Recent articles on injuries/health and sport

Decided I'll sneak this in every once in a while once I find a couple good reads on some deeper talk on injuries and health related to sports today.

ESPN: "NFL - No more pain-tolerance talk"
Battling the age-old, and likely outdated, philosophy that athletes should battle through pain.

Football365: "Ignorance to mental illness not bliss" tweeted from @alimsomji
Talks about a few cases of depression of soccer players in Europe.

OilersNation: "More important than Stanley: Parenthood"
Great article by Jason Gregor on an NHL player's struggle in trying to become a parent

Tony Romo - fractured rib AND pneumothorax

People may call Tony Romo a pretty-boy, but he sure takes the physical punishment. He recently fractured one rib AND was diagnosed with a pneumothorax in last week's game against the 49ers. Oh, and he came back to lead his team to victory before being diagnosed with these two conditions. No big deal. Also, this is the same guy who fractured his left clavicle last year.

I'll discuss both of these diagnoses below.

Fractured rib
You may want to scoff at the fact that I'm making a big deal of Romo coming back to play with a fractured rib, but hold your judgment. Sure, it's a small bone, and it's not involved in running or throwing, and you don't really cast it... but it #%$*ing hurts. Think about it: with a fracture of any of the long bones, you can rest, immobilize it, or plain just stop using it. Now guess what bones move every time you inhale or exhale. Yeah, those ribs... and you can't stop it.

Pain is such an issue with rib fractures that analgesia is the cornerstone of management of rib fractures on an inpatient basis. The reason for this is not only to make sure the patient isn't in excruciating pain every time they breathe, but if pain management isn't under control it can lead to irregular chest movements and breathing which can lead to a pneumonia (complication of 11-17% of patients under 65 with rib fractures). In fact, patients with 3 or more rib fractures are usually admitted to hospital for observation.

Fortunately for Romo, he only fractured one rib which can sometimes be controlled with just non-steroidal anti-inflammatories plus or minus opioids. With that said, most people with rib fractures aren't playing football right away. It's probably an interesting balancing act the training staff have to make with him. Not only is he going to be aggravating the injury (heavy breathing, fast twisting, moving arms/shoulders, more trauma from hits, ie. DeAngelo Hall) but they have to balance how they control his pain. Opioids usually work well for analgesia, but they will inevitably cause sedation, decreased reaction time, or drowsiness, which isn't usually the best side effect profile for a guy who has to make split-second decisions.

We'll see what happens tomorrow night...


Pneumothorax (aka "punctured lung")

Figure 1: NOT Tony Romo's CT scan,
but it does show a pneumothorax
(photo credit: Wikipedia)

Punctured lung is kind of a strange way of putting it (I guess unless his lung was actually physically damaged). Usually a pneumothorax refers to a "collapsed lung" which occurs when air gets in between the lung and the rest of the cavity, preventing the lung from inflating completely. Bigger ones can actually become medical emergencies, like what happened to Drew Bledsoe ten years ago.

To the right is a CT scan of a pneumothorax (i.e. NOT Tony Rom's CT). It's a pretty big one but it also makes it easy to see what happened. When reading CTs, the left lung is on the right and vice versa. You can see in this case the right lung (on the left) is a lot smaller and there's some black (air) surrounding it. That air in the pleural cavity is preventing the lung from inflating fully.

Fortunately for Romo (again), the pneumothorax was quoted as being "very small" (see ESPN article above). I assume that since no invasive treatment was mentioned, it was likely smaller than 3 cm and didn't require anything drastic to re-inflate the lung. A pneumothorax that is <3 cm can just be treated with supplemental oxygen and monitored. Supplemental oxygen can actually help the lung tissue resorb the free air in the cavity spontaneously. Usually if it's larger than that and/or it is causing the patient pain or to be short of breath  it may need to be drained via a needle or inserting a chest tube to relieve the pressurized air. Doesn't sound fun, does it?


In the end, the fractured rib to me is more of a fascinating storyline to follow tomorrow night than the pneumothorax given that after another CT scan Thursday it seems to have resolved. Once again, we don't know Romo's medical information and all of what I discussed above is speculation and a lot of what-ifs, but still interesting nonetheless.

Peyton Manning - cervical disc herniation and disc fusion surgery

Likely the biggest story in the NFL right now is the Indianapolis Colts without their future all-star quarterback Peyton Manning. Last week was the first time he missed a start for the first time in 227 games. The last time Colts fans saw someone else start a game behind center was in 1997.

The reason he isn't starting (or projected to play for at least another couple months) is that he has a herniated disc in his neck (cervical spine). 

Fig. 1

Let's start with the basics. The first seven vertebrae that make up our backbone are known as the cervical vertebrae, or "C-spine". In between each of these vertebra (in our entire "backbone") are intervertebral discs that act as buffers between the vertebrae, shock absorbers, and like mini-joints to provide flexibility/mobility. These discs are made primarily of two parts: the annulus fibrosus and the nucleus pulposus. The annulus fibrosus is made of cartilage and forms the outside of the disc, containing the nucleus pulposus. The nucleus pulposus is made of proteins but has a gel-like consistency. 

Fig. 2
Photo credit: myhealth.alberta.ca

With normal wear and tear or injury, the annulus fibrosus can become damaged or rupture, allowing the jelly-like nucleus pulposus to herniate or prolapse out of the disc. As you can see in Fig. 1, the discs and vertebrae sit neatly on top of each other. When one of these discs is herniated or prolapsed (Fig. 2), it can put physical pressure on the nearby spinal cord and cause the patient a wide range of  symptoms, depending on which nerve roots are affected.

In the case of a cervical herniated disc, it can start with some non-specific neck pain and can progress to pain shooting into the arms or shoulders as well as muscle weakness, numbness, and/or tingling. 

As for treatment, usually conservative measures are tried first. These treatments include rest, anti-inflammatories, glucocorticoids (oral or injections), and physical therapy with increasing mobilization. Out of the above, epidural steroid injections currently have the best evidence for relief of symptoms. 

Surgery is usually considered as an option if 6-8 weeks of conservative therapy provide no improvement in symptoms. Other guidelines propose requiring all of the following: (1) symptoms/signs of nerve root impingement, (2) evidence of nerve root compression on CT or MRI, and (3) persistence of pain despite 6-12 weeks of conservative therapy.

In Peyton Manning's case, he received anterior cervical discectomy and fusion surgery. The ESPN article also states Manning had surgery on two other occasions earlier, but I don't think the procedures were ever specified, so it would be difficult to speculate why he's having his third surgery this year. From the article: 

"An anterior fusion procedure usually involves... removing soft disk tissue between the vertebrae and fusing the bones together with a graft... Recovery from the procedure typically takes at least eight to ten weeks."

So taking what we've learned so far, this make sense that the entire disc is being removed because its physical presence was causing compression of the nerve roots.

In terms of prognosis, from what I've read, previous evidence has produced a mixed bag of results. In many cases, patients improve spontaneously over time. For cervical radiculopathy, it seems that the line between conservative management and surgery is still relatively blurry. A relatively small randomized control trial (n = 81) revealed that patients that received surgery had, at 4 months, less pain and sensory loss and better muscle strength than non-surgical patients. At 1 year, the only difference between the two groups was that the surgical patients reported better muscle strength.

In the end, I guess it's tough to say how Manning's long-term prognosis will be with this issue. It's reassuring to see that many people tend to do well with a cervical herniated disc, but as always, we don't know the full medical story. What were the two previous surgeries for? How long has he dealt with this problem? Only time will tell...

Sources: UpToDate and DynaMed

Sidney Crosby and postconcussion syndrome

One of the biggest stories heading into the start of the NHL season: When will Sydney Crosby play again? Unfortunately, it seems that not even Crosby knows at this point. A growing number of people are starting to wonder if that day will ever happen...

The topic that I'll look at here will revolve around postconcussion syndrome (PCS) and general information about the prognosis of it.

• Symptoms and disability are usually greatest between 7-10 days after the concussion.
• Most recover from PCS by three months, with 10-15% still experiencing symptoms after one year (the article quotes possible biased reporting in the study which means the prevalence may actually be lower).
• In a small study of 79 patients who presented with concussions to the Emergency Department, 28% had one or more complaints after 6 months.
  

In the quick review I did of some studies, the risk factors for a prolonged recovery time usually included...

• older age
• increased number of symptoms immediately after the concussion (i.e. headache, dizziness, nausea, decreased level of consciousness) - one study these symptoms doubled the risk of PCS
• longer post-traumatic amnesia
• abnormalities seen on MRI or CT immediately after the concussion
• more disability when admitted to rehabilitation
  
• preinjury unemployment, substance abuse (you'd like to think that these last two aren't relevant to Crosby's case)

In a nutshell, it looks like the majority of factors that are correlated with long-term disability lie more in the acute injury itself rather than the length of recovery time itself. (Does that make sense?)

One stat that made me think of Marc Savard: In a prospective cohort (I know, not the best evidence) of 2995 people, disability 1 year after a traumatic head injury was also often associated with disability 5-7 years after the injury. However, this was also highly dependent on the severity (i.e. initial level of consciousness) of the injury.

Interestingly, some of what I was reading started to go into complications of repeated traumatic head injuries. Lo and behold, common complications of the repeated injuries include increased risk for depression and chronic pain. Ring a bell?

Here's hoping the NHL takes these head injuries as seriously as trying to keep the Coyotes in Phoenix...


Sources: UpToDate and DynaMed