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Sports Doc Posted: Wednesday, July 29, 2015, 3:38 PM Sunday while the celebrations for the Mexico win over Jamaica in this year’s CONCACAF Gold Cup final at Lincoln Financial Field continued into the night, the work of the venue medical staff wasn’t quite done yet. We still had to conduct the doping control testing where two players from each team are required to undergo drug tests following each match. I didn’t know who had it harder, those who had to grab two players from the losing team or those who had to pull away two players from the winner’s celebration. Luckily, this was the busiest the venue medical staff would be that night. While all teams travel with their own medical staff, each venue is required to have their own people for all of the behind-the-scenes coverage and 3B Orthopaedics had the honor to coordinate the venue medical staff for this Sunday’s big match. With good planning, most of our work was completed long before the players hit the field. Three months prior to the tournament, Dr Arthur Bartolozzi MD (Venue Medical Director), Matt Hay PA-C, ATC (Assistant Venue Medical Director), and I had to put together the game day venue medical staff as well as local medical specialists to have on call to cover any need that may arise for both the teams and CONCACAF staff members. The venue medical staff consists of the stretcher crews and doping control chaperones. While often times, stretcher crews are staffed with volunteers with no medical background, with the recent changes in protocols implemented by CONCACAF for head injuries, sudden cardiac events, and heat and hydration management, we wanted to make sure we had the most qualified medical staff available. Our stretcher crews consisted of athletic trainers, physical therapists, and sports medicine physicians. Along with the stretcher crews and doping chaperones, we also coordinated stadium X-ray coverage as well as ER trauma coverage. Discussions took place prior to the match with each team’s medical staff as well as the officiating crew regarding the new protocols, emergency management plans, and when to enter the field of play for injuries. Plan for the worst and hope for the best. We’re happy to say that everything went smoothly and we all got to sit back and watch a great soccer match. As we look forward to the CONCACAF Confederation’s Cup playoff in October between the US and Mexico, I’m excited that I’ll be able to watch it as a fan and let all of the venue medical planning be handled by the Rose Bowl staff.
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 Philly.com Sports Doc
Posted: Monday, August 25, 2014, 5:30 AM Achilles tendon rupture, the fear of every middle age man on the basketball and tennis court. Now that I am in my 40s I fall into that category. And unfortunately for me, I recently felt the dreaded “pop” while playing doubles tennis. At first, I thought the ball came from the next court and hit me on the back of the leg. Then I came to my senses and realized I had torn my Achilles. The people who stopped playing on the courts next to us must have thought I was in a lot of pain the way I was yelling while lying on the baseline. In truth, I didn’t really have much pain. I was yelling because I knew what was to come: Surgery, weeks of non-weight bearing and partial weight bearing, and the huge inconvenience this would be for work and life in general. My father-in-law, who was my partner in this ill-fated doubles match pointed out, “Hey, at least you won the point.” Not much consolation. My summer fun was over. So what happened? How did I tear my Achilles? As I am known to do, I reviewed all the research hoping to figure out the cause. Maybe I was fatigued which may have contributed to the injury. More likely I’m predisposed as I tore the other side over a decade ago playing soccer. Neither time did I have any Achilles pain leading up to the injury. There are some studies showing possible relationships with risk factors and Achilles ruptures. In the June 2014 edition of the journal Sports Medicine, Claessen et al categorized these potential risk factors into two categories: non-modifiable and modifiable. Non-modifiable factors include age, race, sex, medical issues, pre-existing musculoskeletal disease/tendon changes, ankle/foot alignment and genetic factors. Modifiable risk factors include obesity, sports activity, medication and smoking. From a specific sport perspective, Achilles tendon ruptures are found more frequently in athletes who participate in sports involving explosive acceleration such as basketball, tennis, baseball, and softball. Of the above factors, medications, especially Quinolones (specific antibiotics) and Corticosteroids, have shown to have the greatest risk for Achilles rupture. There are multiple potential risk factors for Achilles tendon ruptures but none have been proven to be key factors. One risk factor that I definitely have is O blood type. A study from 1989 in the American Journal of Sports Medicine stated “In cases of multiple ruptures and re-ruptures, the frequency of blood group O was 71%.” However, the O blood type correlation is still up for debate. Although the mechanism is still up for debate, what you’ll see if you slow down a video of the injury is the player taking a back step to push off and the knee forcibly extending at the same time. The combined force of foot plantar flexion and knee extension is likely too much stress for the tendon to handle. Watch the video of David Beckham tearing his Achilles for the prototypical mechanism of injury. Strauss et al reported the following statistics in 2007 in the International Journal of the Care of the Injured. The incidence of Achilles tendon rupture is approximately 18 per 100,000 people. Ruptures typically occur in males between 30 and 50 years old and account for approximately 40% of all operative tendon repairs. Approximately 75-80% of cases can be attributed to participation in athletic activities, including ball and racquet sports. Surgery or not? There is ongoing debate as to what is the best course of treatment: Surgical repair or non-operative treatment. Surgery involves bringing the two ends of the tear together and suturing them in place while the tendon heals. Non-surgical treatment involves casting the foot in plantarflexion (toes pointed down) and recasting weekly with gradual progression into dorsiflexion (toes up). Non-operative care has demonstrated a re-rupture rate from 10-30% where surgical re-rupture rates are around 3-4%. Surgical complications have been reported to occur in 7-42% of all cases and include difficulty with wound healing, skin necrosis, infection, and sensory loss. For me, it wasn’t a question. I elected to have surgery as I want the best chance at a full recovery. Rehabilitation This is the most frustrating part for me. For surgeries such as an ACL reconstruction, the harder you work the quicker you recover. It’s just the opposite with an Achilles repair. The tendon needs time to heel so for the first 2-4 weeks you can’t put any weight on the foot. Then, over the next 3-4 weeks you gradually increase weight bearing in a boot with a heel lift to take pressure off the tendon. Strengthening is started late in the rehab process which means it takes a long time to get your full strength back, and many people never regain full strength after this injury. I never regained full strength after my first surgery and definitely lost a step with sports (although that could just be me getting older but I’m going with the injury). It takes approximately 4-6 months to start back to running and to initiate sports activities with complete recovery taking close to a year. As you can guess, I’m in for a long and slow recovery following Achilles surgery. Prevention Is there any way to prevent an Achilles injury? There isn’t much research on this topic. In younger, high level athletes, there probably isn’t a way to prevent it other than not playing as intensely. For someone older like me, there is the possibility that by improving flexibility and fitness you may be able to reduce the risk of injury, but it is still probably just bad luck. For me, I’ll do my rehab and get back on the tennis court and the soccer field in the spring. Unless my surgeon and my wife force me to take up a sport with a lower risk of traumatic injuries, but with my luck, I’ll probably fall off the elliptical and break an arm.  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
Justin Shaginaw MPT, ATC RobertSenior, Sports Doc blog Editor Posted: Wednesday, December 11, 2013 Friday’s World Cup 2014 draw was wildly panned by fans of the United States Men’s National Soccer Team (USMNT), as the team was selected into the foreboding “Group of Death” alongside Ghana, Portugal and Germany for June’s world championships in Brazil. The matchups alone are enough to give fans apprehension—Ghana, the nation that’s eliminated the USMNT from the last two World Cups, alongside perennial powerhouse Germany and Portugal, who feature one of the world’s best in Cristiano Ronaldo. But the conditions in which the USMNT will play their games offers equal cause for concern. Over the course of 12 days, the team will travel over 9,000 miles for their three games—more than any other World Cup squad. What’s more, the second of the three games—against Portugal—will be played in Manaus, in the heart of the Amazon rainforest. Concerns about the conditions have already caused enough uproar to cause the game to moved from 3 p.m. to 6 p.m. local time—out of the worst heat of the day—but this game promises to provide the USMNT with their stiffest test, in terms of conditioning. “It’s going to be difficult—for both teams,” says Justin Shaginaw, MPT, ATC, who’s worked extensively with the USMNT. He traveled to South Africa for World Cup 2010. “Most of Portugal’s players are playing professionally in Europe. They’re not accustomed to that climate either. If they were to be playing against a South American country in that environment, the South American nation would have an advantage because of their familiarity with the climate.” Shaginaw adds that people can’t focus on the environment in Manaus as the only challenge the team will face. “It may not be as hot as the jungles,” he admits, “but those other two aren’t exactly going to be mild, either In terms of travel, Shaginaw says that the advantage in South Africa was the ability to set a home base, and drive to and from each game. That won’t be possible in Brazil, with games being played throughout the nation at points hundreds and even thousands of miles from one another. It may sound funny, but at least with all the travel the players won’t be cooped up indoors all day. Shaginaw explains. “There are pluses and minuses—in South Africa, we couldn’t leave the hotel without security detail—and my understanding is it’ll be pretty much the same in Brazil,” he adds. “In Europe, the players can kind of come and go—they can walk around town, have coffee… you can’t really do that in Brazil.” The travel, he added, can be notoriously difficult on team staff members who are responsible for transporting about 10,000 pounds of gear to and from each game. “Warm-up gear, cleats, Gatorade, etc… shipping all that stuff back and forth can take a toll on you,” Shaginaw says. “But for the players? They might like the change in venue—a chance to get out of that same hotel you’ve been in for the last 20 days.” In the end, while Shaginaw admits there’s a decided advantage for South American sides in this tournament, he adds that there’s reason for optimism for USMNT supporters. “If they can make it out of that group, they should have a good shot of going pretty far in the tournament,” he says. “All three of their opponents are strong teams, so if they can make it past that group, that’s evidence you’ve got a pretty strong team.”  Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation POSTED: WEDNESDAY, OCTOBER 2, 2013, Whenever I see a patient with an ACL tear, they always want to blame something or someone for their injury. The biggest culprit in the blame game seems to be turf fields. If you’re old enough you might remember the original AstroTurf, and by all means plenty of blame can be placed on it for athletic injuries. But now we have new 3rd and 4th generation turf fields that are much more similar to natural grass. They are used in the NFL, MLB, MLS, and even international soccer matches are being played on them. People still love to blame turf for their injuries. But are there any facts behind these assumptions that more injuries occur on turf than grass? Research has shown that as the coefficient of friction increases there is an increase in the rate of lower extremity injuries. This means that the more traction you get on the field or court, the higher the risk of injury. The common thought is that turf has more traction than grass and therefore we will see more injuries on turf. Increased injury rate on artificial turf: A study published in 2011 looking at football, rugby, and soccer injuries showed that there was a higher incidence of ankle injuries on artificial turf. In 2012, another study looking at NCAA football injuries showed an increased risk of ACL injuries on artificial turf. Lastly, a 2013 study looking at amateur soccer players in Portugal showed a greater rate of lower extremity injuries on turf during matches vs. training. No difference in injury rates: A 2010 study looking at collegiate football injuries showed that FieldTurf may actually be safer than natural grass for injuries in general. This study also found no significant difference in knee injuries between surfaces. Another study in 2013 looked at injury rates between grass and artificial turf in female collegiate soccer players. This study actually showed a significantly lower total injury incidence rate and a lower rate of substantial injuries on FieldTurf. This study also showed no significant difference in knee injury rates between the two surfaces. Since the research doesn’t give us a definitive answer regarding injury rates and artificial turf, what is the best advice regarding artificial turf? We know that the greater the traction, the higher the rate of injury. Wearing cleats made specifically for artificial turf, or better yet turf shoes, may help to decrease traction and therefore reduce lower extremity injuries. We can apply this same thought process to grass regarding increased traction and increased injury rates. Unfortunately, there may be a decrease in performance as shoes with less traction may cause players to slip. Previous sports doc blogs have discussed ACL reduction programs. For those at higher risk for ACL injuries, maybe the type of shoe you practice and play in should be part of an injury reduction program. So don’t just choose your cleats for the color, but instead pick the ones that are appropriate for the playing surface.  Philly.com Sports Doc
Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation POSTED: Friday, August 30, 2013, 6:00 AM With the start of high school soccer, we can all think back to our athletic days: sitting in a cramped locker room waiting to get our ankles taped, hoping they have any favor of Gatorade other than lemon-lime. Butterflies in our stomachs as we wait for game time. So how do these high school experiences compare to a professional soccer sideline and locker room? Parents always tell me they want their child to be treated just like the pros. When it comes to injuries sustained on the field, they are. The care the high school athletes receive is actually more similar than one would expect. An ankle sprain is an ankle sprain and the high school player is treated just about the same as the pro. We perform a quick injury assessment to determine the severity and if it is minor, tape the ankle, and get the player back on the field. If it is more serious, we tell the coach to call for a sub and get the player to the bench for ice. The level of care is identical for concussions as no player, whether high school or pro, is allowed to return to the game if he or she has a concussion. The biggest difference is the limited subs in soccer at the professional level. In high school, we have time to get the player to the bench and thoroughly evaluate them to see if he or she can return to the game. In the pros, we are limited to 3-7 subs depending on the match. And without timeouts like in other sports, we have about 2-3 minutes to decide whether the player can return. You could say that the pressure to get the player back on the field is greater in the pros—but have you been to a high school game recently? Sometimes I feel there is more pressure from the coach and parents at the high school level than there is on any pro team. But there is a big difference regarding the individual attention the pro players get from an equipment standpoint. Game day uniforms are set out in the locker with little specifics for each player. One player wants the tags cut out of his shorts while another wants the liner cut out of his. Some have four different pairs of cleats ready for him in front of his locker while another only brings one pair with him on the bus. Let’s just pray he doesn’t forget them back at the hotel. One player has a cup of water and a shot of orange Gatorade with a packet of Gatorlytes waiting for him in his locker after warm-ups. Another prefers that one staff member massage his calves but someone else tapes his ankles. Post-game protein shakes are offered to players while they’re sitting in the cold tubs and make sure you don’t forget a strawberry one for you know who. As you can see, there are a lot of differences between the high school and pro athlete, but the medical care is not one of them. When it comes to injuries, all the players I work with get the same level of care. The pros are the ones who can ask for a specific color of tape for their ankles and they know that I will find it for them. The high school player gets two choices—white or white?  World Cup 2014: The "dress rehearsal"06/27/2013
0 Comments Philly.com Sports Doc POSTED: Wednesday, June 26, 2013, 6:00 AM Justin Shaginaw, MPT, ATC, Aria 3B Orthopaedic Institute, Athletic Trainer - US Soccer Federation The 2013 FIFA Confederations Cup is underway. Group play is over and the semifinals are set: Brazil vs. Uruguay; Spain vs Italy. It’s a tune-up, a full dress rehearsal for the biggest event on the soccer world stage—the FIFA World Cup. Confederations Cup competition consists of eight teams: the champions of each of the six FIFA confederation championships (UEFA, CONMEBOL, CONCACAF, CAF, AFC, OFC), along with the FIFA World Cup winner and the host nation. The teams play in the exact same venues where World Cup play will take place. The dry run gives teams a chance to make sure everything is ready and allows the host nation time to make adjustments when they are not. Players get a chance to check out the pitch and the volume of the crowds. Coaches get a sense of how the field will play and plan accordingly. Also, players get an idea of weather conditions, sun positioning, and altitude. All of these factors will play a major role next summer. Also, this dry run allows a team’s staff members to get a chance to assess the amenities so they can bring what they need for the World Cup. In the United States, each professional sports league has specific rules and regulations regarding the locker rooms and athletic training rooms, supplies that the host team provides, and assistance for away teams. That’s not the case in international play. Teams don’t really know what they will find and need to deal with in a stadium overseas. Commandeering the fire hose to fill up the cold tubs is fine as long as you don’t get caught. Among the other things the team will need to consider ahead of time: electrical supply for ball pumps and medical equipment. Will there be running water for showers? Is the water drinkable, or does the team need to bring in bottled water? Will the host nation supply simple amenities such as towels, soap, and toilet paper? It’s the biggest event in the sport and teams want to be totally prepared and make sure they’ve packed all they need from band-aids to Benadryl, Gatorade to gum. If the players might want it, the teams will bring it. Just like you surf the web for the best hotel rooms, the teams check out possible accommodations in the host country while in town for Confederations Cup. How are the rooms? The amenities? The safety? The food? What is the distance to and from the practice field and game stadiums? This base becomes the team’s home away from home for a month or more. The happier and more comfortable the players are with their accommodations, the more likely they are to perform well on the field. Simple things like a good internet connection can make all the difference when you are thousands of miles from home and looking for some creature comforts. Confederations Cup also allows teams to size up the competition a year ahead of the big event. It’s one thing to play these teams in a friendly where only pride is on the line. It’s another to play them when there is a major international trophy at stake. Not only does this allow the team to scout the opponent but also lets the coaching staff see how individual teams stack up and what needs to be changed or worked on in the year ahead. Confederations Cup also gives players a psychological edge going into the World Cup. They spend some time in the host country, play in the real venues, and know how the environmental conditions affect the game. Often, it’s the psychological and not the physical or tactical aspect that makes the difference between winning and losing. While we’re waiting for this year’s Confederation Cup final, remember there will be another international tournament being played here in the United States in July. The winner of this summer’s Gold Cup qualifies for a playoff match against the 2015 Gold Cup winner for a spot in the 2017 Confederations Cup. So buy a ticket, grab your jersey, and support the United States as they are already looking ahead to the 2017 Confederations Cup in Russia and a chance to gain that valuable edge for the 2018 FIFA World Cup. Justin Shaginaw, MPT, ATC, traveled with the United States Men’s National Team for the 2010 World Cup in South Africa. |
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