Hello, everybody. I'm Mike Gaddafi in Kansas City, sports medicine physiatrist, and I am very, very excited to be here today with four of the biggest hitters in the sports medicine arena, Drs. Luca Podesta, Dr. Mike Fredrickson, Brian Todibush, and Ashwin Babu. I'm going to go ahead and get my slides shared here for everybody to see. Preventing these common and often career-ending injuries is really the holy grail of our field, and as you guys learn from these great, great minds, you'll see a handful of patterns that are emerging for injury prevention across body regions, across sports, and across injury types. In that process, we'll be delving into detail on two specific overuse injuries and two specific sudden injuries. These four sports physiatrists are clinicians and researchers, and they're also team physicians for all levels of sports, caring for the full spectrum of age and skill level. This next hour is jam-packed with evidence and pro tips in injury prevention. We're going to get started this evening with Dr. Luca Podesta. Dr. Podesta has been team physician for many, many professional teams, and with particular respect to his talk tonight on prevention of throwing injuries at the elbow, he has been heavily involved in Major League Baseball, and in particular with the Los Angeles Dodgers. In addition to his clinical work, his research on UCL injuries and throwers has influenced most of our practices, certainly my practice. I am very pleased to introduce Dr. Luca Podesta. Thank you very much, Mike, and thanks for inviting me to this session. It's really exciting to talk about something that I really love, injury prevention in the elbow. It's one of my hot topics, and I love speaking about it. If we can advance these slides. These are my disclosures. Nothing really pertains to this talk. Go ahead, Mike. Any conversation about injury prevention in throwers, Mike, you can hit that button again, involves the medial elbow. In the medial elbow, we're talking mostly about the ulnar collateral ligament, and this particular ligament during the throwing motion is under tremendous stress. Next slide. The anterior band of the ulnar collateral ligament complex is the primary restraint to valgus stress across the ligament, especially during this explosive acceleration phase of throwing when that arm is going through that very quick and fast stressful motion. With repetitive throwing, there's microtraumatic tears that develop in the UCL, which triggers thickening of the anterior band. Over time, the ulnar humeral joint will widen due to ligamentous laxity. Eventually, ligamentous calcifications can occur. The ligament becomes stiff and then can actually tear. When we talk about prevention, first of all is looking at the definition. Really, what is prevention? Well, it's an action aimed at eradicating, eliminating, or minimizing the impact of a disease or disability. Over my 32 years of treating professional baseball and all levels of baseball, in my opinion, the only way to truly prevent elbow injuries or UCL injuries in this throwing population is to stop throwing. Unfortunately, the problem is multifactorial and the solution is really not that easy. In my experience, socioeconomic issues are related to the problem that underlie all this are much more difficult to correct than the actual baseball-related factors that result from them, such as repetition, fatigue, velocity, and basically throwing too much. You're going to hear this throughout the talk. The key problems in all throwers and what leads to probably the majority of injuries is velocity and fatigue and repetition. Next slide, please. Every year, 3 million kids throughout the United States play baseball. 25,000 of them will be privileged to go on to the next level and play at some level of collegiate baseball, but a very select and fortunate few go up to the next level, which is either minor or major league baseball or independent baseball. Those are American-born kids that are participating and that number is quite small and that percentage is probably less than 1%. Next slide, Mike. When you add in other countries that are feeding into this system now, from Caribbean, from South America, Asia, Europe, that number gets smaller and smaller and it's much more difficult for these to even get considered from a baseball standpoint. As a result of this and these inflated and unrealistic dreams to win a coveted college scholarship or even more so get signed by a major league team, younger players are being encouraged to specialize in various sports and baseball is in particular the sports specialization that's developed to get to the next level has been tremendous. Unfortunately, we're learning that the risk factors with early specialization far outweigh the benefits. Kids can be rewarded with gaining maybe a competitive edge with early specialization. They may develop their skills a little quicker. They may be recognized a little sooner and they may very rarely get a scholarship or get a pro contract, but those risks, but those rewards are far outweighed by the risks of participation. We know from a risk standpoint, there's an increased risk of overuse injury, which is the hallmark of medial elbow injuries and throwers. There's an increased risk of burnout from that sport because they're around it 24-7. There's reduced physical fitness and gross coordination that occurs with just very specific training. There's reduced general health and psychological well-being and increased risk of dropout from that particular sport. We also know that early sports specialization is not really a requirement for success at higher levels of competition. Next. During my years living in California, I was fortunate to work somewhat with Hall of Fame manager, Sparky Anderson. We've had this discussion because he's very pro Little League and he was a big supporter of Little League and Thousand Oaks and of Cal Lutheran University. And we had this discussion many times and he felt it was mostly adults that were at fault. Kids, when we grew up, when he grew up, certainly, and when I grew up, and I'm a lot older than you guys, most of you guys, when we went out and played and we played in Little League, we went out and played, we got tired and we stopped. Nowadays, that doesn't happen. They're pushed by coaches, by parents, again, to try to reach that holy grail. When they play through injuries and when they probably shouldn't play. His philosophy was give the kids what they needed to play, balls, bats, a field, and take the parents and coaches and adults away. Kids will play until they're done, they're tired, and there's no injuries that way. When we look at parents and coaches, the role of the parent is crucial as well as the coach. When a child complains of arm pain, parents and coaches have to act in the best interest of the child and not push them to play through that pain. There's been studies that have shown up to 46% of youth responders to certain surveys said that they were encouraged on at least one occasion to keep playing despite having arm pain. This is crazy. This is a prime example. Mike Hittet, this is one of my college players, he was at a fall workout with his pitching coach. He threw a pitch and you can see him react. He looks at his elbow, he twists his elbow around a little bit. Unfortunately, you can't hear the sound, but he goes over and talks to the coach, says, hey, something happened in my elbow. What do you think I should do? The coach, what do you think he said? Oh, go throw another pitch. What he should have said was maybe we should look at it, just lob the ball, see if you're having any issues, you know, but he has him throw a full pitch and here's what the results are. Which are quite evident, unfortunately. So he had a partial tear of his omiclateral ligament who wound up being treated and losing a substantial amount of time away from his sport. Luckily, this was in the middle of COVID and it didn't really affect his season. But a lot of this is predicated on the economic growth of the sport. Youth sports is a $15 billion industry and has grown by 55% since 2010. This includes travel, private coaching to apps that organize leagues, live stream viewing of games. Major League Baseball in itself is a $36 billion business. But in Major League Baseball, where injuries lead to lost revenues, injury prevention becomes of extreme importance and the prevention of injuries is important to them. When we look at parents and the economics behind it, parents want their kids to succeed at the highest level of baseball or a highest level of competition. And they feel with the ever rising cost of college tuition that the sport may be their ticket to a college scholarship. Although this is not very common, but they all feel this in some way. And in fact, to a worse extent, I've had parents that come in and I'm asking them, why are they doing this? They'll say, obviously, Doc, the main goal is for Johnny to get into the major leagues. And I look at them, I'm like, are you kidding? I mean, this kid is three years old. I mean, how do you expect that? But there are other goals, or at least for him to get a full rise scholarship, which doesn't happen in baseball very often, unless you're a superstar or get notoriety. And again, I mean, their expectations are pretty inflated. Maybe if they put their money aside into a college fund, they may get a little bit bang, a better bang for their buck. Next slide. There's been a great deal of literature describing risk factors in adolescent baseball, especially involving the shoulder and the elbow. But by far the most common risk factors are overuse, pitching while fatigue, poor pitching mechanics, pitch velocity, or trying to increase velocity, and the number of pitches thrown, whether it's in a game, in an inning, or over a season. Next. Other risk factors that have been associated with elbow pain are pitching while fatigued, as I said, throwing too many innings in a year, not taking enough time off from throwing, throwing too many pitches, not getting enough rest, which is a big one. Pitching on consecutive days, excessive throwing when not pitching, especially if you're a catcher. Pitching on multiple teams at the same time, pitching with injuries to other body parts. This kind of sounds a little interesting, but if you can't pick up your target or you have an injury along the kinetic chain, that'll exponentially change your mechanics as you throw a ball. Poor physical conditioning overall, participation in showcases, radar guns, and throwing, breaking pitches such as curveballs and slackers. Now this, this is an issue and it's a controversy right now. It's more the way the pitch is thrown or the size of the hand when the pitch is trying to be thrown as opposed to the actual pitch itself. So injury profiles as well as prevention strategies will vary from young players to professional players or adults. Overuse is the prominent mechanism of injury in youth baseball players, as we said before, and despite the adoption of safety guidelines, such as pitch counts, recommendations, and increased media coverage regarding these injuries and their prevention, unfortunately, injuries to the medial elbow, particularly on the collateral ligament, is not decreasing, it's actually increasing. And it's hard for me to believe in 2021 that it's a lack of knowledge of what to do and how to do it, but I feel it's more like a lack of compliance by parents and coaches and the athletes themselves that are triggering some of these issues. Next. Injury prevention research has been abundant, both on the professional and youth level. Up to 74% of youth players ages 8 to 18 report some degree of arm pain while throwing at some point. 23% report injury history is consistent with overuse, and 5% of youth pitches will suffer a serious elbow injury or shoulder injury within 10 years of throwing. But the one factor that sticks out is pitching volume is the strongest known predictor of injury, and that's been well defined by Fleissig. So when we talk about prevention strategies, what are we looking at? Well, some way we have to limit the fatigue from overuse, you know, and as I kind of alluded to a little bit before, education and implementing guidelines are helpful as long as someone will follow them. Major League Baseball pitch smart program that's a website is exceptional in delineating the number of pitches and the amount of rest that is necessary for a particular age group. Minimizing the risk of specialization and trying to encourage these athletes not to specialize to later ages, maybe later at a later point in high school or early college can also help minimize that risk from that. Getting them on age appropriate strength and conditioning programs and learning how to take care of their arms are also important. Also having an understanding of the biomechanics and the difference between throwing and pitching is important. The necessity to maintain a range of motion throughout the body and total range of motion of the shoulder, minimizing GERD and restrictive movements, which also will predispose to injuries in the elbow as well as shoulder. And then also there's also controversy always about pitch type. And again, it's not the type of pitch you throw specifically as the amount of time you throw it. And some of the latest research has shown that throwing a fastball more is more problematic than throwing, actually throwing breaking pitches. Pre-season screening has also been very helpful in identifying predisposing factors such as weakness, muscle imbalances, and range of motion deficits that can lead to injury. Next. Next slide, Mike. Participation in age appropriate flexibility and strengthening program has also been shown to prevent injuries such as the Oklahoma Baseball Nine program that was reported recently in the American Journal of Sports Medicine by Sakata. He reported players who participated in this stretch and flexibility program had approximately 50% fewer medial elbow injuries over a course of a 12-month period. And it's kind of similar to an ACL prevention program. This is done with body weight or nothing more than the weight of a baseball glove. But other programs such as the Job's Shoulder and Elbow Program or the Throwers 10 or Advanced Throwers 10 exercise were all similar programs. Next. Learning to prepare to throw is also extremely important for injury prevention. I always will preach to young throwers and their parents. It's important for their child to warm up to throw and not throw to warm up. And what I mean by that, they can't get out of the car and get on the field and start throwing the ball. They're just asking for trouble. So they need to learn some type of general body warmup. They need to break a sweat somehow, jog, ride a bike to get their muscles a little bit more flexible and warm. When I was with the Dodgers early on, we had a lot of elder type pitchers that weren't able to run very effectively. So we used to carry a Versaclimber on the plane with us so these athletes can do this prior to warming up and getting on the field. Getting them started on dynamic warmup programs are important. These type of programs can gradually prepare the muscles for baseball specific movements, decrease the chance of injury while enhancing strength, flexibility, and power, as well as increasing motor unit recruitment and synchronization, which is important in the throwing cycle, whereas static stretching may decrease motor unit function. Then eventually after workouts and training sessions, then static stretching can be implemented. Age-related baseball risk factors are also important to recognize and prevent injury as we kind of talked about a little bit before. In the Little League thrower, overuse, arm fatigue, high pitch velocities, as well as participation in showcases and traveling baseball, that just sheer number of throwing too much are all associated with increased risk. Those kids that are unfortunate to mature early and are bigger kids or those kids that play both pitcher and catcher are the kids that are always in the limelight. They're always the pitchers, they're always the catcher, and they're called upon to do more work at a younger age. They're at more of a risk of injury. Lack of knowledge of safe throwing practices by coaches, parents, and players, and the compliance to perform these safety recommendations or follow these safety recommendations is important because if they don't, they're at risk. Whether or not we allow skeletally immature players to throw breaking pitches, in my opinion, it's the size of their hand and whether or not they can actually throw a curveball appropriately. A curveball is the same thing as a fastball, it's just the wrist is in a different position and you're rotating the ball over the fingers. Unfortunately, it's like an adult with a big hand like mine trying to throw a softball. It's much more difficult to get rotation with your fingers. It's the same kind of analogy in these kids, their hand's not big enough to rotate the ball. Prevention of throwing injuries in the young population revolves around limiting, as well as monitoring throwing volumes and practices and games, obtaining adequate rest from throwing, pitching for it and pitching for at least four consecutive months, participating in an age-appropriate strength and conditioning program and slowly progressing pre-season workout intensities as they ramp up during the season. Most importantly, these kids have to have fun. If it's not fun for them, it's just more of a risk of them getting hurt. Next slide. In the high school and college level, and with these throws, the demand on their arms has increased significantly while the underlying risk factors remain the same, overuse, fatigue, and velocity. So injuries are more severe compared to younger players as evidenced by the increased surgical rates that you see in this age population. 13% of only collateral ligament reconstruction are being performed in high school athletes at this point. When I started with the Dodgers in 2000, when the hell was it, 1990, very rarely would see a kid come into the office with an only collateral ligament injury or a high school kid. That was pretty much limited to professional sports. So over the next 10 years, that completely reversed. And most of these injuries we see at this level are gonna really start to occur in the pre-season and early season practices and games because either they didn't throw a lot during the off season or they're not well conditioned, they get into training camp or in the high school season and they start to ramp it up too quickly and get hurt. So from a prevention standpoint, pitch count limits early on in the season, maintaining that strength and flexibility, use of protective gear for more traumatic injuries like getting hit by the ball or maintaining proper pitching mechanics are important to minimize that risk. Off-season conditioning throughout the year is important and actually getting them on a good periodization program so they peak at the time of competition. And then eventually a progression of that pre-season workout intensity early on and then increase to build as the season goes on. Next slide. And then from a professional standpoint, pitchers have a tremendously increased incidence of only collateral ligament injuries and these injuries are continuing to increase. Overuse, arm fatigue, high pitch velocity also are there, but what we're seeing in the professional population, most commonly these injuries are occurring in pre-season and during early season practices and games, usually they'll present as forearm stiffness or outright pain in the medial elbow. We've also noticed that these pitchers are throwing a higher percentage of fastballs, over 40% of their pitches and they're seeing these injuries occurring. The phenomenon recently of weighted balls is extremely controversial in how these are used. There's data out there that shows that these will increase ball velocity and pitching velocity, but there's significant risk of injury that also occurs with this. So from a prevention standpoint at the professional level, limiting pitch counts early on during the season, maintaining strength and conditioning programs during the off season leading into the season and a vigilant maintenance and correction of pitching mechanics is important. Year-round conditioning as we alluded to, as well as gradual progression of pre-season workout intensity is also important to get these athletes through that early spring training intensity. We also try to maintain total shoulder range of motion and range of motion to cervical, spine, ankle, lower extremity and up the entire kinetic chain. And again, whether or not weighted balls are used is controversy, but you're gonna see it. If you watch the game tonight, you'll see it. I had the privilege of my 16 years with the Dodgers sitting with Sandy Koufek for countless hours in spring training, talking about throwing mechanics and it was essentially having a private tutor on how to throw a baseball. And Sandy was very intuitive on what to do and how to feel when you threw. And he used to, his mantra was, it should feel easy to throw hard. And what he meant, if you overuse your arm and overuse your body, it wasn't that easy to throw. It wasn't that easy to warm up. And I think he was dead on and his philosophy is correct. If you minimize the overuse, you're gonna prevent some of these injuries. Next slide. I can't give a talk about baseball without talking about my mentors, Frank Jobe and Lou Yochum, who I worked with for years with both the Dodgers and the Angels. And I can't express how much they taught me about the game and injuries that happen with the game. And thank you very much. And I guess we'll take questions at the end. Thank you, Dr. Podesta. That was just fantastic. And yes, like you said, we're gonna take questions at the end. Feel free to send them in over the chat or the Q&A. And then at the very end, we're gonna have a panel discussion and we'll field all these questions. All right, next up, we have Dr. Mike Fredrickson. Dr. Fredrickson has taken care of the highest level runners in the world as both the team physician for the US teams, as well as Stanford University's runners and various other teams and runners. In addition to his clinical duties, he has added as much new knowledge to our field as literally anybody with a particular emphasis on running medicine and bone stress injuries. I am very humbled to introduce Dr. Michael Fredrickson to talk about strategies in the prevention of grown bone stress injuries. Great, well, thanks Mike for the introduction and hello to everybody who's out there listening. Wish we could do this in person, but hopefully next year. My main objective is to discuss some current research that we've done to optimize bone health and prevent bone stress injuries in our collegiate runners. And I forgot to put a disclosure slide, but I just wanna say, I don't really have any significant disclosures, but just the research that I'm presenting has been funded by the AMSSM as well as the PAC-12 Health and Wellbeing Initiative. So the first area that I really started to focus in was, initially, could we diagnose these injuries better? But then really, could we start to predict these injuries? So this was one study we did, and this is back when Adam 1040 started working with me when he was actually a med student. And we identified sex-specific risk factors for stress fractures in high school runners. And we went out and prospectively enrolled over 30 high schools in the Bay Area. We had 748 high school athletes and they were in the study for close to two years. And these are the risk factors we found that would predict who went on to develop a stress fracture or you could say a bone stress injury. That includes bone stress reaction through a stress fracture. So first was prior fracture. And this wasn't just whether it was a stress fracture, but any prior fracture increased their risk. In the women, late menarche, BMI less than 19, and then participation in the past in sports that emphasize the leanness. So for instance, gymnastics, dance, or distance running. And it was interesting because each risk factor led to a two to three-fold increased risk. These risk factors that were also cumulative. So if you had three out of four of these risk factors, you had a 40% chance, this is in the females, of sustaining a fracture during the next year. Now we also wanted to look and see, could we predict who would have low bone mineral density? So from that larger cohort of athletes, we had 136 that we brought in to obtain DEXA scans. And we found for the boys, the risk factors for low BMD, and we defined this as a Z-score less than or equal to negative one. In boys and as well as the girls, BMI less than or equal to 17.5 was a risk factor for low bone density. And in boys, and this to me was really interesting, just a belief that being thinner would allow them to run faster was a risk factor. In the girls, not only BMI, but this combination of menstrual irregularities as well as a history of fracture was particularly predictive for low bone mineral density. This is another study I just wanted to mention. It wasn't our research, but I think it's really important. They found a positive association between low bone mineral density and training volume. So basically if you were training too much, you were at higher risk for low bone mineral density. And it would make sense that they found this was associated with a negative energy balance. But keep in mind, they found this even in those who had normal menstrual status. So even in the women who had normal menstrual status, even just having a negative energy balance put them at risk for low bone mineral density. And based on this, they recommended that all elite female endurance athletes undergo DEXA screening. So this led me to my next interest was really was could we prevent these stress fractures? So I joined efforts with a colleague of mine at UCLA, Dr. Rilian Nativ, and we have very similar interests and practices. She's the head physician for the UCLA track and field team, has been for a number of years, like myself at Stanford. And we developed this multicenter prospective interventional study to improve bone health and reduce the incidence of bone stress injuries in these division one female collegiate runners. We also looked at the males, I have to say, but we were funded primarily for the females. Now, initially we called this, just go back for that once, Mike, we called this the Injury Prevention Project. And nobody was signing up, we couldn't get the coaches to buy in, the athletes didn't really wanna participate. So we changed the title to the Healthy Runner Project. And we told them, we're really focused on keeping you healthy and ideally improving your performance by keeping you healthy. And when you know it, now everybody wanted to be part of this. And 100% of the team started signing up for this. This was our research team. Next. So our primary aim was to determine if a nutritional intervention in these distance runners could decrease the incidence, the severity, and the return to play time for bone stress injuries prospectively. And we compare this to a historical control group at each institution. We also wanted to evaluate if something, and I'll go into this in more detail, called the Female Athlete Triad Risk Assessment Tool could help us predict who was going to develop bone stress injury. And if implementing this in conjunction with the nutrition intervention could also help us reduce the incidence, severity, and return to play time. These were our outcome measures. So we looked at all bone stress injuries. And again, just bone stress injuries is sort of the newer term that encompasses a stress reaction to a whole bone stress fracture where you have a cortical break. So all these injuries were documented by a physician. They were all confirmed with radiographic imaging. Energy availability was evaluated with a registered dietitian three times a year. And for bone health, they all obtained a bone mineral density test, ADEXA. We also looked at vitamin D levels and some other recognized bone markers of bone health and energy metabolism. We based a lot of our study on this 2014 consensus statement from the Female Athlete Triad Coalition. And I won't go into this slide too much just because I'm sure most of you are familiar with it, what composes the female triad. But keep in mind, there is also a male triad that has a lot of parallels to the female triad. And we just published two papers from a consensus meeting that we had to define this, going over the scientific basis for this, as well as recommendations for diagnosing, treatment, and return to play for the male triad. So it's real. It definitely exists. And it's very similar in that it's set off with this low energy availability. It can lead to low bone mineral density. Now, in the females, what you're going to see, as we know, is menstrual dysfunction. But in the males, you're going to get hypogonadotrophic hypogonadism. Now, that's a little bit harder to detect, but there are ways to do that with some screening questions, as well as obtaining a testosterone test. So this is that triad risk assessment tool that I mentioned. And I would really encourage anybody who's working with distance runners and doing pre-participation physicals to consider this, if you're not using it already. So the risk factors that are evaluated, one is low energy availability. And this could be with or without a frank eating disorder. This, I have to say, is the most subjective marker and can be the hardest to measure. And that's why working with a dietician can be helpful. I would say as a proxy, though, we have found that 3T3 can be very helpful as an indicator for low energy availability. A low BMI, which is easy to measure in the clinic, is helpful. Any history of delayed menarche, as well as oligomenorrhea or amenorrhea. Low bone inner density. Now you do need a DEXA for that, but even if you don't have that, just looking at these other risk factors can give you a pretty good idea about their risk. And then finally, history of stress reaction or fracture. So basically you document all this, you can assess low risk, moderate or high risk, and then add up the points. And based on that, can determine if your athlete is full clearance, whether they're with low risk or no risk, are they moderate risk? So you'll have provisional or limited clearance, or whether they're high risk and you might consider restricting them from training or competition, or even potentially disqualifying them. So as we know, these are the main components of the female athlete triad. And the one that we really wanted to focus on again, was this idea of energy availability, because this is really what sets off the triad. It's that low energy availability that leads to low estrogen, that sets off the menstrual dysfunction. You then can't absorb calcium very well, and now you've got low bone mineral density. And one of the reasons we wanted to focus on the low energy availability and correcting that, is just that by correcting that, you can start to see changes within days to weeks, in terms of some of their energy markers and hormone markers. Correcting menstrual status is very important, and we certainly do address that, but it can take many months to see a recovery in terms of that. And it can take several years to see a recovery in their bone mineral density. This is just an example of what happens if you have adequate energy availability, you're taking an adequate food intake, basically your sex hormones, your growth hormone, thyroid hormone are all functioning normally, and you have normal stress hormones. So your cortisol levels are at normal levels. Now, if you have low energy intake, now you can see it affects all your hormones, decreased sex hormones, decreased growth hormones, decreased thyroid hormones, and your stress hormones, again, particularly cortisol can go up. This was our study protocol. I'm not going to bore you with all of it, but just very briefly, we had athletes fill out an extensive risk factor questionnaire, and I'll show you one part of that. They had an extensive nutrition assessment with a registered dietitian. They were also involved, and we gave them an app, and we'll go over that that was developed specifically for this study. They all had a DEXA scan, and these are some of the labs we had, and not to say that we're recommending this on everybody, most of these were for the purposes of research, but I would say we have found vitamin D quite helpful just as a routine screen, and then some of these other markers if you really want to do a more extensive workup. And then free T3, again, we found this really helpful in terms of giving you a proxy measure for low energy availability. This is just one part of our study questionnaire, but this looks specifically at some of these questions that were recommended by the female athlete triad consensus statement. So have you ever had a menstrual period? How old were you when you had this? When was your most recent period? How many periods do you have in a year? Are you presently taking any female hormones, particularly, you know, birth control pills? Do you worry about your weight? Are you trying, or has anyone recommended that you gain or lose weight? Are you taking a special diet or avoiding certain foods? Have you ever had an eating disorder, stress fracture? Have you ever been told you have low bone mineral density? So now you have to rely that they're going to give you honest answers on that, but assuming that they do, that can be helpful to include in your PPE. So again, we wanted to focus on getting all these athletes back into normal energy balance and, uh, click it again. So, uh, low energy availability is defined for the purposes of our study. And, uh, some people will use higher numbers with the purpose of our study. We defined it as less than 30 kilocalories per kilogram of fat-free mass per day. And the goal was to get them to balanced energy availability of at least 45 kilocalories per kilogram of fat-free mass per day. They all underwent this web-based nutrition screening survey. They had one-on-one meetings with a sports dietician looking at their current energy intake, any risk factors for low energy availability, other nutrition deficits. And then we tried to keep it simple. Every season we would just give them one or two nutrition goals that they could focus on. We tried not to overwhelm them. Some things that would be very practical to do and to do in a college setting where they're, you know, eating, um, in a dorm setting. We also, uh, involved them, uh, in using our RunFueled app. And this was consisted of two four-week modules, uh, throughout the study period that basically gave them different, uh, information on nutrition, video clips on recipes, um, motivational messages in terms of why it's important, uh, to, uh, have, uh, healthy nutrition, um, how this can improve their performance. And then, as I mentioned, for each of these athletes, we did calculate that, um, female athlete triad cumulative risk assessment score, um, that we went over those six factors at the beginning. And this was very helpful that, uh, we found that, um, in the females, um, the score predicted future bone stress injury, um, quite well. And each additional one point increase, uh, increased the risk by 13 percent. In the males, um, we also found that it was statistically significant, and each one point increase in the cumulative risk score was associated with a 37 percent increase in risk for prospective bone stress injury. We also found that higher scores were associated with a significant delay in return to play in those runners who developed a bone stress injury. And each one, one point increase in the, in this, their cumulative risk score increased the time loss from injury in days by 17 percent. So, just to finish up, these were some of our results, um, and I'm going to focus first on our, uh, bone stress injury rates, um, and we stratified them by school. Um, fortunately, uh, Stanford was quite successful. USOI's results, uh, were not quite the same, but, but I think we have some reasons for that, and, and it actually, um, is quite interesting. So, at Stanford, in the women, there was a significant reduction in our BSI rate, uh, during the intervention phase compared to our historical phase. Um, just to give you an idea, we were up at a point where about 38 percent of our women were developing a, a stress injury every year, and many of them, pretty significant stress injuries, like in the pelvis and such. Uh, we cut this down to about 14 percent. Uh, UCLA, um, actually had an increase in their BSI rate compared to the historical phase, but there are some reasons for that, again, that I'm going to go over. Now, for the men, um, at Stanford, we saw, uh, a reduction in the BSI rates, uh, in the men. Um, it was not significant, but the rate in the men wasn't that high to begin with. It was only about 10 percent incidence. At UCLA, there really wasn't any change, uh, between the intervention phase and the historical phase. We then compared, uh, whether we had a greater impact in decreasing the incidence of trabecular, uh, injuries in trabecular bone versus cortical bone. So, trabecular bones, such as the sacrum, femoral neck, calcaneus, um, if you develop a stress fracture or bone stress injury in trabecular bone, uh, that's worrisome because, uh, that's an indication, uh, that those bones, trabecular bone is more, um, uh, controlled by metabolic function. Um, and so, if you're developing stress injury in that area, it's very concerning that you're risked for something like osteoporosis. So, we were able to cut the rate in both schools of trabecular bone stress injuries, uh, in half. Uh, the rate of cortical bone stress injury was unchanged, um, and this makes some sense just because those are less affected by, um, things such as the triad. Now, in men, uh, the overall rate of trabecular bone stress injuries was really low to begin with, um, so we didn't see much change, but we did see a non-significant, uh, decrease in cortical bone stress injuries. So, just to summarize this, uh, at Stanford, we did see a steady year-to-year decline in our bone stress injury rate for both men and women, um, in both our pilot as well as our intervention phase. One thing we found is that it definitely takes several years, uh, to see an effect for this. It doesn't happen overnight. Um, some of this may be because it takes time for the change in hormonal response and the subsequent bone health changes. As I mentioned, it can take years for the bone health to really improve, um, and you have to say, okay, why did, why did UCLA not have the same, uh, impact as we saw at Stanford? And we tried to figure this out. One is that UCLA, um, was already using a team dietician, so they were already probably implementing some of the interventions we were doing, but more importantly, uh, during the study, they lost their dietician, they had a coaching change, and all these things can really affect the culture of the, uh, team. Um, what I found more than anything in, in getting at Stanford to have a positive effect was that we had to have good communication between our physicians, our coaching staff, our athletic trainers, our athletes, um, and it was really shifting the team culture to really buy into this, that healthy nutrition is really important and it can really not only keep you healthy, but can improve your performance. And it got to the point where, uh, the head coach for the women's team was actually buying nutrition and recipe books for the, for the, uh, team and like going over this at team meetings without us even asking her to, and things like that just make such a difference, particularly when the kids on the team and particularly the captains buy into this, and they're just really emphasizing this to the junior athletes. Again, hormonal response and bone health changes, uh, take time. And then this triad cumulative risk assessment tool, uh, can be very helpful to measure your outcomes and guide, guide your clinical decision-making. So with that, I will stop. And then, uh, again, if we have time for questions at the end, uh, I'd love to answer things. Thank you, Dr. Fredrickson. That was just fantastic. Not too many times in our lives where we hear from a researcher with that much direct data and, uh, certainly hope that we're able to implement programs like that in the future and can decrease our injury rates like the women's Stanford team has over the last four or five years in their runners. And Mike, I, I just, if I could just add, you know, based on the success we had at Stanford, even though we didn't see it at UCLA, the PAC-12 has now asked us to introduce this program to all the PAC-12 schools. And if that goes well, hopefully we'll introduce it throughout the NCAA. Yeah, that's very exciting. And then high schools, you know, that's, that's where a lot of this starts. Absolutely. Excellent. Thank you. Very, very exciting. All right. Well, hard to follow up our first couple of talks, but we're going to let Dr. Brian Totobush, give it a try. Dr. Brian Totobush, who I am excited to have called my colleague for over the last decade, was himself a college basketball player before pursuing medical school and physical medicine and rehabilitation residency at the great university of Missouri, PM&R residency program and a sports medicine fellowship at UC Davis. During his high-level athletic days, he did not undergo any ACL injuries. And so I think he has a little bit of a personal wisdom to pass on. And in his time, and as a sports medicine psychiatrist, as an attending at MU, he's developed a particular expertise in especially ankle and knee injuries. So with all of this, you know, ankle and knee injuries in it. So with all of this experience and expertise, I'm very excited to present to everybody, Dr. Brian Totobush. Thank you, Mike, for that kind introduction. I'm excited to talk to you all tonight. And no, I have not sustained an ACL injury before, but I've had other teammates that have had ACL injuries and hopefully can shed a little bit more light on this injury and go into in-depth on some of the upcoming research. Go ahead. Next slide. So no disclosures to present. I'm going to quickly talk about review of the epidemiology and the impact of ACLs injury, and then we'll move on and have a more in-depth discussion on the risk factors and biomechanical mechanisms that occur during the non-contact ACL injury. And finally, I'd like to spend a little bit more time going to in-depth on some of the established ACL injury prevention programs and what we can do to prevent ACL injuries. So this doesn't come to a shocker to most of you, but, you know, with all due respect to the other talkers tonight, ACL injuries are a pretty big deal. And all you have to do is check your social media, watch your local sports cast, and you'll see some story related to an ACL injury. And for example, this was when I was creating this talk, I just did a quick web search and found six separate stories related to ACL tears. And these were amongst mostly professional athletes from various sports, basketball, football, baseball. But as physicians, we know they're important, but what's also important to know is our patients are aware of the severity of ACL tears. And when we're treating someone with an ACL tear, personally, when I see somebody with a knee injury, the first question they ask is, do you think I tore my ACL? And it's always heartbreaking and disappointing when we have to talk to somebody about an ACL tear. So quickly, the epidemiology, we know the incidence ranges somewhere between 100 and 250,000 in the U.S. per year. And primarily what we're focusing on is kind of that mid to late teenage year into the early 20s associated with either organized athletics or recreational activity. It's important to note that females have a substantially greater incidence compared to male counterparts. And we'll go into detail about why that is later on in our talk. And we know it's primarily with sports with high dynamic loading, such as soccer, basketball, football, and gymnastics. And also very important to note is up to 80% of ACL injuries are due to a non-contact mechanism. So we can't really do anything about the contact mechanisms that cause ACL tear. But if 80% of these are due to non-contact, that leaves a pretty big room for some type of intervention to try to decrease the rates. So quickly, why are ACL injuries so devastating? Well, I think we can break it down into short and long-term consequences. First is just the recovery process. So short term, we're looking likely at a minimum of a year away from sport and return to play, and sometimes up to two years. There's substantial cost with bracing, surgery, rehab, and then there is an elevated risk of contralateral ACL injury during that initial return to play period in that first one to two years. Long term, unfortunately most ACL tears also come with other pathology, and that can include a meniscus problem or intraarticular cartilage problem. And we do know that individuals, sorry Mike, individuals that, can you go back real quick, do have an ACL tear, a much higher significant risk for a future ACL tear, and long term anyone who has had an ACL reconstruction has a significant risk for osteoarthritis in the future. So how do non-contact ACL injuries occur? Well you know it's important to briefly review the anatomy. We know it attaches to the medial wall, the lateral femoral condyle, and inserts into the anterior tibia. The primary function of the ACL as we know is to resist anterior tibial translation and also prevent that rotation of the femur on the tibia, and that's your pivot mechanism. Secondly, it's going to assist in varus and valgus moments of the knee and help stabilize the collateral ligaments. So usually when we're discussing mechanisms for non-contact ACL injuries, we're either talking about a landing movement from a jump or some type of change in direction from a pivot or deceleration. And the famous position, which we'll call the position of no return, is what you see illustrated on the right of the screen. This is landing with an extended hip and knee, the knee in valgus position with internal rotation of the femur and external rotation of the tibia, and this is the most vulnerable injury or this is the most vulnerable position that we're looking to avoid. So there's quite an extensive list when you look at risk factors for ACL injury. I'll briefly mention some of these and go in more in depth on the next slide, but of course you have your non-modifiable risk factors, which we mentioned female and young age, and a lot of that relates to the anatomy, especially with the female. So a smaller intercondylar notch size, decreased ACL volume, posterior tibial slope, increased ligament laxity, and extremity malalignment are all risk factors. And then what the purpose of this talk is to focus more on the modifiable risk factors, which would include an elevated BMI, neuromuscular and biomechanical deficits, which we'll talk more about, the hormonal status of the individual, if they have increased fatigue or decreased fitness level, and then extrinsic mechanisms, which can include footwear level, competition, the type of sport, the playing surface, and also the weather conditions. I'd like to spend a little bit more time just going into depth on neuromuscular and biomechanical deficits in ACL injury. So these are bad, these are the biomechanical deficits that we want to avoid that have been associated with non-contact ACL injuries, and the first is your hip and knee flexion angles. So when we have a decreased hip and knee flexion angle, we put increased stress on the ACL, especially during a jump land or pivot. We do know that the ACL is placed under the most strain during a pivot mechanism when it's between 20 and 30 degrees of knee flexion. Another very important biomechanical feature is knee valgus. So when the knee is placed in the valgus and there is also internal rotation of the hip, external rotation of the tibia, we're going to place more stress on the ACL, and a good way to test this is with just a simple single leg squat, which you can do in clinic, and so we've all seen some very good single leg squats and also some very poor single leg squats. The picture on the left is obviously very poor with poor hip control, increased knee valgus during their dynamic motion, and another simple test you can do is a vertical drop jump. Individuals who have poor knee control during their landing are going to be at much higher risk for ACL injuries, and a few other features that maybe don't think about quite as much when it comes to biomechanics of an ACL injury would be your quadriceps to hamstring ratio. So we mentioned that the mechanism of the ACL is to prevent anterior translation. Well, if we have dominant quadriceps, we don't have that hamstring to help counteract the anterior force, so focus should be on increasing hamstring strength or making that a more one-to-one ratio. Leg dominance is also important, especially in a youngster who's just learning biomechanical skills, and they're going to tend to favor one side to the other, so we want to make sure that we're exercising both sides to try to make a more symmetric base for the individual. And finally, trunk control and proprioception, a displaced center of mass is going to force exponential or greater risk on the lower extremities, so trunk control, abdominal strength are all going to be important when we're talking about stabilizing the base of the individual. So biggest question, can non-contact ACL injuries be prevented? I think we all know the answer to this and if they couldn't this would be a very short talk, but yes there is a lot of research especially randomized control trials that have shown that there are sufficient exercise programs to help prevent injury. I'll just mention briefly a meta-analysis from 2015 which did look at several studies and it grouped about a 27% reduction in knee injuries and a 50% reduction in ACL injuries if a preventive exercise program was completed properly. And when I talk about a preventative exercise program I'm talking about several components of exercise. So these would include proprioception and balance component, neuromuscular and strengthening components, running, plyometrics, and flexibility are all important when we're talking about a comprehensive exercise program. It's important to note that not one single type of exercise has been shown to be superior to the other. Studies that have looked at one type of exercise program really show no benefit if you focus on strengthening versus balance exercise. So again the most successful programs are those that combine multiple forms of exercise. And I'll also mention an important summary from a reviewed article that looked at a proper exercise program. So in this article they mentioned six key principles to any type of ACL prevention program. The first being age. So we do know that most ACL tears occur in younger individuals. So the sooner we can start prevention in the middle and high schools the more likely we are to have impact in the long-term decreases in ACL tears. Second proper biomechanics. We just talked about some of the risk factors with biomechanics but it's extremely important that when performing any type of exercise program that we're avoiding the biomechanics that place risks on the body especially dynamic knee valgus. Three compliance of the performance. So any time as you know any time an exercise program is not performed regularly you're going to have decreased benefit from that program. And then fourth dosage. So we do know that the ideal exercise programs are usually somewhere between 20 to 30 minutes in length and they occur two to three times per week. But it's starting in the preseason and continuing throughout the season. So it shouldn't be something that's just focused on during the actual sporting season. And then feedback from coach and trainer is also essentially important. So a lot of times an athlete especially with a teenager it's not going to focus on their actual form and they try to rush the exercises and we need to have someone with the knowledge to give constant feedback that these exercises are being performed properly. And then six we already talked about that the importance of a variety and some type of exercise performance. So let's go into a little bit more in depth on actual ACL and injury prevention programs. I listed four on this sheet because these are probably the four most popular that are out. There are certainly several others that I did not list in this presentation. In fact you can find over 30 ACL injury prevention programs. FIFA 11 plus is probably the most well known mostly because of the marketing behind it and also the extensive research that's been performed. So it's endorsed by an international organization with FIFA and there's been several randomized control studies that have shown the reduced incidence of ACL injuries. The other three including prevent injury enhanced performance, knee injury prevention program, sports metric have also had research to validate their benefit. Let's go a little bit more in depth starting with FIFA 11 plus. Again I don't necessarily recommend this over any of the other programs but it is by far the most popular program that's available. And if you haven't heard of FIFA 11 plus it can easily be found with the web search and you'll probably see a poster like on the right of the screen or you can find a more in depth manual that is available on the internet. But a general overview of this, it's typically broken down into three parts. Part one being running exercises performed at low speed with active stretching and this includes six individual exercises that are performed on the field which take about eight minutes. Part two includes six sets of exercises focusing more on core and leg strengthening. It's a lot of abdominal work, a lot of hamstring work, followed by balance and plyometric agility exercises. Now this program is a little bit more intense and there's 10 minutes that are devoted to it. It's also important to note that there's three separate skill levels. So you have an intermediate, I'm sorry, a beginner, an intermediate, and advanced level. And then finally running exercises performed at moderate and high speed with planting and cutting. So altogether this program should take no more than 20 to 30 minutes. And again the focus on this is to perform proper biomechanics especially with knee and hip alignment. I'll briefly mention a few of the other programs that are available especially online. So prevent injury enhanced performance is commonly done in the U.S. It can be found online with a quick research. It's a little bit more extensive than the FIFA 11 plus, but it takes about the same amount of time. One benefit is there has been studies that have shown improved risk factors with this exercise program including improved hamstring and quadriceps strength and decreased knee valgus moments during activity. And as I mentioned it's a little bit more extensive, includes a basic warm-up phase following by a strengthening exercise phase, plyometric phase, and then more of a sport-specific agility drills followed by some stretching exercises. And then lastly sports metric. So this by far stands out from some of the other programs because it's a much more intense program that's performed. We tend to see this more with more dynamic exercises especially in football or other contact sports. But it's also been validated and shown decreased injury risk. These programs are quite intense and last for about six weeks. They're more of a 90-minute session so much longer and it's more time commitment and there is more focus on strength, plyometric, speed, and agility. So to summarize just two basic take-home points. First of all risk factors. We know that most non-contact ACL injuries occur during activity in which the knee is placed in excessive doggish moment and reduced hip and knee flexion. And then comprehensive biomechanical training programs if performed properly can induce and decrease the risk of lower extremity injury and ACL injury. And these are my references. I'd like to thank you all for your time and look forward to discussion and taking your questions afterwards. Thank you Dr. Totenbusch. Fantastic. All right. Our last speaker Dr. Ashwin Babu at Harvard Mass General Spalding Network is a sports medicine physiatrist who keeps me company in major league soccer as the only other physiatrist which is very exciting to see to see that grow in the professional leagues. He also serves as a consultant for just about every professional team I've ever heard of in the Boston and Boston area with extensive experience with ankle injuries which are the most common injury outside of muscle strains in our favorite sports soccer. I hope that's other people's favorite sports. Ankle sprains are the most common orthopedic injury and in many other sports as well and I'm very excited to introduce and hear from Dr. Ashwin Babu. Well thanks very much for the kind introduction Mike. Likewise it's always great having you as my physiatry buddy at the MLS medical meetings and hopefully we'll be able to increase those numbers soon. So please go to the next slide here. I have no relevant disclosures. There's like a few products that are listed here more in an informational setting and I'll talk through them but be clear there are no endorsements of any of those. So by way of outline I'll try to make sure I'm to the point in brief here. We'll first go quickly through the anatomy that's relevant to ankle injuries. We'll talk a little bit about how ankles sprain and why they do so with the patterns that we commonly see. We'll talk through some basic epidemiology of how of what these ankle sprains look like and then we'll spend most of the time talking through the prevention literature and we'll answer a handful of very very important questions relative to this and then we'll go quickly through what a relative important therapy program is and then wrap up. So this is the ankle joint we all know from Netter's anatomy from way back when and you know the most important ones that we're going to focus on are on the lateral side of the ankle and so if you get the next slide there by far the most important one is the ATFL right there's a question that almost everyone knows at every age of medical training what is the most common ligament to get injured the answer is the ATFL and then you ask what does which exactly one is that and then depending on the level of the experience of the trainee there may or may not know that it's the anterior talofibular ligament that is of course the first injury that gets the first excuse me ligament that gets injured with an inversion ankle injury after that and this the next ligament that tends to get injured is the CFL or the calcaneofibular ligament and then finally the posterior talofibular ligament will get injured and by the time you get to a PTFL injury you know that you've had you've sustained quite a substantial problem to that angle and you're worried about things like dislocations and such and so I'll go through this quickly but the point is that these are the ligaments that we're most worried about also kind of on the anterolateral side are the ligaments that we get concerned about for high ankle sprains and this is basically the AITFL the anterior inferior talo excuse me tibio fibular ligaments and of course it's buddy on the posterior side the posterior inferior tibio fibular ligament interestingly enough they look very much the same on this anatomical drawing here but the mechanism of injury is actually opposite and different we'll go into that second when you look more to the medial side of the ankle we know that the most commonly injured structure here is the deltoid ligament and although this picture makes it seem very clear that it's these very distinct bundles that you can tell one from another we know from ultrasound evaluations and gross anatomy sections that it is much more spread and and intermixed between the two so it's quite difficult to tell the constituent components apart that being said we know that the deltoid ligament is the main restraint for this in the medial side of the ankle another one that's not let's actually go back for a quick second if you wouldn't mind another ligament that is important although it isn't quite as oftenly discussed in this context is the spring ligament or the calcaneo navicular ligament right there at the bottom just another one that's worthy of mention so why do ankles spread next slide please we'll talk first to the lateral ankle because of course again this is the most common and generally speaking you're looking at a mechanism of plantar flexion and inversion if you look at this cartoon on the right here we're looking at a dorsal view of the talus and you'll notice that in the posterior aspect of the talus the the distance of that ridge is relatively small and it actually opens up more anteriorly this is to say when the ankle is in eversion it's relatively stable as there's a much broader plafond of the talus when you go more posteriorly that actually narrows a fair amount therefore there's less bony congruity and some inherent instability there also when the foot is in end range plantar flexion the atfl is at its greatest stress and therefore more likely to injury with more with the additional movement beyond that um and there's lots of different studies looking at this generally speaking a recent study a relatively recent study in 2006 suggests that 85 of all ankle sprains are going to be of the lateral ankle variety and this is more or less corroborated by other epidemiological data which I'll show you in a second medial and high ankle sprains you can think of as having a relatively similar mechanism of injury certainly with the regards to these epidemiological studies they tend to be grouped relatively closely together and it's at almost exactly the opposite we are now concerned about ankle dorsiflexion and an inversion movement this puts tension across the medial structure specifically the deltoid ligament which can be then ruptured the way this practically moves out particularly in soccer which is what I spend a lot of my time thinking about is an athlete who has their ankle fully bent and then receives a blow to the inside of the ankle forcing it into eversion this is commonly happens with a tackle either the ball hitting the foot when they reach out to try to block a shot something of that nature forcing the foot into dorsiflexion and eversion and then you can get that medial ankle sprain so what does the epidemiology look like well as was already been alluded to this is an exceedingly common injury a recent study looked at ed visits over a five-year period about three million of these injuries that showed up to the er about half of them were from sports or sporting related activity not specifically in organized sports like in collegiate or anything like that just kind of all comers to the er but still a very very common injury an ncaa study looked at 25 sports over a six-year period and they found about 2500 lateral ankle sprains now if you look at the high ankle sprain numbers and the medial ankle sprain numbers 480 and 380 respectively they even together aren't even close to as commonly as lateral ankle sprains so that 80 percent number seems to more or less pan out basically if you're going to get an ankle injury it's probably going to be a lateral ankle sprain so what's most alarming is a we've now demonstrated that it's a very very common injury b what's also alarming is that about 40 percent of these injuries are going to go on to develop persistent symptoms and a lot of literature makes a very clear point that treating an ankle injury is not just a sprain something that can be shaken off is really quite important because concomitant injuries can happen and if not treated properly as we'll discuss shortly you can result it can result in chronic ankle instability which is can be associated with a lot of morbidity lateral ankle sprains we see most commonly the most common sport is men's and women's basketball and there are a couple of reasons for this one of which being that it's a court sport so athletics that occur on a court where there's a high level of friction between the floor and the athlete's shoe or put people at higher risk we'll talk about that again high ankle sprains we tend to see more commonly in american football ice hockey wrestling etc the picture that i have here actually if you go back second is a brandon by so he's our right back for the new england revolution playing against a very tricky player for toronto i believe and right after this picture was taken brandon suffered an inversion ankle injury and um basically he he was trying to make a tackle here got his foot caught under the player got forced into plantar flexion eversion and he suffered the injury unfortunately the good news is we were caught it right away treated him well and he was back playing in a few weeks which is most people's experience however it again is very important to remember 40 of these injuries are going to develop persistent symptoms so you got to catch it early got to treat it right next slide please so let's spend most of our time talking through this prevention literature in detail so there are several questions that need to be answered first is exercise effective in preventing the first time ankle sprains folks who've never gotten hurt can you keep them from getting hurt with some kind of exercise intervention two if in someone who's had an ankle injury how do you make sure it doesn't happen again three bracing and taping is seen very commonly is that effective in preventing ankle sprains and finally what are the risk factors that one needs to pay attention to when building a prevention program for your athletes so we'll take this one at a time first and foremost can you prevent the first ankle sprain this is a surprisingly difficult question to answer with the literature there really are very few studies looking at this directly given how what an important question this is it's really interesting to see so little data on this in general prevention programs are associated somewhere with a 30 to 45 percent decrease in ankle sprain or overall injury risk a number to treat analysis was done they said basically you need somewhere between 5 to 89 athletes doing a prevention program in order to prevent one ankle injury and to me when I see such a broad range and a number to treat analysis it means that the data isn't all that consistent just yet all the studies that are there however are quite clear and all the review papers and position statements etc are quite clear that what's most important is focusing on neuromuscular control and balance perturbation training so basically making sure that when the ankle is kind of in a bad position the athlete has enough neuromuscular control and and the ability to correct the problem instead of tipping over into a full-on injury it's very interesting and important to note though that not all studies are clear that exercise is able to prevent that first ankle injury and this is really in complete contradiction to the next slide if you can move us over which is us looking at what about the second ankle injury here there's tons of literature it's all quite robust and it's all quite clear exercise programs are remarkably effective in general the time frame that we need to worry most about is that two to four week time period after the injury this is usually when the athlete's feeling kind of good they're most the swelling's under control they're probably feeling good but the neuromuscular control is likely not there yet and if you let an athlete in too soon without the proper training and making sure that their mechanics are right their risk of a subsequent injury is unacceptably too high and so this is why that two to four week two to four week period is where we really have to focus our attentions once again neuromuscular control balance training comes up tops that's exactly what you need to be focusing on certainly what we do on the revolution side some data tried to quantify how much actually i'll go back if you could try to quantify how much of a reduction in risk one could get with these with an exercise intervention so the relative risk here is it was 0.38 and for those who are not terribly familiar with this statistic basically one means it's about seven under one means you have a reduction in risk above one means you have an increased risk when comparing two groups so basically in this context we want it to be under one and it clears to be very clearly so i left a couple review papers down there to look at at your leisure they excellently summarize the available literature so let's move on to the next question of course which is should you be bracing well the first studies looking at bracing went back to the 70s they all kind of demonstrated a slight positive effect a couple of recent review articles are worthy of paying attention to in 2010 a british journal of sports medicine review demonstrated about a two to four fold increase in ankle sprains with prophylactic taping this is very prevalent as many of us are aware in the athletic training literature, and this is where a lot of the bases that came from. In 2018, they kind of downgraded that recommendation a little bit, suggesting that bracing and taping have a role, although they didn't quantify it quite as clearly. It's also important to notice that taping and bracing, meaning using a lace-up ankle brace as shown at the bottom right here, are really biomechanically similar but can be different because there's some thought that the tape can actually stretch out over time, particularly after an initial movement. So these aren't exactly apples to apples, but they tend to get lumped together for these studies. When you look at the available literature, it suggests, again, a ratio nice and below one of 0.3 for recurrent sprains and 0.69 for a first-time sprain, although when you look at the confidence intervals, it's not quite as robust in effect. So the end rule taken here, bracing probably has some role. There is a lot of innovation in this area and looked at different things that you can add on to the athlete, like similar to bracing, to try to help prevent sprains both first and subsequent. So one that's very commonly asked is, what if you wear high-top shoes? Well, basketball, I told you, is one of the most common injuries, common sports to get a high lateral ankle sprain, excuse me, and so a lot of those basketball athletes wear high-top shoes. Does it have an effect? The answer, for the most part, appears to be no. There doesn't appear to be any clear effect or any clear recommendation from any of the major sports societies. There is some other interesting innovations. I just threw one in here because it was in a recent British Journal article where they have something called spraina, which is basically this black tape that you see on the outside of the shoe. The thought here is, we think friction is a factor. So if there's a floor and the athlete's foot lands at an angle, if there's too much friction, the ankle can't slide, therefore it tips over into an inversion injury. If you decrease the friction at this point, the ankle will slide flat, thereby preventing an injury. So that's what they tried to demonstrate. They showed a modest result here. So areas for innovation to be thought about. Another question that commonly comes up is orthotics, and the short answer is at the moment there doesn't appear to be any major role for orthotics. I'd say it is important that for athletes who have a significant pes planus and other foot construct abnormalities, it is important to pay attention to using whatever is necessary to put the foot in a proper position, but that's different than looking at this for ankle sprain in particular. So let's talk through risk factors. What can we change? What can't we change? Well, we're in the first group here. We're going to talk about lateral ankle sprains. The most important thing that we can focus on are hip abductor and extensor weakness. If you don't have good core and proximal stability, it's very difficult to do better later distally, and the same is true for balance and hop testing. If you have improper mechanics, you're going to struggle to prevent subsequent injuries. Finally, like I mentioned, participation in court sports, all that have a high level of friction on the floor is a major risk factor. For chronic ankle instability, not using bracing appropriately and not participating in adequate therapy can put you at risk for a CAI or chronic ankle instability, and then finally, I put a big asterisk here because it's obviously not a modifiable risk factor, but there's some conflicting evidence about there being a difference between ankle sprains. We'll go to the next slide here. The therapy side of things appears to be very important. There's some thought as to whether or not one should add some manual work, and certainly we do this a fair amount for runners and other athletes who suffer ankle sprains pretty regularly in the course of a season. RCT in 2013 kind of looked at 74 patients and found a modest effect adding manual therapy to a regular exercise program. I have the manipulations that were done here. In particular, what I found to be helpful are these tailor-accrual posterior mobilizations, which is a motion that most people just can't really get all that well unless done manually. We'll go to the next slide here. This is this kind of sequence in the bottom here is really what I want to have everyone pay attention to. This is a pretty classic therapy program that takes an athlete from an initial situation where they're working on stable ground, doing some band exercises, working on hip abductors, working on balance training, adding some instability, so this is either a wobble board or some unstable surface like a foam pad, finally progressing to jump landing, making sure that their neuromuscular control is perfect to protect their ankle, then adding instability with ball-specific or sport-specific activity, and then finally putting it all together and adding very complex multimodal movements to make sure that the athlete's ready to go. By going through a steady program like this, you can make sure your athlete doesn't have any subsequent injuries or at least decrease the risk. I'll take that next slide here. So to wrap up briefly, the ankle is a very complex joint, many degrees of freedom. Lateral ankle sprains are by far the most common and an unacceptably high number of folks will have disability after this injury. The literature on prevention of primary sprains is really quite sparse, but probably exercise and bracing has a rule. Repeat sprains is very robust literature. Psychotherapy needs to focus on neuromuscular control and bracing, focus on correcting the intrinsic risk factors that the PT will take care of, in particular balance and perturbation training, and remember that a well-designed program can decrease these chance of subsequent injury quite substantially. So with that, I'll thank you all for your attention and we'll move on to questions. Fantastic, Dr. Babu. All right, well, this is the, not that we haven't had a lot of fun yet, but we're going to go ahead and move to the panel discussion here. And so we've had many, many, many questions and I'm going to go ahead and start with some questions that have been put in here on the chat. The first is really mainly for Dr. Podesta from his talk. Is there, has it been defined what age is early for early specialization in sports? I'd love to hear Dr. Fredrickson's thoughts on that too. You're muted. Can you hear me now? Gotcha. So you're asking is what I think the earliest age for specialization or it's too early? Yeah. When do we define, you know, obviously our college athletes are doing one sport, but what age is early, early for an age group and early? I'm seeing kids in my practice that are, you know, in sixth grade, seventh, eighth, ninth grade that are specializing. I think ninth grade, as they're starting to get older and into high school, it may be a little bit more appropriate, but middle school kids and younger, I think it's inappropriate. Yeah. And Dr. Fred, how do you see this affecting runners? Obviously there, there's a lot of talk on when runners should start becoming mainly runners and when you've done a lot of research on, on the topic on runners doing other sports. Yeah. I mean, I tell, I tell parents if they want their kid to be a good runner, don't let them run when they're younger, certainly not specialized because we've done research showing that particularly when you're younger, when your bone's developing, if you can do sports that emphasize higher impact and multi-directional movements, it's much better for your, certainly for your bone health, but I would suspect also for your coordination. And then we found that by doing those sports when you're younger, it certainly helped prevent you from developing a bone stress injury later in life. So, but I would agree. I would say I certainly, you know, there's the reality, right. And then there's what, what we should do. But other than gymnastics, I don't think you should start specializing in at the very earliest high school. Excellent. All right. We've had a lot of questions on for Dr. Totobush on the topic of ACL. So a couple of questions on ACL and OA and draining the hemarthrosis. So what's the latest literature on ACL reconstruction to reduce the rate of OA? Well certainly without reconstruction, you're going to see much higher significant rates of osteoarthritis. And so we certainly would still recommend reconstruction for prevention of osteoarthritis, but I think it's likely multifactorial. So we don't know everything that's involved in the development of osteoarthritis, but it goes back to the actual injury that occurred as their municipal damage and other articular cartilage damage. There is some thought that the hemarthrosis also contributes to cartilage damage. That's something that we're looking at here. So we're currently doing a study with draining all hemarthrosis and studying composition within those. We do know that there are multiple factors involved with the development of arthritis, but without reconstruction, you're going to see that those rates are going to be exponentially higher. Yeah. Very nice. A question for Dr. Babu, and I want to open this up to the others. So implementing these is always, there's two parts, like you guys said, there's the research and then there's how do you actually implement this and what advice would you give for the sports physicians and future sports physicians in the audience on how do you take a program that has been showed to decrease rates by four times or more, how do you take that and bring it to either your team or your individual athletes? I think, so I mean, it's definitely difficult. A lot of it is actually, I think Dr. Fred really did a good job of kind of talking about the importance of the culture in a program and making these things implement and that is really, really important. There are some times and coaching regimes and training and med staff regimes that you may not be as successful as you think regardless of what the literature says and there's others where you can make some significant changes and what I found really is getting folks, talks like this are really quite informative and making it clear what the literature shows and not everyone, what I found is really interesting, not everyone reads the same literature even if you think that it should be the same kind of pool of papers that everyone's looking at but it's really not the case and they tend to kind of pigeonhole themselves into a particular way of thinking and so I don't have any magic certainly to suggest but you giving talks, knowing what the literature is and presenting this to your entire staff, both medical and otherwise I found to be pretty informative and helpful but the culture to me is the end of the pinning. There's other places that have been where people really want to know what's the latest and greatest and how are we going to make this happen and there's other places where who are not quite as interested and that is a very big challenge. Yeah, very good, the culture part is so key and I'm glad to hear that we're on the same boat with that topic. So I'm going to talk to the most experienced guys in our community, Dr. Podesta, Dr. Fredrickson and how do you guys, how do you create that culture, how do you develop your rapport with the coaching staff, the athletic trainer, the physical therapist, sometimes it's the owners who are providing that kind of resistance. What strategies, how do you go about that successful relationship? My experience, especially with professional baseball and this goes with football as well and lacrosse that I've dealt with, typically with most of the trainers that I've dealt with, there's a buy-in and again, the culture of the team that comes from the top and that's on a professional level, it's ownership. Depending on what the ownership wants to provide and what they'll allow you to do. This most recent team that I took care of was an ECHL hockey team and it was very restrictive. I had to discuss injuries with the coach before I could even tell the athlete after I examined him what was wrong. That culture is not a great environment that's inducive for these guys to get better and to report injuries and things like that. On a baseball side, in professional sports, I think it's a lot easier, at least where I was and the coaches and the medical staff that I dealt with, but that's not the case in Little League, in high school and in college. You get a skewed outlook on what is important, what they think is important and I have this argument with parents and coaches all the time as they come in the office with some of these younger athletes. There's that carrot that's dangled in front of them that these kids have to be participating in all these different showcases during the off seasons. Regardless of what they come in with in the diagnosis, the next question is, can they play next week? The whole education part and the whole recommendation part goes out the window because there's something coming up constantly to push them to get to another level or to achieve a goal. That's where you have to get the buy-in. You got to really back away from some of the intensity and the activity that they're going through, especially at a younger age. Parents have to buy into it. That's not always the case. It's difficult. You can preach and preach. But like I said in my talk, compliance with what we tell them is difficult. They understand it. I even gave one of my parents this lecture last week on her kid that continually comes in. The husband will get on the internet and basically puts this kid through these torture sessions of workouts to try to make him a better hitter, pitcher. Every time he does it, he gets hurt and he comes in. Then I don't see him for a while and he comes back in. It's like preaching to the wall sometimes. It's difficult to make that really sink in to some of these people. I don't know, Mike, you may have a different experience. I completely agree. My experience with my two teams are the ballet and the soccer team in Kansas City. An understanding of what the objectives of the team are is so important. The coach, once he has to win games or his entire career is on the line, and if we are not helping them win games, then our opinions aren't going to be respected and listened to. There is this element of developing that rapport with the coach that simply takes time, but it also takes experience and discussions with them. Talk about players, talking outside where they realize that you're also trying to not just be too cushy on these players, but the goal is for these guys and gals to be on the field and be playing and winning games and winning championships. For me, when I started with sporting my third season, I wanted to get all the guys on a treadmill and watch them run. Just for hamstring injuries, if we had a slew of hamstrings, everyone has slews of those. I wanted to look at all their biomechanics. The coaches were very resistant to me changing anything about how they run, worried that we could make them less effective on the field. That is something that now I understand and respect. Making any change to anything they're doing has to be thought of with all kinds of caution. It has to be a discussion. My experience with that is that everyone has to be on the same page as far as what our goals are. Coaches don't want injuries, but they want players on the field more than anything else. Dr. Fred, I'm very eager to hear your thoughts on you've been very successful with your teams and your longstanding relationship with a lot of your coaches you've been with. I would agree with everything that's been said. I think a lot of it is just developing that relationship with the coach and the training staff where they trust your opinion. If you can really explain to them the science, the literature, and the rationale that by doing such and such that you're going to keep their athletes healthy and prevent injury, usually they're going to buy in because that's going to help their bottom line. It just takes time for them to really like, first you have to convince them that it's not going to take away from their training and you're not going to change anything that they're working on, but once you can get past that and you can build this into their normal training program, most of them are going to buy into it. You just have to build that trust first. In your setting, Dr. Fredrickson, obviously you have a lot of runners who their coaches want them to be thinner. I have this with my runners. I have this with my ballet dancers. The leadership wants them to be thinner. Thinner is faster. We know that at some point there's this razor thin edge and they're going to go to the other side and they're going to be out for half a season, but how is that discussion and how does that conflict from the medical side and from their performance side with coaches? We just focus on health, that we want to maximize health and by doing that, you're going to maximize performance because all it takes is for them to see one athlete who doesn't do that, whether it's overtraining or low iron or low bone density or an eating disorder or fatigue and then they get injured, then they start to buy into it. When there is a coaching change, I have to say, and I think that's what we saw at UCLA, the coaches want to bring in their way of doing things and it's going to take a while for them to buy into your way of thinking about things. It took me a long time to get the Stanford coaches to buy into this, but then once they did and once they started to see the results, then they were all over it. It just took a while. Well, excellent. I think we are, any last final comments from our panels? We're just a little over our time here. Thank you everybody for joining in today or in three months or whenever you're joining in. We're excited to be able to be a part of this world-renowned panel of speakers today and thank you to the speakers for all of the work you put in and the research and experience you bring to this discussion. All right. Thank you everybody. Thanks very much. Thank you. Take care, guys.

ACL injuries

female athletes

males

soccer

basketball

anatomy

biomechanics

neuromuscular control

hormonal factors

risk factors

artificial turf

fatigue

landing mechanics