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

Patellar tendon injuries are more common than you think

Dustin Fowler recently made his major league debut in the outfield for the New York Yankees. Unfortunately, his appearance was cut short when he ran into a wall trying to make a play. As a result, he suffered an open rupture of his patellar tendon requiring urgent surgery and months of rehabilitation.

Although rupture is uncommon, injuries to the patellar tendon are often seen in athletes. The patellar tendon is the principal connection between the patella (knee cap) and the tibia. The fact that it connects two bones actually makes it a ligament by definition.

The quadriceps tendon attaches the quadriceps muscle to the patella. Together with the patellar tendon, it plays a crucial role in the extensor mechanism of the knee. This provides stability when the leg is straightened. Weakness and swelling from sprain or rupture will result in a loss of power when extending the leg and potentially the leg collapsing.

Early symptoms include knee pain that worsens with any exertion. This increasing discomfort is often a warning to an impending rupture. An athlete should begin a regimen of rest, ice and possibly anti-inflammatory medications. If the inflammation becomes chronic the tendon will lose elasticity over time and lead to tearing and rupture.

“Common scenarios for injury include: a misstep when going downstairs, stepping into a hole unexpectedly, or slipping on wet grass in which one leg has to sustain body weight,” states Dr. Cory Edgar, Assistant Professor of Orthopedics at the University of Connecticut and Head Team Physician at the Coast Guard Academy.

“The good news is rupture of the patellar tendon is very easy to repair surgically but requires 3-6 months of recovery during which the first 2-3 weeks are very limiting.”

In the case of Dustin Fowler, the rupture was the result of direct trauma without warning signs. Careful attention to knee pain on exertion can avoid serious injury.

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

Hip pain in athletes not easy to diagnose

Hip pain is a frequent injury in athletes who participate in sports requiring running and jumping. The variability of presenting symptoms and pathology make correct diagnosis and treatment a challenge. 

The hip joint is a ball and socket joint between the femur (thigh) and the pelvis. The head of the femur articulates with the acetabulum of the pelvis.

The pelvis is made up of three bones: the ilium, ischium and pubis. These bones come together in the acetabulum. A cartilaginous rim around the acetabulum called the labrum holds the femur in place.

A complex network of ligaments, nerves and blood vessels holds this joint together. Injury to any of these structures can result in pain that is often difficult to localize.

Athletes typically suffer from a variety of overuse syndromes of the hip. The pain in these syndromes is the result of inflammation, arthritis and fractures. Hip pain in young athletes is often related to overuse and can lead to lifetime difficulties unless activities are restricted.

Direct trauma to the pelvis can result in hip and pelvic fractures. A “hip pointer injury” is often seen in high-velocity collision sports like football and hockey when a blow to the rim of the pelvis results in hemorrhage.

Hip pain can also be referred to the low back and be mistaken for a spine injury. Only after careful examination by a qualified physician can the differential be clarified.

“The treatment of hip injuries in elite and recreational athletes is finally beginning to catch up to the treatments we know are routinely successful for shoulder and knee injuries,” reports Dr. Michael Joyce, Co-Director Connecticut Sports Medicine Institute. “Minimally invasive arthroscopic procedures allow athletes the potential to come back from injuries that were once considered career-ending.”

Early diagnosis and treatment are critical to resolving hip pain in athletes.

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

Be wary of skin conditions during summer sports

Summer sports present new challenges for protection from skin conditions that can potentially affect athletic performance. Specifically, sunburn and skin cancers have become increasingly troublesome. 

The human skin constitutes the largest organ in the human body. It is designed to protect the body from harmful microbes. It also has a system of glands, nerves and blood vessels that allow the skin to regulate temperature.

The skin is divided into three levels: the epidermis, dermis and hypodermis. The epidermis is the outermost layer that provides a barrier against the elements. The dermis contains the sweat glands, hair follicles and connective tissue. The hypodermis consists of adipose tissue that insulates the human body. Blood vessels dilate and constrict to allow for cooling and warmth.

Chronic and acute exposure to harmful ultraviolet rays will result in skin damage. Acute damage typically appears in the form of a burn with reddening of the skin and blistering. This leads to pain and the blisters create the potential for infection.

Chronic exposure can result in skin cancer. Skin cancer is the most common form of cancer in the United States, affecting one in five Americans according to the American Academy of Dermatology. 

Basal cell carcinoma and melanoma may be prevented through the use of lotions containing an SPF (skin protection factor) of 30 or greater. Athletic clothing should have a UPF (ultraviolet protection factor) of 50 or more.

“Most skin conditions that come as a result of summer sports can be prevented if precautions are taken ahead of time,” reports Dr. Jennifer Pennoyer, a board certified dermatologist practicing at Pennoyer Dermatology in Bloomfield. “Anticipating potential exposure as well as regular skin checks can avoid a lot of anguish.”

Athletes rely on skin and sweat glands to regulate large variations in climatic conditions during workouts. Skin care can keep an athlete competing longer.

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

Wrist injuries common in sports, can lead to long-term disability

Boston Red Sox second baseman Dustin Pedroia was placed on the disabled list Tuesday after spraining his wrist during a game against the Chicago White Sox on Monday. Peoria’s case is not uncommon since hand and wrist injuries account for up to 25 percent of all sports-related injuries, according to a study published in the Journal of Orthopaedic Surgery and Research last year.

Another recent study revealed that 14.8 percent of youth athletes have suffered upper extremity injuries and 9 percent of those involved the wrist. These injuries account for a significant number of emergency room visits. The correct diagnosis and treatment of wrist injuries can be challenging and lead to extended periods of inactivity and rehabilitation.

The wrist joint is a complex joint that is formed by the connection of the forearm to the hand. The principal forearm bones are the ulna and radius. Although there are eight carpal bones in the hand, only the scaphoid and lunate directly articulate with the radius and ulna.

These bones are held together by a series of ligaments that permit free movement of the joint. The median, ulnar and radial nerves are the principal nerves that innervate the hand. These nerves are intimately associated with the bones and ligaments as they traverse the wrist.

The most common injuries to the wrist are fractures, ligamentous injuries (loose ligaments) and tendonitis. A typical mechanism for an acute injury is falling on an outstretched hand, which is how Pedroia was injured. Although this happen in any sport, it is especially common in snowboarding and contact sports.

Chronic injuries are commonly seen in overuse. These are the result of repetitive movements often seen in racquet sports, golf and gymnastics.

Particular attention should be paid to young athletes who are more prone to overuse injuries as the wrist joints develop.

“Wrist injuries can be worse than you think,” reports Dr. Joel Ferreira, Assistant Professor of Orthopaedics at UConn. “An injury that may feel like a sprain may actually be a fracture or a severe ligament tear. Persistent injuries should be evaluated by a physician with special training and access to advanced imaging techniques.”

Sports-related wrist injuries can lead to long-term disability if not treated properly.

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

Even professional athletes not immune to the yips

Some athletes have faced the sad situation where, for no apparent reason, they suddenly lose the ability to perform a basic skill that was previously effortless. Although most commonly seen in golf and baseball, it also has been known to occur in place-kickers and musicians who have reached the highest levels in their fields.

Commonly known as the “yips,” the cause and treatment continue to elude physicians, psychologists and other sports medicine specialists. There is no consensus regarding a physical or psychological origin of this problem. In baseball, the yips have detoured the careers of Rick Ankiel, Steve Sax and Chuck Knoblauch to name a few.

Many specialists believe the yips are the result of a movement disorder best classified as a focal dystonia. The most common example of a focal dystonia is writer’s cramp.

Movement disorders are neurologic disorders that affect the brain’s ability to execute smooth, coordinated movements. The brain consists of a variety of regions that contribute to movement. These include the cortex, basal ganglia and brain stem. Communication among these areas is accomplished through neurochemicals. Any imbalance in these substances will result in an abnormality.

One part of this chain of activity that is believed to play a crucial role in the yips is proprioception. This is the ability for the brain to recognize the position of an extremity in space. A change in the usual position of the arm when throwing may be the initial disruption of the chain of events.

“Sensorimotor retraining exercises, oral medications and Botox injections can help with the dystonia,” reports Dr. Bernardo Rodrigues, a neurologist specializing in the treatment of movement disorders at UConn. “In some cases, Deep Brain Stimulation (DBS) surgery can also be offered to aggressively treat this condition.”

The yips may be more than a psychological condition and treatment with appropriate medications can possibly revive a failing career.

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

Spinal fusion surgery helping athletes extend careers

Spinal fusion procedures have become increasingly common. Among the patients who have undergone this procedure are athletes with spinal injuries, including Peyton Manning and Tiger Woods. This has allowed them to extend careers that would have ended without modern surgical techniques.

The human spine consists of a system of nerves, bones, cartilage and ligaments divided into the cervical, thoracic and lumbar segments. The cervical segment is the uppermost segment and the lumbar is the lowest.

The vertebrae are bones that surround and protect the spinal cord and nerve roots. Cartilage provides cushioning between the vertebrae. Ligaments that allow the spinal segment to bend and twist hold the vertebrae and cartilage together.

Spinal injuries typically result in extreme amounts of pain given the intimate association with nerves. These injuries include fractures of bone and cartilage, as well as displacement of the cartilaginous discs that can impinge on the nerve roots. Repetitive trauma to the spinal elements can result in arthritis that will narrow the passages through which the nerve roots exit.

Often surgery is required to alleviate these conditions. Multiple surgeries will eventually alter the complex mechanics involved in coordinating spinal movement.

Spinal fusion involves joining bony vertebrae together with the use of metal plates and screws as well as bony fragments that eventually form a solid body of one or more levels. This will result in diminished flexibility and range of motion at those levels.

“With modern surgical techniques, many athletes of all levels can return to sports after one or two level lumbar (low back) and cervical (neck) fusions. Prior to return to sport it must be confirmed that the bone has successfully healed, which can take up to one year from the time of surgery” said Dr. Isaac Moss, assistant professor of orthopaedic and neurosurgery at UConn. “The most significant determinants of return to sport are usually the patient’s preoperative level of function and the extent of surgery required to fix the problem. I recommend that patients be upfront with their surgeon prior to surgery and discuss their functional goals once they have recovered to make sure that the optimal surgical procedure is selected and their post-op expectations are realistic.”

Spinal fusion does not have to be a game-ending condition.

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

Professional athletes not immune to influenza — just ask the Red Sox

The influenza virus affects millions of people each year. It also accounts for tens of thousands of deaths primarily among elderly, infirm patients and children with chronic illnesses. It also has tremendous impact on productivity in the workplace. Recently, that impact became evident by the direct effect of the influenza virus on the Boston Red Sox lineup.

There are multiple types of the influenza virus that can change their genetic footprint. These changes make immunization a challenging guessing game each year to predict what strains will have the most impact.

Immunization consists of administering a weakened form of the virus allowing the immune system to build up antibodies against a potential infection. Infections can spread quickly among individuals living in close proximity, such as in dormitories.

Typical symptoms include: fever, cough, nasal congestion, nausea, vomiting, joint pain and headache. These symptoms can persist for days or weeks. Treatment is best described as symptomatic with fluid replacement to avoid dehydration and medications to bring down a fever. More recently, antiviral medications are helpful if they are taken soon enough.

Flu season in the United States extends from October to May with peak frequency in February. Unfortunately, baseball spring training begins at the height of flu season and precautions need to be taken to avoid spread if an individual athlete begins to show symptoms.

Like many workers, baseball players are afraid that they may be risking their positions and may force themselves to come to work when ill. This puts other team members at risk.

Clearly the initially-infected athlete was not identified and isolated on the Boston Red Sox team. This has led to numerous players missing time in the starting lineup. Sanitizing locker rooms and avoiding excessive personal contact will avoid prolongation and recurrence.

An outbreak of influenza can slow workplace productivity, even in professional sports.

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

Mental training an important part of recovery

Recovery from an injury or illness of any type can be challenging. It is especially difficult for an athlete who is accustomed to performing at a high level. Incorporating a regimen of mental training can speed recovery and possibly even improve pre-injury performance.

The concept of neuroplasticity involves the ability of the human brain to recover after injury. This is most commonly seen after a stroke or traumatic brain injury. Early rehabilitation will limit the extent of permanent damage by allowing new pathways to compensate for those that were injured.

One of the biggest challenges when going through rehabilitation is that suddenly a patient will have time available that they did not have before. That time element must be managed carefully in a positive sense or it can lead to depression, anxiety and slowed or incomplete recovery.

Mature athletes accept that injury is part of sports and rehabilitation is part of the experience. These athletes often return to successful careers. Unfortunately, some athletes are consumed by the injury and never return.

Among the most notable success stories are those of Peyton Manning and Adrian Peterson, who both returned from serious injuries to have great seasons.

The key elements to the mental aspect of injury recovery include: setting realistic goals, positive self-talk, relaxation and visualization. The visualization component is the most intriguing and difficult.

Visualizing a task in great detail can activate neural pathways from the visual cortex to the motor strip of the human brain. This has been confirmed in recent studies performed with functional MRI imaging. The regular practice of visualizing the throwing motion in detail after a shoulder injury has proven to shorten recovery when the physical ability returns.

The mental aspects of recovery from any injury should not be ignored.

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