Concussions – diagnosis and treatment

By Moin Salahuddin | January 19, 2011

NHL superstar Sidney Crosby is currently suffering the lingering effects of a concussion and has been unable to play for several weeks.

Sidney Crosby

Crosby, and others afflicted with concussions, undergo routine testing by sports medicine physicians.

Initial testing focuses on:

* Orientation – what is the date and season, what time is it

* Immediate Memory -give the athlete three words to repeat, ask them to remember those words

* Concentration – spell the word “world” backwards, count backwards from 100 by 7′s

* Delayed Recall – ask athlete to recall those three words

If the athlete is slow to respond or is unable to perform any of the aforementioned tasks, a concussion is likely. But there is no single test that can guarantee an athlete does have a concussion, so symptomology (i.e. headaches, trouble concentrating) and a series of tests can help us decide if a diagnosis of concussion is more likely than not.

Concussion testing in a youth football player

The athlete may also undergo other provocative tests, including IMPACT testing. IMPACT is a twenty minute computerized test that shows different images and words on a screen and has the athlete respond appropriately. Athletes are measured in terms of reaction time, verbal and visual memory. IMPACT tests are especially helpful when there is a baseline assessment that is done when the athlete is asymptomatic (typically done during the pre-season of their respective sport). This allows the sports medicine physician to compare the athlete’s current scores with their baseline and see if there are any differences, which if seen could support a diagnosis of concussion.

TREATMENT

Major sporting organizations, including the NHL, NFL, NCAA, and California Interscholastic Federation (CIF) have adopted strict guidelines for return to play for athletes with concussions.

Once diagnosed with a concussion, athletes are advised to have “brain rest.” Much like resting an injured elbow or knee by limiting its use, an injured brain also needs time to recuperate. The athlete should REST – no television, cell phone use, video games, or exercise!

After the athlete has been COMPLETELY asymptomatic for three days (or longer if a repeat concussion), the athlete can undergo an exercise stress test. The athlete is asked to exert themselves either by running on a treadmill, using a stationary bike, or jumping jacks to increase their heart rate and essentially “get a good sweat going.” This test is typically monitored by an athletic trainer. If the athlete can do this test without ANY symptoms occurring, they can be advanced on a slow return to play protocol. If the athlete does have any symptoms, they will immediately stop and restart the brain rest process. The entire process is repeated until the athlete remains asymptomatic with exertion.

As in the case of Crosby, after passing his exercise stress test, he will be allowed to return to practice but will likely be limited. Crosby might initially be asked to simply skate around the ice without a helmet and pads for a few days, then add on his helmet and take shots, then participate in a light contact practice, then in a full practice. If Crosby can tolerate contact without any symptoms, he will likely be cleared to play.

If Crosby were to return too early from his concussion (i.e. while symptomatic), he could risk getting another concussion again very quickly. Typically, these repeat concussions have symptoms that last longer and requires much more brain rest than the first concussion. There is also a risk of  “second impact syndrome” where a second concussion on top of an initial one can lead to serious disability and chronic impairment.

In summary, time is the best healer for concussions. Allowing proper brain rest and slow return to play with a gradual increase in physical exertion is the key to proper treatment for concussions and preventing further incidents from occurring.

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When it’s more than just a headache…

By Moin Salahuddin | November 4, 2010

“Bonking” your head, getting “dinged” up, being “dazed” – all have been descriptions athletes have used to describe their head injuries. “Concussion” would have been a much better word.

Now that concussion has entered the lexicon of daily sports media, the term tends to be poorly defined. What is a concussion and how do I know if I or my athlete has one?

A concussion, or mild traumatic brain injury (MTBI), is caused by a direct or indirect force that impacts the brain, leading to temporary impairment of neurologic function. The skull will usually transmit the force to the brain, which then will bounce off the opposite side of skull.

There is a common mis-perception about concussions regarding direct impact. While concussions tend to be seen commonly in direct hits to the head in football and soccer, an athlete that gets hit in the abdomen could get a type of “whiplash” injury that causes their head to violently recoil. These types of indirect force can cause just as much damage to a brain.

PRESENTATION

The most common presenting symptom is a headache. Athletes can also have nausea, vomiting, light sensitivity, ringing in their ears, confusion, trouble sleeping and/or concentrating, and amnesia. Athletes may also complain of neck pain due to the jarring hit.

Any loss of consciousness or seizure type activity after the initial hit typically suggests a more moderate to severe concussion, if not a worse diagnosis.

DIAGNOSIS

As you come upon the athlete on the field of play, the sideline, or your office, you can note several signs of a concussion prior to speaking with them. Concussed athletes typically are sensitive to light, fail to make eye contact, appear depressed in mood, and might stumble or be slow with their gait.

As you start chatting with the athlete, ask them simple questions such as:  “What is your name? Where are you right now? What happened on that play and how did you get hurt? What is the score of the game?” These questions can give you some quick information on how the athlete’s basic thought processes are.

Once you examine their cervical spine and determine they have no pain or tenderness in that area, you can take them safely to the sideline to evaluate them further.

CONCUSSION TESTING

Stay tuned to next week’s blog for further information on diagnosis and testing – including SAC and IMPACT tests.

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Head Injuries

By Moin Salahuddin | October 20, 2010

From recent NFL injuries, to high school athletes, to BMX riders like TJ Lavin, head injuries in athletics have become far too common.

This past weekend saw several prominent NFL players injured due to vicious blows to their bodies – Baltimore Raven TE Todd Heap and Cleveland Brown WRs Mohamed Massaquoi and Joshua Cribbs. All three were taken off the field and diagnosed with concussions.

In the world of college football, Rutgers football player Eric LeGrand suffered an apparent spinal cord injury after lowering his head to make a tackle on a kick off return. LeGrand’s head struck at a 90 degree angle to the opposing player, placing direct pressure on his cervical spine and subsequently the special nerve protected by those bones – the spinal cord. LeGrand is currently paralyzed.

At the 2010 Dew Games Championships in Las Vegas, MTV icon and BMX rider TJ Lavin clipped his back tire while attempting to land a jump, propelling him forward over his handlebars and causing him to strike his head straight into the dirt. Lavin is currently hospitalized with a severe head injury.

Far too many athletes are suffering from the consequences of head trauma and concussions by direct or indirect trauma, with repeated concussions on the rise in nearly all sports.

Do athletes have adequate protection? Are we recognizing concussions and treating them appropriately? Are some sports such as football actually better off with less head protection?

These are some of the questions I’ll answer in my upcoming head injury series. Stay tuned as each week I will be discussing a different aspect of this troubling problem.

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Good luck but don’t break a leg!

By Moin Salahuddin | September 21, 2009

Ankle sprains are common, pesky injuries that affect all types of athletes – from a 40 year old playing recreational basketball who twisted their ankle after landing on an opponent’s foot, a 75 year old walker stepping off of a curb wrong, or NFL wide receiver Terrell Owens suffering a “high ankle sprain” while getting tackled.

Let’s take a closer look at these simple yet troublesome injuries.

The ankle jointANATOMY: The ankle is comprised of the tibia (large, shin bone) and fibula (smaller bone that runs along the outside of the tibia) above and the talus (just above the calcaneus aka heel bone) below. A series of ligaments anchors the bones to each other and are aided by the Achilles tendon (which connects the gastrocnemius and soleus – calf muscles – to the calcaneus).

The most commonly injured ligament is the anterior talofibular ligament (ATFL), which supports the front of the outside of the ankle. Other crucial ligaments include the calcaneofibular (CFL), posterior talofibular (PTFL), and deltoid ligaments.

Ligaments of the ankle

RANGE OF MOTION: The ankle is a unique joint that can have plantarflexion (pointing your toes/foot down), dorsiflexion (pointing your toes/foot up), inversion (rolling the inner half of your foot in), or eversion (rolling the outer half of your foot out).

MECHANISM OF INJURY:

The most common type of injury is an inversion injury, as seen in the figure below. The inner half of one’s foot will essentially roll up, causing the outer/lateral half to stretch. This will cause the ATFL to suffer a partial or complete tear.

An eversion injury is more rare, but is seen in sports such as football and soccer. The outer half of one’s foot will roll up, causing the inner/medial half to stretch and possibly tear the deltoid ligament.

Inversion injury causing a tear of the ATFL

Athletes can also suffer injuries to their Achilles tendon, with either chronic wear-and-tear leading to inflammation (tendonitis) or a partial/complete tear of the tendon (seen commonly in recreational basketball players in their 30-40′s).

GRADING:

  • Grade I Ankle Sprain:
    Grade I ankle sprains cause stretching of the ligament. The symptoms tend to be limited to pain and swelling. Most people can walk without crutches, but may not be able to jog or jump.
  • Grade II Ankle Sprain:
    A grade II ankle sprain is more severe partial tearing of the ligament. There is usually more significant swelling and bruising caused by bleeding under the skin. People usually have pain with walking, but can take a few steps.
  • Grade III Ankle Sprain:
    Grade III ankle sprains are complete tears of the ligaments. The ankle is usually quite painful, and walking can be difficult. People may complain of instability, or a giving-way sensation in the ankle joint.

DIAGNOSIS: Ankle sprains are diagnosed by looking at the mechanism of injury and evaluating the injured joint itself. An injured ankle with typically be painful, swollen, and possibly bruised – with the hematoma (collection of blood from torn ligaments) gathering in the foot (due to gravity).

Xray’s can help with diagnosing bony abnormalities like fractures but do not identify ligament injuries. MRI’s can see soft tissue injuries such as ligament tears, however aren’t usually needed unless conservative treatment measures do not work.

A system of evaluating the necessity for xrays is called the Ottawa Ankle Rules, which states that xrays should be done if:

Ottawa Ankle Rules

High ankle sprains affect the ligaments that connect the tibia to the fibula. These syndesmosis ligaments are affected usually by an outward twisting of the lower leg and foot. The “squeeze” test where the tibia and fibula are compressed by two hands is positive (elicit pain) with this type of injury.

Terrell Owens suffering a high ankle sprain

TREATMENT: Always begins with RICE – rest, ice, compression, elevation. Rest your leg. Ice for 15 minutes on the area of pain/swelling followed by 15 minutes off – repeat several times. Compress with an ACE bandage, lace up ankle brace, air cast (Grade II sprains), or possibly a short leg cast (for severe Grade II-III injuries).

Don’t forget to be examined by your local sports medicine physician if these conservative measures do not improve your injury since you are likely to have suffered a Grade II-III sprain.

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Don’t poke me in the eye!

By Moin Salahuddin | May 27, 2009

Of all five senses, vision is arguably the most important in our everyday lives. Eyesight becomes an even greater commodity in athletics, for our superstar professional athletes as well as amateurs alike. From using glasses to corrective lenses to LASIX, athletes have placed a premium on their vision. And while our other senses and musculoskeletal frame remain well protected, our vision is shielded only by a thinly-lined membrane known as an eyelid.

Their relative fragility and highly specialized function leaves our eyes extremely vulnerable to injuries. Among the most common injuries that occur, and ones that we will discuss further, are corneal abrasions and detached retinas.

First, let’s review the basic anatomy of the eye:

Light enters the eye via the cornea, and travels through the colored iris. Light then is transmitted through a clear gel that comprises the majority of the eye, called the vitreous humor. Light then reaches the “back” of the eye, hitting the retina, which then converts the photons into electrical signals that are sent via the optic nerve to the brain. Damage along any part of this pathway can lead to vision problems.

Now let’s examine possible eye injuries in each sport:

* Baseball and softball athletes rely on their vision to help make contact with a hard ball. When that ball strikes the face, it can cause severe damage to the eye socket – which is the surrounding tissue and bones around the eye – but it is not likely to do any direct damage to the eye. Orbital fracture injuries are common.

* Hockey players have a 1 inch thick, 3 inches in diameter puck flying around the ice rink – with the majority of these athletes wearing protective face shields. When ice hockey pucks strike the face, these athletes suffers similar injuries to that caused by baseballs or softballs, with more frequent lacerations.

* Basketball athletes have the unenviable task of dodging fingers, elbows, and basketballs. Phoenix Suns forward Amare Stoudemire suffered a partially torn iris during the 2008-2009 NBA preseason after being poked in the right eye. Stoudemire was advised to wear goggles to prevent any further injury, which the forward complied with for several games prior to ditching the plastic protection. Stoudemire was subsequently poked in the same eye in February 2009, this time resulting in a partially detached retina.

The iris is the colored section of one’s eye. If torn, one’s vision could be partially compromised but the iris can heal on its own (as with Stoudemire) or be surgically repaired.

Conversely, if one suffers a partially detached retina, they will notice “floaters” in their vision and/or a “black curtain” moving across their field of vision. This is a medical emergency and usually require immediate corrective surgery. The longer the retina has been detached, the less vision should be expected to return with treatment. Since Stoudemire had two injuries to crucial structures on the same eye, he is very susceptible to major injury with even minor trauma.

* Cleveland Browns lineman Orlando Brown is one of the few football players to suffer an eye injury. In 1999, Brown was struck in the right eye with a penalty flag, causing bleeding into the chamber of the eye where vitreous humor is located. Brown ended up missing several NFL seasons and settled for monetary damages with the league for his unfortunate injury.

A foreign body such as an insect or fingers can scratch the cornea, leaving a small abrasion. These scratches are easily diagnosed in a doctor’s office using dye in the eye and can be treated with ophthalmic antibiotic drops. If the abrasion is more severe and leads to a corneal ulcer, the eye can become infected and one could lose a part of or the majority of their vision.

Brown had more direct trauma, causing compression of the “globe” of his eye, which then led to bleeding. Brown required multiple surgeries, with the majority of his vision reappearing after three years.

* And even the media has been affected. ESPN anchor Stuart Scott injured his right eye during NY Jets training camp in 2002. Scott was playing the role of a wide receiver and was sadly hit directly in the right eye with a football from a machine. Scott’s exact injury is not publicly known however the sports anchor has had multiple corrective surgeries.

The take home message from all of these athletes is to wear eye protection. Whether you sport the Horace Grant or James Worth goggles, or the LaDainian Tomlinson visor, please protect your eyes. Sunglasses with UV protection can also help prevent damage from the sun’s powerful rays.

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Welcome!

By Moin Salahuddin | April 12, 2009

Welcome to the blog where we talk about everything sports medicine. Whether you are a 12 year-old, a fantasy football player, or a coach, I’d like to give you an interesting perspective and a “behind the scenes” look at injuries that plague superstar athletes and people like you and me.

We could start chatting about A-Rod’s hip labrum tear or the retinal detachment that is affecting Amare Stoudemire.

But I’d rather start talking about Los Angeles Lakers center Andrew Bynum, who has recently returned from a torn MCL injury that sidelined him from the Lakers for 32 games. Bynum tore his right knee when Kobe Bryant had rolled into his planted lower leg.

For starters, if Bynum had to tear anything in his knee, he chose the right ligament! The MCL is a small fibrous band of tissue, one of four major knee ligaments, that connects one’s femur (above the knee) to their tibia (the larger, below the knee bone). It’s known as the MEDIAL collateral ligament because it lies along the inner part of the knee. When a force is placed on the lateral (outside) part of one’s leg, pressure is translated to the inner ligaments. Kobe falling into the lateral part of Bynum’s right knee caused the star center’s MCL to stretch and tear.

As for why Bynum was fortunate for tearing only his MCL, here’s a brief anatomy lesson. The MCL is connected to the ACL and medial meniscus, anchoring the knee in place. When most people tear their ACL or MCL’s, the rest of the ligaments that are connected usually go with it. So Bynum was lucky to keep his ACL and medial meniscus intact. And that meant that Andrew was able to only miss a few months rather than an entire year!

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