lessons learned from the playing field

Monday, January 18, 2016

Learning about medicine from the playing field.

Randall Cobb of the green Bay Packers, leaps to catch a pass, lands awkwardly and sustains a pulmonary contusion, or bruised lung. After coughing up some blood, never a good thing but many times not disastrous, he is observed in hospital and is discharged home where his lung will slowly heal, just like any other bruise. The injury is a reminder that with chest trauma, and many people fall and hit their ribs, the x-rays done are to evaluate the lungs and not the bones. Doctors are more interested in whether there is a collapsed lung (pneumothorax) or lung contusion, while the patient is more interested in whether there is a broken rib. Regardless of whether the ribs are bruised or broken, the treatment is the same: pain control so that the patient can take a deep breath and expand the lung to prevent pneumonia, the most important complication of a minor chest injury.

Steeler receiver, Antonio Brown, suffered a concussion in the game against the Cincinnati Bengals and within 24 hours there were reports that he would be recovered within the week to play in the team’s next game. He did not. After his concussion, Green Bay Packer, Sam Shields took a month to recover before play9ing again. It is a reminder that there is no way to predict the brain’s path to recovery from concussion and there is no definitive test to determine that a brain has fully recovered and is able to withstand another blow. No matter the NFL protocols, concussion remains a diagnosis made at the bedside and return to play has no standard playbook to follow.

finger bony anatomy

Carson Palmer of the Arizona Cardinals had a new splint on the right index finger of his throwing hand to protect the PIP joint that had been dislocated. Fingers have three joints (the thumb has two), the metacarpophalangeal (MCP) that connects the finger to the hand, and the proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joint. The PIP joint is commonly dislocated and can heal relatively easily but because of the complex anatomy of the hand, the bones can damage the tissues and tendons that surround the joint when they dislocate. Complications include a volar fracture of the thin plate of bone on the palmar surface of the joint can be broken, leading to joint instability and a boutonniere deformity where the tendons slide to the side of the joint and prevent the finger from completely straightening. It’s a reminder that hands are complicated and minor injuries may lead to major long term complications.

Joakim Noah of the Chicago Bulls dislocated his shoulder and will undergo surgery to stabilize the joint. In most people, surgery is not the first step in rehabilitation. They are allowed to undergo physical therapy to strengthen the shoulder and return range of motion before considering an operation. But in athletes or those who may not be able or willing to limit their activities, surgery is often the first and potentially curative step. Studies of young athletes and military recruits, that surgery after the first shoulder dislocation can prevent future dislocation 95% of the time. Without an operation only 5% will have stable shoulders. The reason has to do with the inherent instability of the shoulder. It is designed to have a wide arc of range of motion in all directions and for that reason, the surface area of bone in the joint is very small. The stability has to do with the soft tissues that hold the shoulder together from the capsule and the labrum to the ligaments and surrounding muscles.  When the shoulder dislocates, all these structures are damaged and stretched. Surgery, either arthroscopic or through an incision, is meant to tighten all the structures that have been torn apart. Rehabilitation takes months to return range of motion and power; Mother Nature does not like to be rushed when she heals soft tissues.

More lessons from the playing field next week.

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shoulders and elbows

Tuesday, January 20, 2015

Medical advice can only work in two given situations: if the patient chooses to seek that care and if the patient chooses to follow that given advice. It comes as no surprise that those two situations were ignored by two Seahawks in their playoff game. Earl Thomas dislocates his shoulder, reluctantly runs to the locker room and is back on the field minutes later. Richard Sherman sprains his elbow and refuses to come near a trainer or doctor, but instead, stays on the field grimacing in pain. NFL players and other driven athletes tend to ignore damage to their body because the will to play and win is stronger than the pain that they experience. But a warning should appear on the video screen: “Trained professionals. Do not try this at home.”

The shoulders is the most common dislocated joint of the body. The mechanism of injury can be a fall on an outstretched arm or from a blow that occurs when the arm is abducted (moved away from the body) and externally rotated it (forearm turned palm side up). The shoulder is a ball and socket joint and when dislocated, the humeral head or the ball of the joint, is ripped out of the socket, the glenoid fossa. The structures that hold the shoulder together are torn, including the labrum, the joint capsule, the cartilage and the ligaments of the rotator cuff. If a player is lucky, the shoulder can be popped back into place immediately on the field before the surrounding muscles start to spasm. That can make it tough to provide the traction needed to reduce the dislocation and return the bones to their normal position. For many patients, mild sedation may be needed to help with reduction, often because there is a significant delay getting to medical care.

 

shouledr norm

Normal

shoulder dislo

Dislocated

Once the shoulder is reduced, the goal is to allow the shoulder to heal and remain stable, meaning that it will not dislocate again. There is a balance between that healing and allowing range of motion to occur. It takes weeks for all the damaged tissue, from muscles and ligament to joint capsules to become strong and stable. If one waited until that happened to move the shoulder, it would stiffen and require weeks of rehab to help return range of motion. It is safe to say that Mr. Thomas did not heal in the few minutes that he was in the locker. Instead, he was fitted with a brace that prevented the shoulder from abducting or rotating, the movements that likely occur with reaching for a football or stretching to make a tackle. It is likely that this was not the first treatment option for the medical staff, but when a patient refuses to consider option one, negotiations likely occur to try to minimize future risk and damage. In general, a shoulder dislocation will require six weeks of treatment before return to play.

It is easier to speculate about the Thomas shoulder dislocation than Mr. Sherman’s elbow sprain. Practically, there are only two types of shoulder dislocation, anterior and posterior, and posterior is rare. The elbow is a much more complicated joint. Three bones come together, the humerus, the radius and the ulna, to allow both flexion and extension (bending and straightening) as well as supination and pronation, turning the palm upwards or toward the ground. The medical collateral and the lateral ligaments hold the elbow stable but they have different bundles that protect the elbow depending upon the position of each bone within the joint and the movement that is trying to be accomplished. As well, the biceps and triceps muscles of the upper arm and the muscles of the forearm also work to promote joint stability. Sprains of the elbow, like any other ligament injury are graded by severity of the damage. In grade 1 sprains, the ligament fibers are stretched, in grade 2, they are partially torn and grade 3 sprains denote a completely torn ligament but even a grade 1 elbow ligament sprain can allow the elbow joint to dislocate completely or partially dislocate (subluxate). Injuries to the area can cause bleeding within the elbow joint and a little blood goes a long way to cause significant pain, even with small movements. Mr. Sherman’s cradling his arm and wincing is a testament to the amount of pain a pro athlete can endure. And while his teammate saw visited the trainer and negotiated his care, Sherman refused to come off the field and when he did, tried his best to avoid being evaluated. Treatment of this injury depends upon what is damaged but the time to recovery is measured in weeks.

elbowligament

 

Playing through injury is the stuff legends are made of, but should not be considered the stuff of role model. The potential for long term damage is real when joints are damaged and not allowed to properly heal. There is a real risk that other injuries might occur because the player cannot react instinctively while still protecting the injured body part, but the invincibility of youth and the athlete often take precedence over common sense.

In the real world, patient compliance in following advice and instruction is somewhat lacking. Moderating diets, alcohol use and smoking are the big three but others follow close behind. Studies show that patients who take blood thinners because of blood clots or atrial fibrillation, often missed taking their medications 30% of the time. Patients do not complete a course of antibiotics, stopping when they begin to feel better. Post op physical therapy sessions get missed when they are not a patient’s priority. At the end of the day, the doctor’s advice has to be practical and apply to that specific patient’s situation and hopefully the patient will buy into that advice…hopefully, because the doc and the patient, just like in football, require teamwork to make the miracle of modern medicine happen.

 

Figure attribution: American academy of Orthopedic Surgery

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