Philly.com Sports Doc
Posted: Tuesday, July 15, 2014, 1:14 

PMRIO DE JANEIRO, BRAZIL - JULY 13: Christoph Kramer of Germany receives treatment as referee Nicola Rizzoli looks on during the 2014 FIFA World Cup Brazil Final match between Germany and Argentina at Maracana on July 13, 2014 in Rio de Janeiro, Brazil. (Photo by Robert Cianflone/Getty Images)

Concussions in soccer are becoming more evident, as seen in the World Cup final. Germany’s Christoph Kramer was injured in a shoulder-to-head collision during the first half. He appeared concussed to the average viewer. Kramer even told the German newspaper Die Walt, “I can’t really remember much of the game.” 

Germany’s medical staff evaluated Kramer on the sideline and returned him to the match. Approximately 15 minutes, later Kramer fell down on the field and was subsequently substituted.FIFA’s concussion management protocol is based on Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport, which is the gold standard for concussion management. The SCAT 3 and pocket SCAT 2 are the concussion tools used to evaluate athletes suspected of having a concussion. According to the consensus statement, if it is determined that the athlete has suffered a concussion, he is immediately removed from the game and may not play for a minimum of one week.

Did Kramer pass his sideline testing? Was the German staff not competent in assessing his concussion? Did they return him to play despite having a concussion?

From my observation, he had some obvious signs that would have raised serious concerns about a concussion. We will never know what truly occurred on the sideline, and these situations are becoming more common as seen in this World Cup like Gonzalo Higuaín in the final match, Javier Mascherano in the semi-finals and Álvaro Pereira in the group stages. 

In any American sport, Kramer would have been removed from the game and a thorough concussion assessment would have been performed. The NFL even has independent concussion evaluators on each sideline to limit any bias from the team physician.

International soccer is behind American sports in the assessment and management of concussion. One problem is that they don’t take them as seriously as we do here in the U.S.

Having to play down a man during the evaluation and the limited number of subs is another big problem for concussion assessment and management in international soccer. If the quick sideline test – as performed in the U.S. – shows signs of a possible concussion, a more formal evaluation can take upwards of 10-15 minutes to perform, which means the team will have to play down a man until it’s completed. 

Another issue is who is doing the assessment.  As we’ve seen, the team physicians have been very liberal about letting a player return. There is talk in soccer circles about having an independent physician on the sidelines that has the final say, much like the NFL. Another option may be to allow a temporary sub until the concussion evaluation is completed.

Besides a cultural change, there will need to be some significant rule changes to allow appropriate and unbiased sideline concussion evaluations in international soccer. I just hope that these changes occur before it ends up in the courts as it did here with the NFL.

Philly.com Sports Doc
POSTED: WEDNESDAY, JULY 9, 2014

We've all heard of ACL and Tommy John surgeries. But, have you heard of “hip scope,” the newest surgery in sports? Chase Utley, Alex Rodriguez, Tim Thomas, Osi Umenyiora, Ed Reed: these are just a few of the big time athletes who have undergone hip arthroscopy.  So, what is a hip scope? What does it fix? And how are athletes recovering from it?

Hip scope is short for hip arthroscopy and it describes the way the surgery is performed and not actually what is done. Hip arthroscopy is a newer technique and has advanced significantly over the last 5-10 years. With hip arthroscopy, the surgeon makes small portals or holes and uses a camera and surgical tools instead of making a large open incision.

There are numerous procedures that can be done through the scope. The most common are femoral acetabular impingement (FAI) decompression and labral debridement/repair. FAI decompression involves shaving down bone where the neck of the ball (femoral neck) pinches on the socket (acetabulum). Bone can either be shaved down on the femoral neck, the acetabulum, or both. For a torn labrum, it can either be trimmed or repaired with sutures depending on the location of the tear and the quality of the tissue. Other procedures that can be done arthroscopically are synovectomy, removal of loose bodies, articular cartilage procedures, capsular release (loosening) or plication (tightening), psoas tendon release, IT band release, and repair of a hip rotator cuff tear.

In young, athletic patients we can expect a full return to activity and sports after the surgery. The time frame to return to full athletic participation is about 4-6 months. A 2011 American Journal of Sports Medicine study by Kelly et al looked at outcomes after the arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes. In that group, 78 percent of athletes were able to return to play by one year and 73 percent of athletes were able to play at a two-year follow-up. Another 2011 American Journal of Sports Medicine study by Byrd et al looked at arthroscopic management of femoroacetabular impingement in athletes.  In Byrd’s study, 95 percent of professional athletes and 85 percent of intercollegiate athletes were able to return to their previous level of competition. These articles show that in younger, high level athletes the outcomes are very successful.  What they don’t show are the results at 5 and 10 years. In patients over 35, the outcomes aren’t as good, as the problem is usually longer standing and has likely started to show some signs of early cartilage damage (i.e. arthritis). A 2014 study in Knee Surgery, Sports Traumatology, Arthroscopy by Krych et al looked at isolated arthroscopic labral debridement for hip labral tears in patients between the ages of 32 and 60. Of these patients, 45 percent had combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. As with most orthopedic problems, patients under 35 show good results, while patients over 35 show less favorable outcomes.

Postoperative rehabilitation is a very important factor in the outcome of hip arthroscopy. The key is to correct any underlying dysfunction that may have led to the surgery (ie flexibility, strength, alignment, etc). What we typically see with hip problems is a loss of internal rotation range of motion, gluteus medius weakness, and core weakness. It is important to see an athletic trainer or physical therapist that specializes in hip rehabilitation as the postoperative rehabilitation guidelines are still being developed and those without experience may do more harm than good. 

So the next time you see an athlete on the IR or DL following a hip scope, you might be wondering (as I always do) what they really had done. We know that following this procedure, the athlete should be back and playing at some point, but the question is when. Your fantasy draft may depend on it.