All right, pardon the interruption, everybody, but we're going to go ahead and get started here. Thank you. Thanks, everyone, for being here. So we've got to see if the clicker works. There we go. All right, so I just want to start out with the format of what we're doing today. First question is, does this look familiar? If you're a fan of ESPN and the show, pardon the interruption, that's what we're basing our talk on today. So all credit to ESPN and pardon the interruption and Mike Wilbon and Tony Kornheiser for the idea for the format for what we'll be doing today. We'll try to get through five topics. We have a couple people up here that may have a few words to say about some different things, but we're going to do our best. Ten minutes, roughly, for discussion. At the end, a Q&A as time allows. We have no financial disclosures, but a disclaimer. We're going to be looking at some publicly available news articles today that mention prominent athletes and some of the medical care that they have received. And again, this is through kind of publicly available news sources. None of us up here are directly involved in the medical care of these athletes, so we are basing our assessments off of what comes out of the news article. So I just want to state that explicitly. Who's here? So we have Dr. Adele Miron to my right here. She is representing the University of Colorado. Is program director of their residency program. And she is joined today by Dr. Bainu Akathoda, who is the chair of PM&R at the University of Colorado. And then there's myself, Dr. Chris McMullen. Thank you. I am an associate program director of our residency program at the University of Washington. And last but not least, to my left here, Dr. Stan Herring, who has more titles than the rest of us up there, co-medical director of our orthopedic and sports medicine at UW. And Zachary Leistat, concussion endowed chair and professor at UW. And old. I didn't say that. Don't say that. I didn't say that. All right, with that, we are going to jump right in. We will. We will. Maybe wait right after you. We'll start talking. So we lead off today with an Olympic story. Many of you may have witnessed the competitive climbing this year, including this prominent climber. This American climber who took home the silver in the bouldering and lead events at the Olympics. In her bio, we can see that she started climbing at the age of one. In an interview prior to the games, in reference to the end of the competition season, she said, I'm going to take like a week and a half off because I've never done that in my life. And you can see the rest of the quote here, or you will be able to shortly. Meanwhile, we in the sports medicine community are fighting the good fight and warning parents and kids about the harms of early sports specialization. So Dr. McMullen, what am I supposed to tell parents and kids who insist on training to this degree to emulate their idols and succeed in their sport? Yes. Thank you for the question. So this, this definitely comes up all the time in our clinic. We have athletes coming in with their parents and they see what is happening at the elite level and they want to emulate that. And so I kind of think through it in a few different ways. First off, these athletes are unique. If we look at this athlete here, both of her parents were world champion rock climbers. I am sure this athlete was surrounded by trainers and coaches and had access to things that most climbers don't, most youth athletes don't. So one thing I try to get across to our young athletes is some of these elite athletes grew up in a very different situation. Secondly, we can look at some of the evidence. So what is the evidence in climbing? Well, there's not a whole lot, but one study came out of Colorado looking at early sports specialization in climbers. And what they found in a small study with a low number of injuries was there didn't seem to be this injury link to specialization and injury later on. But we've looked at a lot of other sports too, and there does seem to be some link in at least some sports, as you can see up there, to certain sports being associated with burnouts and injury when those athletes specialize earlier in that sport. So it is something we think about. But honestly, what I'm more concerned about or looking at more is just the overtraining that is occurring in some of these athletes. So the NATA has these guidelines on how much our athletes should be training. And I show this to parents, and it's shocking for parents, especially things like not training more than eight months out of the year and some of the hours restrictions listed here. We actually have a poster this year in the poster hall where we surveyed a climbing team in Seattle to see how many of the climbers were following these guidelines, and it was a whole whopping 0%. So most of our athletes are not meeting these guidelines. And honestly, that's what tends to concern me more when we think about injury and burnout. Last point I will make on this is that this is not the only way to get to the Olympics. So this was another climber on the US team who said that climbing was just for fun until about age 15 when they started competitively climbing, and they were in the Olympics at age 18. So this is a very different pathway, but still a pathway of success for an elite athlete. So we can get athletes there sort of one way or the other. So just to summarize some of this here, the things that I'm thinking about, these elite athletes are unique, look at the data, and lastly, kind of think about other ways where we can get our athletes to that high competitive level. My question for the group, and I'll start with Dr. Akathota, is you're a parent of a rock climber shown here. What from a sort of parent's perspective do you go into a visit with a doctor thinking or when you think about these guidelines, does this make sense? Yeah, I think this makes sense. Thanks for taking this off his Tinder profile. Being an Asian parent, I try to get them not too much into sports, unless they get a scholarship. But what I typically tell them is there's the indoor season, the outdoor season, and then you got to do other stuff. That works pretty well, but parents will come back and say, well, especially climbers, they need calluses formed and things like that. But that doesn't take that long to form, so I think the eight-month rule is actually pretty well-conceived. I would say, in theory, it's a great theory, but as a sports parent and as a doctor of patients who have sports parents, you pay for year-round clubs for our kids, and living in Denver, if you don't play soccer year-round as a 10-year-old, your chances of playing in high school are a lot less. And that is the sense around the community, so while I agree with all of this stuff scientifically, it is really hard to convince parents and community, even myself and my spouse, to take those four months off. I mean, four months off is a lot, so taking four months off during the year, and I believe in cross-training, I believe in playing multiple sports, but I think the battle is tough, talking to these parents and convincing them, when they've paid for a year-round climbing gym membership or a year-round club team, to take those four months off. Dr. Aaron? I agree that the parents are an important part of this, and in this situation, particularly, I would want some history from the parents. I would want to know, in their training as elite climbers, if they trained at altitude, because that would explain the hypoxic brain injury that would make them train their child since the age of one. Yeah, live high, train low, I think. And after that warm-up question, I think that I would tell them it doesn't work. They think it works, but every athlete that I have had the privilege of taking care of who performed at an elite level did not over-train as a kid. It just doesn't work. So, I mean, they can believe it works, and they can put their child through it. I think you're right, until you change their belief system, I don't think you're going to get anywhere. You can still have an autograph of my kids in the major leagues. What do you mean when they're not talking to you anymore? Sacrifices we do as parents. All right, I'm going to move us on to our next topic, which is nerve hydro-dissections. So this technique has gained popularity within the sports medicine field in the past several years, and that's translated to newsworthy headlines like the one I'm about to pop up here. Any second. There we go. Notable athletes have undergone the procedure, including this gold-winning shot-putter. There we go. There we go. According to an AP article published in July, the athlete underwent a procedure where the doctor, quote, lifted the nerve out of the ulnar groove with a saline solution. Again, none of us are directly involved in the care of athletes presented today, but this sounds an awful lot like a nerve hydro-dissection. Dr. Miron, what's the theoretical mechanism here, and is there any evidence to support it? Yeah, thank you for that question. I think it's a great question because a lot of us in this room and a lot of us in the community are performing nerve hydro-dissections, and it's important to look at the evidence behind it. So the theoretical mechanism behind nerve hydro-dissection is introducing hydrostatic pressure around a nerve to relieve compression. So the idea is you're introducing fluid circumferentially around the nerve to release compression on that nerve. And the way this is done is inserting the needle tip under the gliding adventitial layer of the nerve, which is outside of the epineurium. And the idea is when that fluid flows circumferentially around the nerve, any compression on that nerve can be released, whether that's something we see visually on imaging, in ultrasound, like a bony prominence, soft tissue adhesion, scar tissue from a surgical procedure. The idea is to separate the nerve from whatever's causing that compression to relieve the pain that's caused on that nerve. So we can see this is done. The technique is done by inserting that tip into that adventitial layer, sending fluid around the nerve. And one tip is to position the bevel so that the tip of the needle is not pointed towards the nerve to avoid biotrogenic nerve injury. So you can see here an excellent example that someone on this stage performed, who may later argue against this procedure, for a median nerve in the carpal tunnel. So you can see the needle targeting the nerve, and then the fluid starting to flow circumferentially around the nerve. Now there is evidence that the mechanical properties of a nerve can change following hydrodissection. So there have been some pretty clever studies. This one was a Cadveric model that looked at gliding resistance of the median nerve in the carpal tunnel. Now the carpal tunnel is the most commonly studied hydrodissection. And they looked at gliding resistance of this nerve before and after hydrodissection. And actually the gliding resistance decreased. How's Dan doing? You doing okay? I took my medicine. Following hydrodissection. So mechanical changes, actual mechanical properties change of this nerve following hydrodissection. Now this was, this particular case that we're talking about was cubital tunnel ulnar neuropathy. So there are some studies, not quite as many, but one ultrasound study showed actual lifting of the nerve, so separation of the nerve with fluid away from the bony and soft tissue prominences in the cubital tunnel. So we don't know how long these changes last, but we do know that there are some mechanical changes around the nerve. So that is one half of the theoretical mechanism of hydrodissection. The other is more chemical. So the most studied here is the injectate itself. And the most commonly used one is 5% dextrose. It's isotonic to normal saline, so it's not an irritant to the nerve. And it potentially has some anti-inflammatory properties. And then it inhibits capsaicin sensitive receptors. So we have theory and some evidence for the mechanism of nerve hydrodissection. But I think the main question that we all want to know is clinically, does it actually work? And I think the data here is a little mixed, but there is good data to show that there are some changes in clinical picture after a nerve hydrodissection. So again, most of the studies are in the median nerve in the carpal tunnel. In 2017, Wu and colleagues performed a bunch of randomized controlled trials and showed that there were improvements in both pain and functional scores for median neuropathy after hydrodissection in the carpal tunnel. There is also some studies in the cubital tunnel, since this was an ulnar neuropathy case, which showed changes in cross-sectional area of the ulnar nerve and changes in electro-diagnostic factors following a hydrodissection in the cubital tunnel. So we have evidence for the mechanism. We have some evidence that there are changes in the clinical outcome. Overall, I think there's still some questions, and usually this boils down to patient selection. So this is true with all of our patients. I think we can say that there's a good safety profile for this. So there's evidence that it doesn't create nerve injury. I think in my clinical practice where I see this work most commonly is when there's post-surgical scar tissue around a nerve, and I can actually feel changes in the resistance as I'm injecting fluid around the nerve. That's when I'm the most confident this is going to work and when I tell my patients that they're going to, and I see the most benefit from this. But I know there are some dissenting opinions on the stage, so I'm going to open it up to the group to ask, what are your concerns about this procedure? Yeah, I'm happy to jump in here. So sort of a couple of concerns, and the first being around the theoretical mechanism of how this works, especially this idea of mechanical breaking of adhesions. The question I've always had is, why are there adhesions? Where is the evidence that any nerve that is irritated is actually adhered to surrounding tissue? When I've talked to our surgical colleagues who decompress these nerves, and I ask the question, in someone who has not had a prior surgery, do you ever come across adhesions of the nerve to the surrounding tissue? And the answer is a resounding no, that they're just not there, they're not being seen. So I absolutely have questions about the mechanism of how this is supposed to work. My second concern is around the safety of this procedure. And I agree that if you have someone that is technically capable of doing these injections and staying away from the nerve, that the risk is lower. But again, talking with some of our surgical colleagues, the concern was that if someone has had repetitive injections around a nerve, or repetitive hydrodissections around a nerve, and that person then has to eventually go to an operation, that operation becomes technically more difficult for the surgeon, because things have kind of been mucked with. If there wasn't scar tissue there before, maybe there is now from repetitive procedures. The tissue planes have potentially changed. And so from our surgeon's perspective, they're kind of like, we would prefer that this be avoided for those reasons. So those are just some of my thoughts and concerns around this, and I'll let Dr. Herring add any other thoughts to that. So much to say in so little time. So since I've practiced for 127 years, I've heard this story before. Everything is new, and it's exciting, and it seems like it makes sense, and you have a little bit of literature. I read the literature, too. It didn't take long. And the literature is preliminary, and you get enough intermittent reinforcement when you do the procedure. You know, and I think that's kind of how medicine progresses. And you are a conscientious injector, which is helpful. But if this gains wildfire like it does, it becomes indiscriminate. So one of the problems is to support this so it's used indiscriminately. The other problem is to support it in physicians who do it in the absence of comprehensive rehab. If you can make somebody feel better, that's good for you. But the question is, what do you do to maintain that? So this becomes a default, maybe not for the people in this room, but certainly within the field of sports medicine. I do agree with Chris. I mean, I think of those pesky things like the basonosorum and the nirvanosorum, the little things that innervate the nerve and give it the blood supply, and kind of what are we doing mucking around there. So it's been my experience that nothing ruins enthusiasm like further follow-up. So I'm not opposed to this. I mean, I am very concerned, though, that we make assumptions about the mechanism. We have short-term follow-up, oftentimes use cadaver models to make a point. And then it's just hard for me to imagine that this little bit of magic is going to cure a problem. Certainly I don't think it cures an entrapped nerve, but it's going to cure any chronic or recurrent problem alone. Yeah, I think you make some very good points. I agree the nerve supply and the blood supply to the nerve are very important. Ranks right up there. Some of the theory behind when we can't see these adhesions, when surgeons go in and they can't see these adhesions, are that there are smaller adhesions that are actually putting pressure on the vasa, nirvorum, and the nerve by nirvorum. Like secret adhesions. They're super top, triple secret. But studies have shown that release of that pressure, so when there's pressure on a nerve, so they can control, they did these studies in rat sciatic nerves, and they controlled the amount of pressure. And even when there was no visible compression of the nerve, the rats still had pain. And they said they did. And then we relieved that pressure, the pain got better. So we may not be able to see all these adhesions, but I think it's possible that they're there, and that's why we need to continue to do these studies that look at clinical outcomes that will show us. And as you know, what happens in mice and rats doesn't often translate well into people. Most people. I identify with the mice and the rats. And so I think that, I don't know, this is just an opportunity for physiatrists to rise above the temptation to just start squirting stuff. Yes, I agree. That's a technical term. Well, I'll be the additional steel man here. I think I had a wise professor from Seattle once say the absence of proof is not the proof of absence. So this may work if research comes out. In this particular scenario, where you need temporary improvement, I think this is a case scenario where it can make sense. So the person that needs to compete for hopefully really good reasons, or the pregnant lady that has acute carpal tunnel syndrome because of swelling, and you wanna release her nerve to a degree, and then her swelling comes down after pregnancy. Excellent points. The last piece of that though is, the athlete that needs to compete at a high level, it's great unless this goes wrong. Then it is not great at all. So think about who you're putting the needle in. All right, should we wrap that one up? Yeah, we'll move on. So our next topic moves us to the brain, something several people here are experts in. And in the last few years, we have seen multiple NFL stars under the age of 30 announce their retirement from the game. These high profile players have cited health concerns, particularly a history of concussions as a primary factor in their decision. Dr. McMullen, can we expect more early retirements in the future? And how much of the decision for early retirement is based in evidence? Yeah, I think this is a good question as we're kind of clicking through here. I mean, seeing these kind of prominent athletes retire early is obviously something newer, and we're seeing these news stories about athletes taking this real concern in repetitive concussions, and they should be. We should be thinking this through. As far as the question around what is the evidence behind this, that's where we're lacking a lot of information. I mean, the question up there, how many is too many concussions, we don't know. We don't have the evidence that there is a specific number that is gonna be the number that we retire athletes at. And so obviously, this takes a lot of thoughts and discussion with an athlete and with all stakeholders involved, and takes physiatrists who have an expert in brain injury and an expertise in sports medicine to really think this through and try to answer these hard questions in these athletes, where there isn't necessarily this robustness of data. We have this review article, which Dr. Herring was involved with, which brings up several points here, kind of listed up there. We wanna involve clinicians with expertise in brain injury. This is an individualized decision-making process. We wanna treat any preexisting and coexisting pathology. So we need to be thinking beyond just kind of prior history of concussions, and is there other comorbidities that we need to treat in these athletes when these decisions are being made? You wanna make sure you're discussing openly these kind of uncertainties with the athlete and with the team. And then I think one really important piece here is if a decision is made to retire an athlete from a collision sport or contact sport, this is not retiring an athlete from physical activity. Absolutely there needs to be a backup plan for how is this person going to still engage in sports, engage in physical activity, and just sort of remain engaged in being physical. But we have someone with a little experience in concussions up here, but I'll go to Dr. Herring for any further thoughts on the review article. This is a challenging question, and it's impossible to answer in hours of conversation, much less briefly, but we need to make sure that we don't confuse what we know versus what we think we know. There is no data on when you should retire from sport. It's credible, none. Number of concussions close together, there's just not, which is why I signed up for this review, less homework. And having said that, the decision, taking professional athletes off the table, the decision about retiring from competition or play because of the limitation of data really needs to be a shared decision issue, which means it's not just your tolerance for risk, it's the athlete's. And so the shared decision model works well here. It's sort of uncomfortable. I used to think that shared decision meant that I would share my decision with the patient as to whether they should play sports or not. That wasn't perfectly correct, apparently. So be careful. Read the literature carefully. Understand what we do and don't know about things like chronic encephalopathy. I find it helpful what the patient, the first visit around this is to ask them and to explain in their own words what they understand about this. That's the unlearning visit. And then try to help them build consensus. But the single most dangerous thing that we can do for young people to increase their chance of chronic neurodegenerative disease, poor psychological adaptation, and poor academic performance is to be physically inactive. That's the crisis. It's almost a guarantee. So when we make these kind of, well, gee, I don't know, I don't think you should play rugby anymore because it's dangerous and everybody who plays rugby gets chronic neurodegenerative disease, that messaging has to really be carefully thought out in context or in contrast to what you're sending them to by not being physically active. And I would say to you that there are some situations where playing a contact or collision sport in a young person's life is the safest thing they can do. If they don't do that and they have unsupervised activity after school in a dangerous part of the world, there's a really good chance they're gonna have a brain injury. So be careful about the microaggression of that as well. And I could go on, but I will not. I don't think either of us are gonna argue. I know you want arguments, but I don't think we're gonna argue with Dr. Herring about concussions. Yeah, just any other kind of thoughts on how you sort of think through these situations or when you counsel your athletes. You don't have to have any fitness. You have to know the subject matter. You can't be a dilettante in this space and you probably shouldn't do this alone. This is a team needs to make, this is why you're a physiatrist. You have a brain injury team. Every brain injury is a psychological injury by definition. So this is to really understand the family's risk tolerance and what their understanding of brain injury is and their honesty in reporting and what the goals for that young person is. Now, I know that you're never gonna let your child stop no matter what, but. They're not playing football. They're not playing football. Okay, so you've made my point. And you think that by not playing football that you've made them safe. You have not exposed them to head trauma. But that statement suggests that everyone who plays football then will be demented, present company excluded. So I just think we have to be careful about the things that we say to patients or even our own belief systems. And I encourage you and read this paper and read the Amsterdam Consensus paper and read the paper on chronic neurodegenerative disease so that you have the data in front of you. And then take that into the exam room when you're talking to people about the risk of what they're choosing to do. Well said. All right, moving on. So our next story takes us to the NHL. In recent years, artificial disc replacements have quote, opened a whole new world of hockey medicine. The surgery became famous after a professional player sought a trade to another team specifically to be able to undergo the procedure. His own team had been recommending a standard fusion surgery. He ultimately did undergo the disc replacement with his new team in 2022. And that team went on to win the Stanley Cup the following year. Well, there you go. In that year, two other NHL players ended up undergoing the surgery. So disc replacements have gained so much esteem. We have even certain tech billionaires weighing in. Dr. Miron, is this the future for our athletes? So it might be. And the bottom line is that we need more evidence around this. But I'm glad that this topic is being brought up because even though we're not surgeons, we often are and should be the initial contact point for athletes with cervical spine injuries. So we do need to be able to counsel our patients on both surgical and non-surgical options for their care. So artificial disc replacement was developed in the 1960s basically to improve on existing technology like anterior cervical discectomy infusion, ACDF, posterior foraminotomy, to reduce the rates of adjacent segment disease and to improve mobility. And these are both things that we want in our patients and we want for our athletes. So if we compare, you know, this initially, these were fraught with complications, but over time, like most things, they have improved. So over the last 60 years, we've seen fewer complications with these and to be able to compare it to ACDF, which is now the most common spine surgery in athletes. We do see some in the general population improvements. So we do see lower rates of adjacent segment disease and we do see lower rates of adjacent segment surgeries. And we also see improvements in patient reported outcomes. So all of these are desirable effects of the artificial disc replacement in the cervical spine. However, we know that our athletes have much different requirements and restrictions in terms of the amount of force they're putting through their cervical spine in the amount of motion they want as professional athletes and even non-professional athletes. So as with everything, we need more data in this, but what we know is with artificial disc replacement, what our athletes want to know, what our coaches and managers want to know is return to play and recovery time. So we can compare this to the existing technology of ACDF. ACDF has been studied for a long time. We have long-term follow-up studies. We know that return to play rates are about 70 to 80% in the general population and that this takes about nine and a half months. The average time to return to play is about nine and a half months. So this is a whole season. So it's understandable that our athletes would want an alternative that showed shorter return to play times. And the artificial disc replacement, although there have not been many studies, have shown return to play times as short as 10 weeks. So this is really appealing to our athletes. The two main considerations here are mobility of the segment and stability of the segment. So when an athlete has an ACDF and they get hit, there's a collision, there's a contact, we're not worried about the fusion failing. We're worried about the adjacent segments failing. When we have an artificial disc replacement, it's the actual operative level that we're worried about. So we have to think about the device selection when we talk about artificial disc replacement. And there are a lot of options. So I won't go into the details of this, but the main differences here are, the big categories are constrained devices and unconstrained devices. So the constrained devices have a really solid contact point with the end plates and have a fixed center of rotation. So they're rotating around the same axis no matter what. The unconstrained devices, which impart a lot of mobility, have a mobile center of axis of rotation. So this changes based on the position of the neck. When we're talking about athletes who undergo extreme forces in the neck, these highly unconstrained mobile devices are not indicated for surgery. So this is one thing we know for our athletes that we're gonna want a much more constrained device. So we have some data to support that these artificial discs can improve mobility. We need to make sure that they have high levels of stability especially in the athletes that are undergoing and participating in contact and collision sports. Of course, we have to think about safety in terms of not just the mobility and stability of the device, but in terms of complications. So artificial disc replacement, like any joint replacement surgery, comes with the risk of heterotopic ossification or HO. And in these artificial discs, we actually see up to 60% radiographic evidence of HO development around the surgical site. Fortunately, a lot of this is not functionally limiting their range of motion. But again, we need a lot more studies in athletes to determine if this is gonna impact the level of range of motion that our athletes need. We also have device failure. So again, a lot more stress and strain through the device in athletes compared to the general population. So they are very likely at a higher risk of device failure. Now the catastrophic device failure that I think we worry about the most, which would be retropulsion of the device into the canal, has not been reported. I think there's maybe a couple cases of retropulsion of the device, but none of those patients had nerve injuries. So that's much less likely, especially in these constrained devices. But we do need to worry about the need for revision, which is in most cases a fusion, when there's device failure after we're not sure how many years of playing football, of playing hockey, of playing rugby. So I think we can make some conclusions, but really the conclusion is that we don't have enough evidence here to make an evidence-based decision. So we just have to, for these patients, make a thoughtful decision with the best evidence we have. And that is that an artificial disc replacement may be a viable alternative, but we have to use a constrained device, and we have to continue to follow these athletes to make sure that their safety profile is maintained. So with that, I'll go to the group, if anyone has any thoughts or concerns about this. Sure, I got two words for you, Peyton Manning. Yeah. So Peyton Manning, I think this is one of those situations where you have to really figure out the patient's values. So in Peyton Manning's case, he had a contract that was for three more years, and he was willing to have some suffering to get to a successful Super Bowl in those three years. This other gentleman, playing hockey, he might be going for a 10-year, a 20-year hockey career, which would be a very different thing. Yeah. It's well said in terms of your presentation. The challenge here is that a single-level ACDF works well in collision sports. See it all the time in professional football, go to the combine, you don't flunk a guy because he's fused a C5-6. So it works. And you can get into tiger territory when one of these devices fails. Even if it's not catastrophic failure, it's hard to get out. There's all those pesky structures in the way, like the current laryngeal nerve and all those things that are problematic. So I think the player has to understand, you're taking a procedure off the table which has been proven time and time again to be successful in collision and contact sport, and you're doing something else under the idea that it may spare segmental motion. Part of the problem is that people who have early disc herniation may have multiple-level degenerative disease anyway, so they're gonna go bad no matter what you do. So you can't make this guarantee that if I do this, it's gonna save these other segments. So those are the problems. And the other question is one of level. So what if it's a 3-4 disc? What if it's a 2-3 disc, with or without fusion? I mean, do you put an artificial disc at C-3-4 and clear that athlete with the same assurance you do if it's 5-6, all that pesky stuff, the phrenic nerve and all that stuff? And those are the more common disc herniations in our athletes, right, compared to the general population. So I think all these points are really good. I think we are, the point is to think about the future of these athletes, not just while they're playing, but later. So I do think the evidence that adjacent segments are preserved is important for their future because we've seen lots of patients with chronic neck pain that are dealing with this, getting an additional level, getting a fusion extended. So we're trying to save them from that in their future, not just necessarily their playing career. You just can't promise them you're gonna do it, though. That's what I'm saying. You can say it makes sense, but you can't promise them it's gonna happen to them. And you can't promise them that they're gonna, if they have problems, they're gonna end up having a fusion. You can say, I hope this is a shorter recovery. I know this case, and I mean, it is a challenge. But once again, it's sort of like, well, what did Dr. Google say? These players come in, and I say, I say, who have you been talking to about this? And my agent, and there's a guy at the bar that I like. There's a lot of stakeholders for these athletes. I've never promised a patient anything. But I do think, though, it's a good strategy, actually. Makes the visit shorter, too. I do think, though, as non-surgeons, that it's important that you own this conversation, because you're just passionate. You're not putting it in. You're not getting, you're not a content expert for the company that's putting it in. So I think as a non-surgeon, you can say, listen, I don't know if I have all the answers, but I raise the exact same things that we're talking about. What have you been told about the guarantee that it will preserve motion? You ask the player, what have you been told? Or you say, what have you been told about how hard it is to fix this if it goes sideways? And I just think that you can raise those questions so that they can have an informed consent conversation with their surgeon. When I'm talking to patients about surgery of all types, I often use the adage, to a hammer, everything's a nail. So don't go be a nail, consider your options. I mean, this is why we wanted to have this discussion, is we're not doing these surgeries, but we should be thinking about when patients are coming in, seeing these news stories, and seeing a billionaire tweet about it, having some understanding of counseling the patient. Okay, let's go ahead and move on. All right, so our next segment here comes from the show. If you're familiar with part of the interruption, you'll recognize a segment which we're calling 10 Good Minutes. This is an interview with an expert, and we were able to talk to Dr. Charlie Kenyon on baseball injuries. And so we're gonna play that interview for you now. That's my future major leaguer right there. Yeah. Yeah. Kenyon is a physiatrist and sports medicine doctor who Dr. Herring and I are lucky to have work with us at UW. He has a passion for and expertise in all things baseball. And in fact, before he became a physician, he worked in sports science with the Seattle Mariners. Dr. Kenyon, welcome to the show. Thank you both for having me today. So I'll start us off with a question here. A news article was published earlier this year and highlighted the story of a young man who underwent Tommy John surgery as a senior in high school. There was a doctor quoted in that story who said, there's just been an explosion of these injuries in these throwing athletes. Dr. Kenyon, you recently authored a review article called Physical Development and Workload Considerations for Youth and Adolescent Baseball Athletes. What do you feel, in your opinion, is driving this, quote, explosion of injuries in young baseball players? Well, Dr. McMullin, I think this is a very complex issue that's affecting us all, not only as physicians, but also all of us as parents out there. I think in the physiatry world, we're very lucky to have some dedicated researchers and advocates in this area led by Dr. Zeramski, Dr. Bowers out in Emory, and on the softball side by Kayla Holtz up in our neighbors in the northwest corner up there in Canada. But certainly there's gotten a lot of attention on the Major League side of these injuries getting bigger, but also we're seeing this data mirrored for our adolescent athletes, which is a growing concern, particularly as these are getting to surgical cases more frequently, there's growth of baseball. First, we used to worry about this in the southeast, we could play baseball a year, and now even up here in the gloomy northwest this time of year, there's plenty of indoor baseball facilities, and kids are playing all year, they're seeing their heroes throwing 100, 105 miles an hour and they're wanting to get out there and do the same thing. And quite frankly, their growing skeletons aren't always prepared for that. So I think it's a combination of a lot of factors we discussed in the review. One, there's a certain amount of load that the elbow can tolerate. Two, these are vulnerable skeletons. Three, in that period of early adolescence is oftentimes when people are optimizing their throwing mechanics while also getting a lot of power, strength, and velocity. And then we're also asking these athletes at the same time period to often begin specializing, which we also know can be a risk factor. So, you know, I think it was very important that we as physicians, but also as parents, advocate for the safe and healthy development of our young athletes. Yeah, speaking of being a parent, I have a 10-year-old, and while I have you here, I'll ask. He plays competitive baseball. He plays 10 months a year, three to five days a week. They follow the MLB restrictions for pitch counts in games, but is there another way he should be managing training load? Like, is this enough, or are we thinking more broadly across the year? Yeah, so see, even in Colorado, there's year-round baseball players these days. So I believe what we're referring to is the MLB Pitch Smart pitch count recommendations, which do have age-appropriate recommendations at each level. So I think that's a great foundation. I think the challenge is, I'm sure this is not just one team. It's a team, either, that your son's participating in. So the challenge not only becomes this following the pitch counts for one team, but then making sure there's communication across leagues, and different leagues will mandate different guidelines. It's different across states, again, as our colleagues have demonstrated in their review articles. So it's a challenge. I think it's a good foundation, but I definitely recommend that anyone interested in this topic reads the recent publication by Dr. Kriz and Dr. Zemski and Dr. Bowers and other colleagues on that article as well, that these recommendations, while they have a good foundation, they're still, we're seeing this rise in injuries. I think we still need to be comprehensive. We need to lay a good foundation of athleticism for youth athletes. And in particular, again, at this 10-year-old age, he's about to enter this period of early adolescence where he's about to hit his growth spurt, which will lead to whole other considerations in terms of Little League elbow, Little League shoulder, some of these growth plates are becoming vulnerable. So I think we need to take careful considerations in how we're managing these athletes. I think the pitch count, other guidelines are a great foundation, but we are starting to see some other tools such as technology, wearable sleeves, accelerometers, or tracking some of these loads in more objective fashions. But also then you're asking your 10-year-old to try and remember to plug in his sleeve every night and upload his data, which if anything like mine, we're still working on brushing our teeth. So I think in the end, a nice practical foundational approach and establishing good habits is great. But I think, again, we need to have both our parent hat and our physician hat and make sure that we're advocating for our athletes in a time where there's certainly other pressures. And I think just keep bringing that emphasis back onto athletic development and making sure that they're having fun out there. He would love to buy more gear, so I like that recommendation for more technology. My six-year-old, my first grader is always already deep down on the gear train. Exactly. You had mentioned earlier on seeing some of this in the MLB. And earlier this year, we had a lot of articles coming out saying that there's, you know, quote, this epidemic in injuries in Major League Baseball. Is some of what you're seeing in the youth game translating to the MLB? What factors are at play there? Yeah, I mean, I think it's twofold. I think that pathway goes both ways, right? So I think we're seeing generations starting to enter those higher levels of competition that were raised on more aggressive travel ball schedules, more opportunities to play. And we're still learning about how all that sorts out. There's some interesting studies that compared, you know, single sport MLB athletes, multi-sport athletes. You know, these are observational studies, but does seem to have some protective effect to be a multi-sport athlete in your development. But then on the flip side too, you know, we just talked about it with the gear, right? Like I can already see my six-year-old that he's out there emulating Julio Rodriguez out there in center field. You know, Julio's got this protective pad. He wants to wear that. And, you know, they're just wired to try and replicate their idols. So I think, again, when their idols are out there throwing a hundred miles an hour, and that's the primary goal that can drive some behaviors and load and the young athletes not always ready to go that way. We know that the growth plates around the proximal humerus, those are closing somewhere between 60 to 20 years old. And similarly, the medial epicondyle typically closes around 14 to 16 years old. So we're asking these young athletes to put on loads and stress as well before they're fully skeletally mature. And, you know, it's our nature. We want to replicate our idols. But, you know, I think, again, we need to focus on having fun as the primary answer and everything else will come. Yeah, Dr. Miron and I know nothing about replicating our idols. We're not up here on stage with a couple of people we've looked up to at all or anything like that. Yes. Well, this has been great. Maybe as closing, we'll ask you, Dr. Kenyon, what's the next big thing in baseball medicine? What should we be looking forward to seeing in the next review article, the next papers coming out? Yeah, I mean, I would love to get the chance to expand these thoughts to some practical recommendations. I think a lot of this comes down to a question of risk award, right? So there's this perceived reward of getting out there throwing hard, earning a scholarship, and hopefully being a major league baseball athlete. You know, statistically, that's a small percentage of people that get there. But, you know, I think we all want to encourage everybody to be as skilled as Chris in his epidural injections, right? So I think that there's a risk and reward to this. We want to encourage, as in all times, our young athletes to be out there and active and playing. We want to make sure they're doing that and having fun in age-appropriate fashions, but acknowledging that, you know, some athletes will choose to specialize and choose to take these paths, and our job is to help mitigate some of those risks as they develop. So, you know, I think the next big thing may be easy to point to, you know, technology, whether that's motionless or markerless motion capture, these wearable technologies that may facilitate monitoring some of these things more in real time. But what I would really like to see become the next big thing is just a re-emphasis on the youth athlete as an environment to have fun, play with your friends, be out in the park. And I would really like to see a resurgence of a wiffle ball this next summer. So getting out there, playing some wiffle ball games rather than getting out there and sweating it out in fields out in Eastern Colorado, wait for the next tournament game. But I think if we can bring it back to fun and fundamentals and continue to learn how to best apply age-appropriate development models during athletes, then we have a chance to move things forward. Well said, Dr. Kenyon. We'll let you get back to work. Thanks for being with us today, though. Thank you, guys. Thank you so much. All right, take care. Yeah, you know they're training. Yeah, but they're not crazy training, right? All right, so we're getting closer to the end of our time here. We have one last topic to go over. So again, if you're familiar with the show, you may see the segment Mail Time where we talk through a submitted question. So our question here is, I've got a 19-year-old gymnast with lower back pain. I'm suspecting they have a spondylolisis. Should I get a SPECT CT or MRI? So this question has been around for a while. This expert opinion article came out. Dr. Stander, who I saw earlier in the audience, and Dr. Herring authored this one back in 07. And there it was labeled as a current controversy in sports and musculoskeletal medicine. And so this is a question we still think through. And there have been changes over time. Back in 07, they referenced this article here, which looked at CT versus MRI as far as the diagnostic accuracy of looking for a PARS defect. And what was found was of 40 athletes in which a PARS defect was seen on the CT SPECT scan, the MRI picked up 29 of those. So 29 out of 40, which means about a quarter of those athletes, the MRI missed the PARS defect. So at least at that time, we're still seeing the CT scan as being a gold standard of diagnosis. Technology, of course, has evolved over time. And this has been restudied. But even in more recent studies, we still see that CT scans have a higher sensitivity and lower false negative rate than MRI. And this was a study done in 2019. Even fancier technology is coming along. This is a kind of special sequencing on MRI. And the picture in A there is a T2 sequence where really we're not seeing a PARS defect. But with this sequencing in images B and C through the MRI, we actually can make out that defect. So maybe with a change sequence, we can pick up more of these. But you'll see the clarity in that CT scan in the letter D there is still probably much sharper Of course, CT scans come with radiation exposure. And when we're dealing with teenage athletes, that's maybe not as ideal. And so that's the kind of balance we're thinking through. But I'll just kind of toss it to the group. Are we doing a spec CT or an MRI for this athlete? I'll start. And so if it looks like a duck and smells like a duck, I'm wondering if it really needs some advanced imaging. So I try to do my best to not get the advanced imaging because then you get into this almost false controversy of using the imaging to treat the patient. So personally, maybe an AP lateral, no blikes to begin with. And if you see something suspicious or if their story really fits, then just treat them like they have a stress injury to their parts. Yeah, but I got to play in the game in a month and I don't have time to rest this for three months. So what am I doing then? Going to a different doctor. Fainter's answer is ultimately correct. And the reason it's ultimately correct besides he's a nice guy and has read a book is that whether or not porous fractures heal with bony union, they often do well. All right, so the disconnect between bony union and clinical improvement is, so you could make the case that say, well, you may have a porous stress reaction or fracture that we can't see. And whether we rest you or not, it may or may not heal. But we do know if we rest you 10 to 12 weeks, you do well. So if we're not really careful, you'll be fine, right? That's, you know, I didn't figure the other way. So you can make that. I think that's a very strong argument and a good epidemiological argument. If this is a 19 year old, let's just say it's your kid who's on the cusp of making his mother's dreams come true. And there is a time push. The temptation is to use MR because there's no radiation. Unfortunately, the 2018 study and the 2019 study never compared the MR findings to bone spec. They compared it to CT. So it has, the 2007 study hasn't been replicated. And so while there's a discussion about certain image sequences may be helpful, as we all know, what magnet, you know, what tech, what radiologist, there's so much variation that translate that to practice. So I tell my patients the same thing you do. I say, look, if you really need to know, you know, if you really need to know if there's a porous stress reaction here, particularly an early one or a fracture, you have to get the spec scan. I mean, I'm sorry, you can get the MRI and if it's normal, you feel better, but you're not home. If you wanna get the MRI, because it's Seattle and we need to do some advanced imaging, you know, then you can do that. But if the MRI is normal, I still, I'm probably gonna recommend that you rest to see if you get better. But if your tolerance for uncertainty is zero, which often is for many of the people that we all treat in this room who are very high level athletes, or there's contract issues or there's aging issues, or parent issues, you know, actually, if you came to see me, I would get a spec scan on you and your son. It's just a, just, you know, the whole family would get scanned. It's a, you know, it's kind of a, just, you know, and everybody goes home happy. I wish it was the case that we could say MRI had, consistently, and Chris, we, Chris and I weren't, Chris Stannard is, oh, it's good to write papers with Chris Stannard because he's so smart. Well, Chris and I saw, the old Chris and the new Chris, but what we all see is, to this day, I see it. They come in and the MRI is normal and they're still hurting, you know, and their parents are not helicopter parents, they're Apache attack helicopter parents. And they need to know, and the spec scan lights up. I'd say, I'm not sure this is gonna make any difference, but I can tell you with certainty what this is. I just wish that we were there, but I don't think we can be there because we want to be there because we just want the MRI to work without someone doing, repeating the 2007 validation study. I got another question. So how do you really say this word? Spondylolisis? Yeah, exactly. Spondylolisis. But when you're in sports medicine, you can abbreviate everything. Hey, doc, you can call them spondies, you just call them spondy, you know, and you go with that, exactly. Or you say, I think this is more serious. This isn't a spondylolisis, this is a spondylolisis. You can. All right. That is just about our time. Thank you all. I am gonna read a couple of questions that we got submitted through the live stream and then we'll take questions with any time left. So, first one I'll read here. Though there is no evidence on number of concussions that should merit retirement from sport, do any of you have a number of concussions threshold that would prompt you to have the retirement discussion in a high school athlete in your clinical practice? I would say just kind of my personal practice, it varies a lot on the kind of severity of the concussion, severity meaning the severity of the symptoms following the concussion, the duration of those symptoms, how disruptive those symptoms were. If someone has had three concussions in the last couple of years and they have missed a lot of time from school, yeah, I'm thinking this through that another concussion might mean a lot of time off and missing more school and is that gonna affect future kind of college career plans and so that's how I'm thinking of it is what are gonna be the consequences of another concussion? And so that's how I'm thinking through it a little bit but again, it's not necessarily a specific number. Yeah, I think about it the same way with particularly with increasing duration of symptoms, I'm gonna be starting to have that conversation earlier. If there's three concussions in 18 months and they've all resolved really quickly and haven't resulted in a lot of time loss from school or sport, then that conversation is much different. Right, and this fits well with the shared decision-making model. If you read that retirement paper or if you read the team position consensus paper on concussion that we wrote, this is pretty well listed. So in your rubric of this, it's the number, it's also proximity, severity, recovery curve, did the concussion occur with a smaller, lesser blow? Right, and did the symptom cluster expand? You know, because if you've seen one concussion, you've seen one concussion. I've retired kids after one that didn't get better in six months. So there's no magic number, but I think it's just what your experts here are saying. It's the whole sense of what your tolerance for risk is. Here's the real thing. When people play sports, eventually the sport wins, right? You know, people are not playing NFL when they're 80, unless Brady comes back. And so the realistic conversation is, I know every, your child excluded, who is gonna be a professional athlete, I know that every young athlete thinks they're gonna play in the NBA, right? And you say, listen, you've had seven concussions and you're 17 years old. I got news for you, basketball at college is harder. There's more contact, the season's longer, and this isn't gonna go well for you. Not to mention that no school's gonna take you. So it's just conversation of saying, the future doesn't portend well, the future doesn't portend well, and I know that you like playing basketball, but please do your geometry homework, because there's a bigger chance that you're gonna make a living outside of sports. So it's all those sort of, this is why physiatry is good in this space. It's not a number, it's a psychosocial biological decision, right? So using your skillset to understand the social context of this injury, as well as helping them understand what their future hold is really important, and no one can do that better than the people in this room. So that's why I like this question. So yeah, get your, read those papers, and we've laid out things that concern us, but the biggest piece is just a moment of reality testing. And if you take away the sport, though, give them something else. You just can't take it away without, it's not retirement, it's redirecting. Other question, this was in response to the discussion on nerve hydro dissection. What is your patient selection criteria? For those with clear ulnar nerve motor weakness from entrapment, would you pursue this prior to referring for surgery? And do you have medical legal concerns about this? I think if I am seeing someone with ulnar nerve motor weakness, I mean, obviously, I wanna look at what the severity, the degree of that weakness is. I think, I'm looking at the EMG. Do they have signs of axonal injury, signs of loss of motor unit recruitment? And I am, prior to a surgery or a nerve hydro dissection, I'm seeing if I can treat this through a rehab approach. What are they doing that is irritating the ulnar nerve, whether it's sport-related and it's their throwing mechanics, or it's job-related. And so I'm first taking that approach. And then going from there, I would be having them meet with a surgeon prior to doing a nerve hydro dissection. I'm not just jumping to a nerve hydro dissection and then referring. I want them to at least have that discussion first. And that doesn't mean I'm signing them up for surgery either, but that's kind of how I'm thinking through it. Yeah, I would just add, my branch point wouldn't be weakness. So weakness, as you guys know, can be from conduction block or axonal loss. So I think the electrodiagnostic testing would be helpful in this case. Perhaps if it's more demyelinating, a hydro dissection would be more favorable, but I think more research is needed. Get rid of those invisible adhesions. Yeah, and I just want to reiterate, it's mechanics, mechanics, mechanics first. So if this is a throwing athlete, you have to look at the mechanics, what additional stresses are being put on the nerve from that, and can you make those changes to resolve some of these symptoms before considering surgery or hydro dissection. Okay, those were all our submitted questions. Thank you all very much. If, yeah, anyone has questions that we can take now, we're happy to. Thank you.

sports medicine

early sports specialization

nerve hydro-dissections

concussion management

artificial disc replacements

youth baseball injuries

overuse injuries

athlete assessments

training limits

evidence-informed decisions