Wrist, hand injuries a concern in youth sports

Youth sports injuries have become a topic of concern for physicians, coaches and athletes. The biggest fear centers on how these injuries will affect a child’s growth and intellectual abilities. 

Among the injuries that have raised the most interest is concussion. But a recent study published this month in the medical journal for Pediatrics reports that the rates of injuries to the wrist and hand are unusually high.

Sports such as football, ice and field hockey, lacrosse, softball and wrestling were most represented in frequency of injury. Overall, any stick, puck, ball or contact sport can have a high rate of injury. The human wrist is a complex joint that consists of 15 bones that form connections enabling the wrist to move in multiple planes.

The carpal bones in the hand attach to the two bones of the forearm: the ulna and radius.

These bones are connected to each other as well as various muscles by an intricate network of tendons and ligaments. Blood vessels and nerves are intertwined in this grid to provide circulation and sensation.

The most common injuries cited in the study include fracture, contusion, and ligament sprain in descending order of frequency. While most of the injured athletes were able to return to their sports in seven days or less, 12.4 per cent were out for more than three weeks.

Initial treatment often includes rest, ice and immobilization but some fractures may require surgery. 

“Persistent pain and swelling after a wrist or hand injury in a child requires further evaluation by a physician,” reports Dr. Joel Ferreira, an Assistant Professor of Orthopaedics at the University of Connecticut, where he specializes in hand and wrist injuries. “Imaging studies may be necessary to rule out fractures affecting the growth plate that may result in a chronic condition.”

Prompt evaluation and treatment of hand and wrist injuries in young athletes can help speed recovery.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Improper use of smelling salts a growing concern

Athletes are always looking for an edge that will improve performance.

Often these efforts are ill-advised and at times harmful. One practice that has become popular among high-level athletes is the use of smelling salts to increase alertness.

Smelling salts consist of spirits of ammonia. The use of smelling salts dates back to the Roman Empire but they became popular during the Victorian era. They were used to help revive women who were fainting.

Syncope or fainting is a loss of consciousness as a result of a slowed heart rate triggered by a vagal reflex. This reflex is often initiated by dehydration, anxiety or pain. Ammonia salts directly irritate the nasal mucosa and elicit a noxious reflex. This causes the heart to beat faster and hopefully counteract the vagal response.

Approximately 50 years ago, they became popular in sports to supposedly counteract the effects of head trauma. Smelling salts became popular in boxing where their use eventually was banned.

Trauma patients often suffer neck injuries that may be undetected. The first response to the noxious smell is to suddenly jerk the head away from the stimulus. This can result in dislocating an injured spine and potential paralysis.

More recently, athletes have begun to use smelling salts with the belief that their use will keep them more alert.

The use of smelling salts is particularly popular among football and hockey players who believe this reflex will counteract the effects of concussion.

Recent estimates report 80 percent of NFL players using smelling salts, according to a recent article in ESPN The Magazine.

It is only natural that athletes at lower levels will follow this practice.

Smelling salts should only be used in limited situations under the guidance of a health professional.

Coaches, parents and athletic trainers are crucial to ending the inappropriate use of smelling salts in young athletes.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport.








As cheerleading evolves, injuries continue to rise

The controversy over whether cheerleading should be classified as a sport or an activity is ongoing. One thing that is not disputed is that cheerleaders are athletes with athletic injuries.

Cheerleading first became prominent in the late 19th century in Ivy League schools. In the 1920s, it became more common in other universities. Interestingly, it was a male-dominated activity until the 1940s when many men had enlisted in the military.

The two venues today for cheerleading are scholastic, where the emphasis is placed on energizing the crowd for a sporting event, and competitive, consisting of cheerleading squads that compete in front of judges for points.

The basic cheerleading skills include tumbling, jumping and stunting. Stunting involves complex formations of team members and airborne acrobatics. As cheerleading has evolved, it is stunting that has gained the most attention.

The participants in stunting are classified as “base” and “flyers.”

Several recent publications have looked at the most dangerous youth sports. Cheerleading is on all these lists and considered the most dangerous in a report published by the National Center for Catastrophic Sports Injury Research.

Lower extremity injuries are the most common and include sprains and strains. The most catastrophic injuries involve the brain and spinal cord in the form of traumatic brain injuries and spinal injuries that result in temporary or permanent paralysis.

These injuries have been on the rise due to the growing popularity of cheerleading and the increasing complexity of the stunts being performed.

The American Academy of Pediatrics has called for changes to make cheerleading safer. Among these is the need for coaches at all levels to be properly trained and certified to direct stunting maneuvers and be able to recognize head injuries.

Parents should not be shy about inquiring about any coach’s credentials when it comes to their child’s safety.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Learning about shin splints and leg pain

Long distance runners are in the midst of both cross-country and marathon running seasons. Running on trails or asphalt can lead to lower leg pain. Shin splints, also known as medial tibial stress syndrome, is a general term used to describe lower leg pain.

The lower portion of the leg consists of two large bones: the tibia and the fibula. A membrane between these bones, the interosseous membrane and the anterior intermuscular septum, form four compartments. These compartments consist of an intricate network of muscles, arteries, veins and nerves that allows the ankle to move in multiple directions.

Shin splints are often associated with changes in running patterns. They can be attributed to using different types of footwear including excessively worn running shoes, rapidly increasing running distances and association with other injuries in the same or opposite extremity.

Compartment syndrome is among the most serious conditions that may be mistaken for shin splints. This syndrome consists of increased pressure within one of the four compartments of the lower leg. The increased pressure is a direct result of an injury causing swelling within a closed space.

The increased compartment pressure results in an inability for venous blood to drain and arterial blood to enter. The consequence is a lack of nutrients and oxygenated blood to muscles and nerves causing these tissues to atrophy and cease to function.

“The first step in treating shin splints is to find the cause,” reports Ms. Janeen Beetle, head athletic trainer at Norwich Free Academy. “Ice cup massage combined with anti-inflammatory medications provides the best treatment. Strengthening lower extremity muscles can help prevent recurrences.” 

Careful evaluation of lower leg pain can avoid serious complications.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

What does CTE really mean?

The recent information that former New England Patriots football player, Aaron Hernandez, was found to have evidence of Chronic Traumatic Encephalopathy (CTE) at autopsy has been followed by multiple opinions and at least one lawsuit.

Before drawing conclusions it is important to understand CTE and what the initial scientific studies really mean.

CTE is a diagnosis based on post-mortem findings of the brain. The diagnosis is actually a refinement of the previous findings of Dr. Harrison Martland, a medical examiner in Newark, N.J., who first described post-mortem changes in the brains of boxers in 1928.

A hallmark of CTE is the presence of tau protein, a substance that naturally occurs in nerve cells and appears to leak from the cells with repeated head trauma. The amount and distribution of the staining for tau coincide with the severity of CTE.

Although the predominant studies have been done on a group of deceased football players, many of whom have faced some life challenges, a direct causation between football and CTE has not been established.

One challenge with this condition is the fact that this can only be diagnosed after death. A study published last week in the journal PLOS ONE reports the identification of a potential biomarker to diagnose CTE in the living. The protein, known as CCL11, can be found in the spinal fluid of patients suspected of suffering from CTE.

It is important to note that no one has firmly linked the actions of someone with the CTE findings. The only thing we do know is that there are changes in the brain after repeated blows.

CTE research is ongoing and there is much to learn about chronic brain injury and its relation to sports. It is unfair and dangerous to make clinical assumptions that affect society and peoples’ lives at this early stage of investigation.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu






Ankle sprains becoming more common among athletes

As athletes are drawn to more extreme sports that involve increasingly challenging terrain, the frequency of ankle injuries increases. Depending on the severity, ankle injuries can require an extended period of rehabilitation.

The ankle joint is made up of three bones — the tibia and fibula that make up the lower part of the leg and the talus that is part of the foot. A complex network of ligaments that allow the foot to bend upward and downward holds the joint together.

The principal mechanism of injury involves a forceful overpowering of the ligaments in a variety of directions. This type of injury is known as a sprain. The most common ankle injuries are the inversion, eversion and high ankle sprains.

The inversion ankle sprain is the result of suddenly turning the foot inward and damaging the ligaments on the outside of the ankle joint. An eversion sprain is the consequence of the foot turning outward and stressing the ligaments on the inside of the ankle.

A high ankle sprain is the result of injury to the ligaments that attach the tibia and fibula. It is caused by the sudden rotation of the foot outward.

The best treatment approach to an ankle sprain is the RICE protocol (Rest, Ice, Compression, Elevation). Reducing blood circulation to ligaments diminishes the availability of factors that aid healing.

“Sprains can take a long time to recover,” states Dr. Lauren Geaney, Assistant Professor of Orthopedic Surgery at the University of Connecticut, who specializes in foot and ankle injuries. “Ice and elevation in the early stages and early mobilization and strengthening as soon as the swelling and pain allow. Surgery is rarely needed and almost never indicated during early recovery.”

Appropriate treatment of ankle sprains can avoid having them develop into a chronic problem.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu.

Ex-UConn, sports medicine doctor will be missed

Last week, with the sudden passing of Dr. Jeffrey Anderson, the UConn athletics family and athletes everywhere lost a compassionate physician and strong advocate for health and safety in sports. Dr. Anderson was head team physician for UConn from 1993-2014. He left that position to take on the challenges of directing student health services at UConn while serving as the impartial administrator for Major League Baseball and the Major League Baseball Players Association Joint Drug Prevention and Treatment Program.

Dr. Anderson graduated from the University of Michigan Medical School, where he did his residency in Family Medicine. This provided him with a broad medical background that he decided to apply to sports medicine. He did a fellowship in Primary Care Sports Medicine (PCSM) before taking the position at UConn.

PCSM, a relatively new field thirty years ago, has continued to grow and attract many bright young physicians. Prior to the increased involvement of primary care physicians, orthopedic surgeons managed most of sports medicine.

The increasing complexities of sports performance have resulted in the expansion of the sports medicine team. Dr. Anderson saw the need before others and invited a variety of specialists to join him including this writer.

PCSM fellowships are open to physicians who have completed residencies in family medicine, emergency medicine, pediatrics or internal medicine. The principal focus of these specialists is non-operative orthopedic problems and general medical conditions.

Another crucial role of the PCSM physician is preventing injury. This often involves counseling athletes and creating an effective rehabilitation program.

Knowledge of performance enhancing drugs and how they are used has become another important facet to PCSM. In many of these situations athletes are trying to gain an edge by taking supplements that unknowingly contain banned substances. These circumstances can only be avoided by education.

Dr. Anderson was masterful at treating and protecting athletes while providing an example for other physicians.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu.






Health protocols vital for scholastic sports

Millions of students will be returning to scholastic sports in the coming weeks. Reducing the risk of catastrophic injury is a priority for everyone involved in sports.

The most common causes of sudden death in athletes are cardiac, neurologic and heat-related. Measures to minimize tragedies associated with these conditions include effective screening of athletes and the availability of established protocols with appropriate resuscitative equipment in the event of an emergency.

Cardiac conditions can be effectively screened based on careful evaluation of symptoms and testing performed on athletes who have a significant personal or family history of cardiac arrhythmias. The availability of an AED (automated external defibrillator) at all athletic events has proven to be lifesaving.

Traumatic brain injuries result from high-velocity impact causing hemorrhage and swelling in the brain. Recognizing the signs and symptoms of this injury and taking immediate steps can avoid a tragedy. Any athlete who sustains head trauma should be removed from play and evaluated.

Exertional heat stroke occurs when the body temperature reaches 105 degrees Fahrenheit. Symptoms include confusion, lightheadedness and headache. If untreated, persistent hyperthermia will result in coma and death.

One effective way to avoid these catastrophes is to have appropriate protocols and policies in place. Among these are emergency action plans (EAPs) that apply to each situation.

In a recent report published in the Orthopedic Journal of Sports Medicine, Connecticut ranked 38th in a survey of all states with respect to having the proper protocols in place.

“EAPs are a no-cost way to facilitate communication across all key stakeholders for athletics programs and reduce critical delays in care for athletes,” reports Samantha Scarneo, Director of Sport Safety at the Korey Stringer Institute at UConn and one of the study’s authors.

Every school should have a plan that can be easily put into action to deal with medical emergencies on the athletic field.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

New CTE study provides uncertain link to football

A recent study published in the Journal of the American Medical Association-Neurology looks at the first large-scale study of the brains of deceased American football players. This study has attracted the attention of the media and comes at a time when parents must decide whether to permit their children to play football this season.

The study reports the results of neuropathological and clinical studies performed on 202 football players. The athletes studied played at multiple levels of competition: 14 high school, 53 college, 14 semiprofessional, eight Canadian Football League and 110 National Football League.

The principal neurological condition studied was Chronic Traumatic Encephalopathy (CTE). This entity has been studied in a variety of forms since Dr. Harrison Martland published his original studies in JAMA in 1928 titled “Punch Drunk.”

In 2009, Dr. Ann McKee and her colleagues at Boston University published a seminal paper in the Journal of Neuropathology describing CTE in three professional athletes. That same group published this most recent study. The pathology in CTE is based on brain atrophy and the deposition of tau protein. Tau protein is a normal constituent of the brain that is believed to leak after trauma.

Clinical findings in CTE are primarily changes in behavior, motor abnormalities and dementia. These features can be present in isolation or in total. Several of the athletes studied committed suicide.

The recent study reports an escalating frequency of CTE based on the level of football played. The percentage of players affected increased from 21 per cent of high school players to 99 per cent of NFL players.

Although this study demonstrates an association between CTE and football it does not prove that football is the cause of this condition. Among the faults in this study is “selection bias.” This refers to the fact that the only athletes who volunteered were those who had clinical symptoms. Healthy football players who went on to successful careers and stable family lives were not part of this study. 

Unfortunately, this study provides little direction for parents who are faced with a difficult decision. Several important factors to consider are whether a child has had previous concussions, if the child is of high school age and how important playing football is to the child’s overall well being.

Football is a great sport but parents must make responsible decisions regarding participation in any high-velocity collision sport.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

MMA fighters risk lives during bouts

Recent deaths during combat sports events have attracted the attention of fans and officials. The circumstances surrounding these catastrophes require further review.

As opposed to boxing, Mixed Martial Arts allows the application of multiple fighting disciplines including: wrestling, judo, Brazilian Jiu-Jitsu, boxing and Muay Thai kickboxing. The variety of these skills has helped attract fans who follow and participate in these martial arts primarily for fitness and self-defense.

Unfortunately, the operative word in these contests is “combat” and it is meant to be taken literally. These amateur and professional fighters are placed in a situation where the body invokes the “fight or flight” response. This reflex causes the heart to race, muscles to tighten, blood pressure to rise and glucose to elevate. Essentially, these changes prepare the human body for battle. This level of stress demands that the athlete be in excellent condition.

Since 2007, at least 15 MMA fighters have died either preparing for or during a contest. Two of those deaths have occurred in the last six weeks.

Tim Hague, an MMA fighter, died in a boxing match in Edmonton, Alberta, after a punishing blow resulted in a brain hemorrhage. Donshay White died of what is believed to be a cardiac event after an amateur MMA event.

Pre-fight medical requirements vary among states and Native American tribal jurisdictions. Although not perfect, these studies are important to screen for potential tragedies. 

“Deaths in combat sports are unfortunate occurrences. Uniform medical requirements across all state and tribal commissions must be established,” reports Mr. Michael Mazzulli who heads the Mohegan Tribe Department of Athletic Regulation and currently serves as president of the United States Association of Boxing Commissions. “In Connecticut, the medical regulations are identical for the State, Mashantucket-Pequot and Mohegan commissions.”

Despite its popularity, participants in MMA contests must realize that potential death is a very real risk.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu