Team Doc 101 Lutul D. Farrow, MD Cleveland Clinic Sports Health Assistant Team Physician Baldwin-Wallace College

History 19th century Almost banned 1905 Rule/equipment changes 1st Physicians on sidelines Almost banned 1905 Serious injuries Deaths Rule/equipment changes Formation of NCAA Greatly reduced injuries

History Hundreds of thousands athletes Thousands of team docs Adolescent High school Collegiate Professional Thousands of team docs

Definition Licensed MD/DO responsible for treating and coordinating the medical care of athletic team members

Principle Responsibility Provide for the well-being of individual athletes

How to Get There Early desire Athletic Background 4 years college 4 years medical school Allopathic (MD) Osteopathic (DO)

How to Get There Medical Surgical Internal medicine Pediatrics Family medicine Physical Medicine and Rehabilitation Surgical Orthopaedic Surgery Sports medicine Other subspecialties

Case Presentation

Case #1 D.B. 22 yo Varsity College FB player (DE) Chief Complaint: Right ankle pain

Case #1 History “Coming off of a block and rolled my right ankle” Inversion injury Felt a ‘pop’ in the ankle Able to walk off the field Not able to return to play

Differential Diagnosis Most likely diagnosis? Ankle sprain Fracture/dislocation Muscle strain Dislocated tendon Torn tendon

ATC’s Role Alert coaching staff Initial athlete evaluation “ATC gestalt” Triage Patch and go Versus Communicate with Doc

Team Doc’s Role OBSERVATION! Be a trained observer! Gait Swelling Deformity On-field performance Compare to other side

Team Doc’s Role Communicate with ATC Help coordinate care Timely athlete evaluation In gear Versus Gear off Sideline vs Locker room SAFELY get patient back into competition

Anatomy

Ankle Anatomy Bones Tibia Fibula Talus

Ankle Anatomy Ligaments “ORTHO PROOF” Named by bones

Ankle Anatomy

High Ankle Anatomy

Ankle Sprain Anatomy Type I Type II Type III Stretched Partially torn Completely torn

Ankle Exam

Ankle Exam Observation Palpation Swelling Bruising Deformity Medial Lateral Proximal

Ankle Exam Special tests Anterior drawer Talar tilt

Ankle Exam Special Tests Squeeze test External rotation test

Case #1 Exam on sideline Antalgic gait (visible limp) +Swelling No deformity No ecchymosis (bruising) Significant TTP (pain to touch) No bony TTP Stable No “Syndesmosis pain” “NV intact”

Case #1 On field Similar exam in injury clinic next day Ankle taped Standard tape job + ‘spats’ Unable to perform sport-specific drills Placed in walking boot/crutches Similar exam in injury clinic next day Sent for xrays on Post-injury day (PID) #2

Case #1 Interval history PID #7 PID #7 – 21 Weaned out of boot Attempt to ramp up activity No go Back into boot PID #7 – 21 Continued ankle rehab Step-wise improvement (objective/subjective)

Case #1 Returned to play 3 weeks after injury Played in 2 Varsity Games Still mildly hobbled by injury Ankle not at 100% No interval injury MRI obtained at 5 ½ weeks post injury Continued pain

Not a sprain MRI showed talus fracture Nondisplaced Also showed ligament tears

Differential Diagnosis Most likely diagnosis? Ankle sprain Fracture/dislocation Muscle strain Dislocated tendon Torn tendon

10/29/2007

9/13/2007

Capsular Distention – Original Films

Case #1 Treatment Foot & Ankle Specialist consulted Non-operative management Cast x 3 weeks Aircast boot x 3 weeks Follow with serial imaging

Case #1 Healed fracture 10 months later 10 month xrays No pain Full motion Spring practice

Discussion Talar neck fractures Hi energy trauma Usually require surgery This is the first reported case in athletic competition

Submitted for Publication

Conclusions Take home message Keep the athlete first Communication is key Keep an open mind Observe, observe, observe When in doubt, get more information

Questions?

Prospective plain film evaluation Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Clark et al Am J Roentgen 1995 Prospective plain film evaluation 1,153 ankles w/acute trauma All with negative x-rays 33 patients with capsular distention on x-ray 11/33 with fracture on tomography Clark TW, Janzen DL, Ho K, Grunfeld A, Connell DG. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Am J Roentgen. 1995;164(5):1185-1189

Vascular supply Inokuchi S, Ogawa K, Usami N: Classification of fractures of the talus: Clear differentiation between neck and body fractures. Foot Ankle Intl 17:748-750, 1996.

Clark et al (cont) Cumulative measurement of anterior/posterior fat pads Predictive for fracture Composite measure > 13mm 82% sensitive 91% specific Retrospective analysis of our athlete 16mm composite measure Highly suggestive of occult fracture Clark TW, Janzen DL, Ho K, Grunfeld A, Connell DG. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Am J Roentgen. 1995;164(5):1185-1189