to the “baseline level of signs and symptoms and neurological examination,” only limited stretching and balance activities are recommended. Electronics, social media and team meetings are all to be avoided.
  2. Light aerobic exercise: The NFL recommends 10-20 minutes on a stationary bike or treadmill without resistance training or weight training. The cardiovascular activity is monitored by an athletic trainer to “determine if there are any recurrent concussion signs or symptoms.” A player in step 2  can attend team meetings, position meetings and watch film, however if any recurrence of symptoms occurs the player must stop the offending activity and report the symptoms to the athletic trainer assigned to monitor his recovery.
  3. Continued aerobic exercise and introduction of strength training:Increased duration and intensity of aerobic exercise with strength training added. An athletic trainer will supervise to watch for recurrent concussions signs or symptoms.
  4. Football specific activities: The cognitive load of playing football will be added and players will participate in non-contact activities for the typical duration of a full practice.  Non- contact includes contact with sideline apparatus such as sleds and tackling dummies.
  5. Full football activity/clearance: A player returns to full participation in practice, including contact without restriction.  If he does not experience any symptom recurrence following the practice, the team doctor can deem the player is cleared.  Once that happens, all medical records must be made available to the independent neurological consultant who will review the record and has the final say in whether a player is ready to return or not.

A protocol is in place and teams are expected to follow it.  Unfortunately, every year there are one or two instances where the protocol is either ignored outright or misinterpreted, however compliance has improved since the protocol was put into place.  Hopefully 2018 will show even better compliance with this important safety protocol.


NFL Injuries – Why the increase? Read this doctor’s opinion.

Dr Sullivan explains sports injuries

Every year when athletes report to training camp, they feel they are ready to begin a great new season. A few days in, the injuries begin to mount.  Why with all the safety initiatives seen implemented in recent years do severe NFL injuries continue to rise? Several studies are underway to try to determine a reason.

Everyone has an opinion: artificial turf being used instead of natural grass, change in off season training programs implemented by the last CBA, decreased number and duration of practices in general permitted in both the preseason and during the season. If you ask fans it is because the teams strength and conditioning staff need to be tarred and feathered or run out of town on a rail.


Could parents be the key to NFL Injuries?

One issue that has not been looked at as much is the early specialization by athletes. Parents used to spend their lives running their kids to practices. Baseball in the summer, football in the fall and basketball in the winter and perhaps track and field in the spring.
This was a lot of work for parents and the kids, then a move to pick a single sport earlier was initiated in the late 90’s. Parents tried to decide what sport their child should excel in and rather than let them play all sports and decide for themselves. This lead to year round leagues for football, baseball, basketball and hockey.

Several studies are currently underway across all professional sports to try to determine if the trend to specialize early is actually leading to the increase in serious injuries being seen in recent years. One study has shown, there is a 77% decrease in the number of athletes entering college on a scholarship to play a particular sport who participated in more than one sport since 2005.

While injuries from participation my have decreased on the field, the benefits from multi-sport participation is lost. Improved conditioning and dexterity of the body overall is gone by the early specialization.  Over use is a concern, but lack of is, too. Players who engage in football exclusively starting at an earlier age, are 10 times more likely to suffer a serious potential career ending injury than athletes who played multiple sports thru high school and college.

Picking only one sport may lead to more NFL injuries

While injuries are a concern to everyone, and trying to make a sport safer is a great goal, the trend to have a student athlete pick a sport early to concentrate on, may or may not increase their skills for future success. Most athletes polled in the NFL and MLB stated that early concentration on a single sport actually was a detriment to their long term career due to increased incidence of serious injury.

Overall muscle and movement dexterity developed in athletes who participate in multiple sports is lost on single sport participants.  What I mean by this is reaching up to catch a pass is a different subset of muscles than the muscles used to bend and scoop a ground ball off the turf.  Different muscles are maximized in different sports.

More investigation needs to be done on this subject, but they may be onto something. I encourage my parents to let their kids be kids and to play all sports they are interested in.  Youth leagues are great and maybe the kid will find they like and are better at a sport than the one their parents decided they would be great at.

Hopefully a definitive answer to why NFL injuries is occur is found, I think since it is a multisport issue, returning to playing multiple sports might actually decrease the serious injury rate and also produce better athletes for all sports.

Dr Sullivan explains, Performance Post Injury Evaluations.

Dr Sullivan explains sports injuries

Player X was injured in the game or practice are the words every sports fan hate to hear. Even before the athlete is evaluated by the medical and training staff fans are wondering if an athlete will be able to return to preinjury performance levels.  In other words, will the athlete still be able to do their job?  Often you will hear percentages thrown around and everyone has an idea what they think this all means, but what does it actually mean?

When an athlete comes into their teams facilities for the first time, they undergo a physical which includes performance function testing.  This testing includes a series of standardized tasks to evaluate mental and physical abilities to obtain a baseline score on each of these tasks for each athlete.

This testing takes place at the start of each new season to access the athletes performance relative to their baseline and the baseline of others with similar physical demands on the playing field. This testing also occurs as an athlete works to get back on the playing field following an injury as well as part of the physical evaluation when a player is traded and has to pass a physical.  If initial baseline is considered to be 100%, then when someone says he is at 75% you don’t have to ask 75% of what.
When an athlete is injured, a continuous process starts which involves several members of the medical and coaching staff.

  • Step 1 – Medical treatment. This is shared by the treating physician who examines, diagnoses and performs any corrective procedures to facilitate recovery and the Athletic trainers and physical therapists who work with the physician to manage pain, limit swelling and protect injured tissues.
  • Step 2 – Initial Rehabilitation. This is the job of the Athletic trainers and the physical therapists.  This stage is designed to restore motion and neuromuscular control of muscles and muscle groups.  It is not designed to build additional muscle, just to stabilize and strengthen the muscle already traumatized by the injury
  • Step 3 – End Stage Rehabilitation.  The athletic trainers and physical therapists are joined by the strength and conditioning staff in managing this stage of the recovery process.  In this stage, the athletes balance and stability as well as strength and endurance are maximized as the athelete continues to progress toward a return to the playing field.
  • Step 4 – Generic Specific Development and Rehabilitation. Once the athlete has been deemed ready to begin to work back to the playing field, he is ready to start working with the strength and conditioning staff in a more concentrated capacity to restore basic physical performance functions of the athletes body.  Steps 1-4 are basically the same steps that anyone who sustains an injury go thru as they recover from their injury. Athlete or Joe fan, the recovery process is very similar.
  • Step 5 – Sports Specific Development. The final stage of the recovery process is when the athlete is permitted to return to practice and begin working with the position coaches and Strength and Conditioning staff to restore competitive performance functions.  These are the tasks that an athlete does to show they can handle the rigors of the position they play.  Running, jumping, pushing pulling etc.  This is dictated by the necessary functional ability dictated by their on the field job.

While player and fans alike would like to think this is a simple and very organized process, it often gets messy because of setbacks from day to day in the recovery period.  Another problem occurs when the process is tried to be sped along, which generally just results in further injury and rather than a faster return to the playing field it actually results in a prolonged recovery period.  All along the way in this process, the athletes performance function testing is evaluated and measured, to get a sense of how the athlete is doing in their recovery.

Each time a player is injured, it impacts their ability to recover from the injury and also increases the possibility of reinjury or further injury.  Most of the time an athlete is able to return to their preinjury level of performance however, occasionally that is not the case.  Sometimes the level of performance is decreased so little that except for the training staff who do the performance evaluations and have the statistics to look at, it isn’t really discernable.

Over time and a multiseason playing career, this slight decreases begin to buildup to a point where a player is determined to no longer fulfill the demands of the job or the cost to retain the player is deemed to be to great to the long term goals of the team.  I explain this to patient’s as the used car effect.  A new car has a value when you get it, but as soon as you leave the dealer the value begins to drop, eventually the cost of maintaining and repairing the car becomes less cost effective than trading the car in on a new model.  Exactly what happens when an athlete is either traded, released or decides to retire.

Chest Pain is not a Straight Forward Diagnosis: Dr Sullivan Explains

In light of the tragic passing of long time NFL and NCAA coach Tony Sparano on Sunday July 22nd, a quick review of chest pain seemed to be timely and appropriate.

The first thing that needs to be said is chest pain is not a medical diagnosis.  Chest pain is a symptom.  It means it is treated by medical personnel like elevated blood pressure or an elevated temperature, a clue as to what maybe going on with a patient.

When people hear chest pain, most people assume this means heart attack, but in an emergency department/hospital setting heart attack or acute myocardial infarction as it is known in the medical community is only 1 of a whole list of conditions that include some type of chest pain as a symptom.

CHEST PAIN – Possible Diagnoses 

  • Acute Cardiac Syndrome – Acute Myocardial Infarction
  • Chest Wall Pain – musculoskeletal pain that is reproducible when chest is palpated
  • GERD – Gastroesophageal Reflux Disease (heartburn)
  • Panic Disorder or Acute Anxiety Attack
  • Pneumonia or Bronchitis
  • Pericarditis – this is diagnosed based on the presence of  a triad of symptoms and is not common
  • Pulmonary Embolism – this is related to a blood clot in the lungs
  • Heart Failure – generally occurs in patients with a history of previous myocardial infarction

A lot of people posted on various social media sites that Coach Sparano was admitted for chest pain and discharged the next day without proper diagnosis and died 2 days later so therefore the doctors didn’t do their job properly.

This is not an accurate assessment and most likely, he was discharged because the initial workup was found to be negative and based on current guidelines under which medical professionals are trained, the risk of remaining in the hospital was greater than the risk of an acute life threatening event occuring in the 24-72 hours after discharge.

Several algorithms are used, but basically if the initial workup is negative, patients are discharged home with follow up for further testing as outpatients scheduled in the week following discharge.  This testing can include advanced cardiac testing and if deemed necessary, based on the results of these tests, more invasive procedures like cardiac catheterization and angioplasty.

Chest pain is a complex symptom. The loss of Coach Sparano was a shock to everyone, but if you experience chest pain which is associated with heavy sweating and/or worse with exertion, are over the age of 40, have a family history of cardiac disease, have other conditions like obesity, diabetes, & hypertension, you are a current or former smoker or have had a previous myocardial infarction you should go to the closest emergency room, your family doctor or call 911 so you can be evaluated ASAP.

Coach did exactly what he was supposed to but sometimes bad things happen to good people despite the best efforts to the contrary.

Finally, my heartfelt condolences go out to the Sparano family and #Vikings everywhere.  Rest in Peace Coach Sparano, You will have a seat on the 50 yard line in heaven for eternity.