Hypothermia, Frostbite, Basketball Injuries – PediaCast 392
- Winter has arrived! This week, we describe warning signs for hypothermia and frostbite and provide tips on keeping kids safe when the temperature drops. The sports medicine team also visits the studio to discuss prevention and treatment of basketball injuries, including sprains and strains, torn ligaments, finger fractures and head injuries. We hope you can join us!
- Basketball Injuries
- Basketball Conditioning
- Cold Weather Safety (AAP)
- Extreme Temperature Exposure (AAP)
- Winter Safety Tips (AAP)
- Ankle Injuries – PediaCast 364
- Concussion – PediaCast 177
- Concussions & Mobile Apps – PediaCast 261
- Concussion Update – PediaCast 362
- Refining the Sports Physical – PediaCast CME 005
- Sports Medicine at Nationwide Children’s
- Sports Medicine at Nationwide Children’s
- NCH Sports Medicine Concussion Information
- NCH Sports Medicine Concussion Clinic
- NCH Athletic Training Workshop for High School Students
- NCH Sports Medicine Student Internship Programs
- The Nourished Child Podcast (POD Network)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads.
This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It's Episode 392 for January 3rd, 2018. We're calling this one "Hypothermia, Frostbite and Basketball Injuries". I wanna welcome everyone to the program.
Also wanna welcome you to 2018. It's the beginning of the New Year and we are kicking things off, hopefully with some practical information that you can use as a parent.
All of them really winter-related topics. It's really cold outside in the Eastern part of the United States and also here in Central Ohio with a single digits in terms of daily highs.
We're below zero at night and the wind chills like 10-20 below zero. So we are definitely in the midst of winter. And so I thought it would be a great idea to talk about Hypothermia and Frostbite today.
You know, one of the science, especially one of the early science of hypothermia and frostbite so you can intervene quickly if your child seems to be having a problem with that.
We'll also talk of prevention and then what happens if you really do get full fledged hypothermia so you kinda go passed those early warning signs.
And same with frostbite, what is treatment look like and what is the long term outlook for frostbite in skin. You know, when is sort of permanent damage occur and what you do about that.
So, we sort of take a comprehensive approach as we talk about hypothermia, frostbite, keeping your kids warm and the importance of doing so especially when it's as cold out as it's been here recently.
And then we'll cover basketball injuries. So we're also in you know, really knee-deep in basketball season both at the college level, high school, middle school and a lot of folks also playing basketball just from a recreational standpoint.
In fact, basketball is the most participated in sport in the United States of America. So it's not a surprise that the basketball injuries are very common this time of year.
They generate lots of interest. So we gonna spend some time outlining the possibilities from musculoskeletal injuries like sprained ankles and torn ACLs.
We also cover finger fractures, head injuries, including lacerations and concussions. Now keep in mind we're not trying to scare you. Basketball is a great source of physical activity.
The benefits of playing basketball greatly outnumbered these risks. But we want you to know the possibilities and be able to distinguish them from one another.
For example is it really a sprained ankle? Or there could be growth plate injury? Is the knee strained? Or is there a torn ligament? Do you have a bruised bone in the finger? Or is the bone broken? And is there concussion present with the head injury or no?
So we'll cover the possibilities. I hope you sort through the differences and to let you know when to seek medical evaluation and treatment and what that treatment might look like.
All important considerations. We'll also talk about injury prevention, what sort of conditioning during the basketball season.
And maybe more importantly during the off season that will keep you in shape, ready to play when the competitive season rolls around. And hopefully keep those injuries to a minimum.
Although you know, you can't plan for and prevent every possibility as we consider sports-related injuries. Have a couple of great studio guests joining me for this discussion.
Dr. Jonathan Napolitano, he's a Sports Medicine Physician here at Nationwide Children's Hospital. And Gail Swisher, she is a Certified Athletic Trainer here at Nationwide Children's. And they will join us shortly.
First of all I wanna remind you that if there is a topic that you would like us to talk about, it is really easy to get in touch with me. Just head over the PediaCast.org, look for the contact link, it's up at the top where we have the buttons for you to push to get to the Shownotes, to get the online web player.
There's also a contact page if you just click on that up in the header, that will take you to the contact page and you can fill that out, send that in. I do read each and everyone of those that come through and we'll try to get your comment, your suggestion, your topic idea on the program.
Also wanna remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face to face interview and hands-on physical examination.
Let's take a quick break. We'll get our guests settled into the studio and then we'll be back, we'll talk about Hypothermia, Frostbite, and Basketball Injuries. So coming up right after this.
Dr. Mike Patrick: It is cold outside, in the Eastern part of the United States, the Mid-West, and that includes Ohio. And here in Central Ohio we're having the coldest spell that we've had in the couple of years.
We're really, you know, really spoiled with couple of mild winters. And now it is cold again. 6 degrees outside right now in Columbus. It's going below zero overnight, wind chills 10-20 degrees below 0.
And just to put that on the perspective, the Columbus, Ohio yesterday was colder than Anchorage, Alaska and colder than places in Antarctica.
So it's really cold and I thought this would be good opportunity to talk about hypothermia and frostbite, sort of what they are, what symptoms to watch for, and what to do if you do encounter hypothermia and or frostbite.
So let's start with some definitions. Hypothermia – hypo, meaning low, thermia, referring to body temperature. So when the core body temperature is low, and we're talking less than 95 degrees Fahrenheit, that's when we will consider it to be hypothermia.
Keep in mind normal body temperature officially 98.6 degrees Fahrenheit. But it can range, you know, 97-99. So when we drop below 95, that's when we would call it hypothermia.
Frostbite, on the other hand, doesn't really affect your whole body. It's a severe localized tissue injury that is from the cold. We'll talk about that in a moment.
In terms of cause, keep in mind that a cold does not move. So when you get cold, you get hypothermia, the cold does not entering your body, it's heat that moves.
And so heat moves from an area where there's more heat to where there's less heat. So your body loses heat as it warms the air surrounding you. So that's the main problem with hypothermia.
And wind and wetness moisture that heat loss. That's why we talk about the importance of paying attention to wind chills because you lose heat faster when wind carries the heat away from your body.
And then also wet conditions, so if your clothing gets cold, gets wet with snow, water, ice, that wetness also increases the movement of heat from your body to where the wetness is and then into the air. So wind and wet are not your friend when you're trying to stay warm.
And then for kids, there are some additional consideration. Children are really more of risk for hypothermia and there's a few reasons for that.
First, they have a larger ratio of body surface to their body mass. So they have more skin compared to the mass of the rest of their body.
And since the heat leaves through the surface, when you have an increase proportion of surface area, you're gonna get more heat loss. And so kids lose heat more quickly in cold conditions.
The other thing with kids is they have a decrease ability to recognize that there's a problem, that this is a dangerous situation. Or they may not be able to avoid it. Maybe their locked out or there, you know, someone's forgotten about them.
They can't necessarily escape the dangerous exposure situation. And so supervision of your kids during winter months of all times really but, especially during the winter months as we consider hypothermia and frostbite.
It's important to really be their advocate. Make sure they're not out too long, that they're not starting to have early symptoms of hypothermia that may not recognize as a problem at all. So they really, really need your help there.
And then the other thing, if you think about how we counter hypothermia, you know, we shiver and that's our body moving muscles in order to create heat. And in order for muscles to move, you have to have some sugar around.
And kids have a decrease ability to make sugar quickly. They have limited of what we call glycogen stores. Glycogen is a sort of the base of how we begin to make our own sugars when we are getting through the diet. And so kids have a limited glycogen store that then they're sort of not able to make extra sugar, which would be needed in order to shiver.
And in fact, young infants do not have the ability to shiver at all. And the kids, the length of time they can shiver might be limited again because of this low glycogen that they have in their body.
So all of this amounts to the fact that the kids are little more risk for hypothermia. It can happen faster. It doesn't necessarily have to be in extreme exposure. Just lower temperature for shorter amount of time that aren't necessarily even extremely low can result in hypothermia.
So it's important to recognize the symptoms to do something about it as soon as possible. In terms of frostbite, the cause there is really just the cold is inducing cell death.
So the cell start to die because of the cold. And then as the skin rewarms, a blood cells come in to sort of clean up those dead cells and then we get an inflammatory process that sort of follows the cold injury. We'll talk more about that in a moment.
Now in terms of symptoms, we can divide hypothermia into mild, moderate, and severe. And we can see how the progression of symptoms happen as our body temperature goes lower.
So as you fall below 95 degrees, sort of between 90 and 95 degrees Fahrenheit, we call that mild hypothermia. And you start to shiver, again, you're trying to make heat.
You get the goosebumps, the blood vessels in the skin vasoconstrict so they clamp down, which in fact moves a blood from the skin, deeper into the core of the body.
And so the skin itself can look a little pale. You can get what's called Acrocyanosis. So you have sort of blueness looking to your finger, your toes, your lips, the tip of your nose. And again that's just because you are moving a blood from the skin down deeper in order to warm your core.
Now as we drop down belo 90 degrees, sort of 82 degrees to 90 degrees Fahrenheit range, now the cold actually starts to affect your brain.
And you can get some of impaired thinkings, slurred speech, clumsy movements, may even produce a picture of intoxication. In fact sometimes, hypothermia is mistaken for someone using substances, but really it's just because they're cold.
The cold really does affect your brain in that way. And one of the bad things with this is it really reduces your ability to recognize that there's a danger.
And the impaired thinking, you know, you may not go seek something out that's warm or warm condition because you don't recognize that there's a problem as your mental function continues to degrade.
And that sort of leads to agitation, distress, and then ultimately, total confusion, lethargy, and then your heart rate starts to drop, respiratory rate drops, blood pressure begins to drop.
And then as we get into the severe hypothermia, so now we're talking less than 82 degrees Fahrenheit, now really we can get unresponsiveness. And sometimes, you can appear to be dead with fixed and dilated pupils, you can have heart arrhythmias is.
And then eventually that is gonna lead to death as the body temperature lowers. Although, you've certainly heard the stories of folks who've been very, very cold. They look like they're dead. And you warm them up and they're back again.
And so, it is important from an emergency medicine standpoint that we warm folks up before we say that they're no longer with us. So it's one of the interesting things about hypothermia that you really can look at but you're not really.
It's just the heart rate can slow down so much and it can be hard to find the pulse sometimes. So that's sort of the varying degrees of hypothermia. And if you think about it in terms of intervening quickly, that shivering is the first sign that your body is trying to make heat.
And so if you are shivering, that's the beginning of hypothermia. It's time to get inside where it's warm, cover up. And we'll talk about more about treatment here in just a minute.
Frostbite, we can also look at varying levels of frostbite. So with frostbite we call, rather than mild, moderate, and severe, sort of like burns. We talk about 1st degree, 2nd degree, and then 3rd and 4th degrees of frostbite.
So 1st degree is just the surface of the tissue is involved. You can look kind of pale. It definitely feels numb. And then when you warm up, it becomes red and tender, kind of like 1st degree burn. And it's, you know very similar. There cellular damage and the redness and inflammation as your body is trying to heal.
2nd degree frostbite just like a 2nd degree burn, you got blisters. 3rd degree is a deeper injury. We start to get bleeding in to the blisters and you can get sort of the black crusty over the top.
And then 4th degree is just complete tissue necrosis. And then 3rd and 4th degree really require medical attention, especially surgical attention 'coz you might need tissue crafts as you heal or even amputation is a possibility.
So anytime you have frostbite and there's blisters, you definitely want to have someone take a look at it. Or if it's 1st degree and just redness and tenderness but it's over a large area, that too would warrant immediate attention.
In terms of how you diagnose hypothermia and frostbite really it's based on what is the core body temperature and think about clinical scenarios.
So someone was outside and exposed, they have low body temperature, you know it's hypothermia. As I mention, it can be sort of easy to overlook because you know, maybe mistaken for intoxication.
And the other thing is rewarming efforts will sometimes aren't officially elevate your temperature reading. So you know, someone starts to get warm if you're only taking a superficial temperature like a forehead scanner for instance or even an oral temperature.
The fact that you're starting to warm them may show a normal temperature at that point. But it's the core temperature so like a rectal temperature that's really more important to try to figure out what the core temperature is.
So usually it's easy to diagnose these things but sometimes there can be an issue on deciding for sure if hypothermia is going on, especially when you're getting a normal body temperature reading. But it's at the core temperature.
In terms of treatment, if there's any mental dysfunction, confusion, impairment in anyway, you call 911. And of course, you know if that they're having any trouble breathing, you know, if the person is unresponsive, you gonna call 911. No question there.
But if it's just a matter of you're shivering, you're cold, you know it's time to get warm and make sure that you remove wet clothing, increase the ambient temperature. So get inside where it's warm, you know cover up with blankets, sleeping bags.
And then if you do need medical attention so you have more moderate hypothermia or in the severe. There are additional things that can be done like warmed IV fluids, especially with the central lines we get IV fluids into the deep core of the body in order to warm it up.
In fact, that vasoconstriction that I talked about can make it hard to start a regular IV, a warm humidified oxygen. A lot of other things that you can do. You can take warm ceiling and actually put it in to body cavities and suck it back out, what we call a vage in order to try to warm someone.
And then of course remember you're using that glucose, the sugar to shiver. And so monitoring the glucose levels and had giving someone glucose can be important during hypothermia.
Now in terms of frostbite, the treatment it's really just rewarming the area that is cold so that we can stop that cellular damage.
Now the key here though is to avoid burning the skin which is actually easy to do 'coz remember you have that numbness. You have a sort of anaesthesia. The nerves aren't working right because they're so cold.
And you know I'm talking about you're fingers or toes, it numb. And when they're numb, you may not recognize that you're getting burned. And so you wanna make sure that that is your rewarming, that you're not getting your skin too hot.
So someone who is not suffering from the cold who maybe with that person would be good to say "hey is this, you know, if it's fingers and you're gonna run them under some warm water. You gonna submerge them in warm water".
You wanna make sure that it's just warm water not hot water. And the person who has the injury may not be in the position to make that judgement, you know that this is not burning water.
So you wanna be careful with that. Again, remove wet clothing, increase the ambient temperature. Get inside where it's warm. Submerge the body part if you can in warm water again not hot.
You can also use your body heat. So you know fingers in your armpit for instance. Use your body to warm those areas. Any skin that's frostbitten again, it's gonna look pale at first but then kind of red and then can blister.
You don't wanna rub that. You don't wanna break those blisters. You don't wanna damage the skin more by rubbing. You know rubbing will create heat but it also causes more damage.
So, no rubbing. If you have frostbitten skin on the feet, you don't wanna walk on that, particularly if there's blisters involve.
And also this is interesting. You don't wanna rewarm if refreezing is likely do occur. So if you're in a definitive place, you're inside now, you're in an emergency department, you're not gonna get cold again, then fine.
You're gonna rewarm. But if you, if it's likely that you're gonna be back out in the cold immediately and refreezing can happen, you just wanna wait and warm once.
Again if there's 2nd degree, you wanna see someone to make sure that's not turning into a 3rd or 4th degree frostbite just like with the burns.
Now in terms of preventing all of these things, of course layers of warm clothing, covering hats, gloves, scarves, really cover up all parts of your body when it's really cold outside. And layers are gonna be important.
Multiple thinner layers are more protective 'coz you get some insulating war air trapped between those layers that can act as an insulation compared to one big bulky layer or you know, put one big bulky layer on the outside but have some thinner layers on the inside that's gonna keep you warmer for longer, less likely to lose heat that way.
And then the other thing is just really adequate supervision. You know, there needs to be a responsible, can be an adult, can be an older child who's responsible and has good judgement and can make good decisions, but someone around who can say "hey look you're shivering, it's time to get inside" or you know, "how are your toes, how are your fingers, I'm gonna check on you every few minutes, every 15 minutes" or so.
Make sure that things are changing and intervene if something starts to become a problem. And if there's any mental impairment at all, just call 911. Or if you get them you know, inside and they're still shivering, you can't really get them warm up, that's gonna be another reason to call EMS.
And really a frostbite the same you wanna intervene. You know, you got numbness, an area looks pale, you wanna get inside, get it warm but not too hot, that's gonna be the most important thing.
Now, that's all well and good when you can make some of those decisions but you know, when you're outside you and can't get back inside, and maybe you're trapped in a car, all sorts of the situations where you may not able to avoid the cold and intervene.
In those situations you wanna just stay as warm as you can but get emergency help as soon as you are possibly able to do so.
Some additional resources from The American Academy of Pediatrics and their website – healthychildren.org. They have some great resources on cold weather safety, extreme temperature exposures, and winter safety tips.
And I'll put links to all of those things in the Shownotes for this Episode 392 over PediaCast.org so you can find those easily.
So it is cold outside. It's suppose to warm up in the next few days but I don't know. I have a feeling that this is gonna be at least in the Midwest and the Eastern portion of the United States a little bit of a colder winter than we've had at the last couple of years. So it's important to keep hypothermia and frostbite in mind.
Dr. Jonathan Napolitano is an Assistant Professor of Physical Medicine and Rehabilitation at the Ohio State University College of Medicine and Sports Medicine Physician at Nationwide Children's Hospital.
Thanks for stopping by to talk about basketball injuries today.
Dr. Jonathan Napolitano: Thanks for having me Dr. Mike.
Dr. Mike Patrick: And we also have Gail Swisher with this. She is a Certified Athletic Trainer with our sports medicine program. Thanks to you as well.
Gail Swisher: Thanks for having me.
Dr. Mike Patrick: Really appreciate both of you stopping by. Gail, let's start with you. As an athletic trainer, what are some of the more common injuries that you see that occurred during basketball?
Gail Swisher: A lot of the basketball injuries that we see are based in the lower body. They start all the way down on the floor with the foot and very commonly in the ankle, that's probably the bulk of what we see. But there's also fair number of knee injuries in basketball.
And then when we move up to the upper body, you see wrist and hand injuries, occasionally shoulders and elbows, and the ever present concussion –
Dr. Mike Patrick: Yeah.
Gail Swisher: – unfortunately.
Dr. Mike Patrick: Is the basketball really is a contact sport, right?
Gail Swisher: It is very much so.
Dr. Mike Patrick: So let's start down with the ankles, those are very common injuries in the basketball players. And Dr. Napolitano, what ankle injuries do we typically see in basketball players?
Dr. Jonathan Napolitano: Yeah you're right. They sure are the most common injury that we do see. They are actually the most common reason that you missed time from sport.
So ankle injuries, primary thing that we see is the sprain of the ankle. Sprain is a stretch in or tearing of ligaments of the ankle. 90 percent of the time that involves just 1 ligament. And we grade them on a scale of 1-3.
There are more severe multi-ligament ankles are other injuries that involved that are more severe and require more time away from sport. But sprains are the most common.
We also see other injuries in the ankle while skeletally mature patients will always have sprain of that ankle or that ligament. But that ligament also attaches to growth plates and bones and –
Dr. Mike Patrick: Yeah.
Dr. Jonathan Napolitano: – a lot of our pediatric patients are at risk of stressing, straining, or even fracturing the bones as part of those ankle injuries.
So we see everything from ligaments to bones and even muscular strains within the muscle or even chronic conditions as well.
Dr. Mike Patrick: How do you tell the difference between whether it's just a strain or there could be a growth plate injury?
Dr. Jonathan Napolitano: You know that's a really good question and that's why evaluation of your ankle injury was so important. A lot of them are both associated with swelling, bruising so you can't really use much of that.
In our physical exam we have some sort of tests in identifying where the location is specifically. And oftentimes we need an X-Ray to really tell the difference here. An X-Ray in most sprains are normal but they can be abnormal in a fracture.
Dr. Mike Patrick: Yeah. And with a growth plate injuries in particular, sometimes the X-Ray can be normal right after the injury occurs. Maybe a week later before you start to see changes in the X-Ray.
So sometimes we treat those ankle injuries as if they could be a growth plate injury even though really they're just a sprain.
Dr. Jonathan Napolitano: That's correct. And it's really is monitoring in that acute period from that first time. A lot of them as I mentioned is on the physical exam and on the clinical suspicion.
If that location is, where that growth plate is is where that patients is most tender, then I have a higher suspicion and I go ahead, as you said. Treating kind of presumptively assuming until proven otherwise that it might be one of those fractures.
Dr. Mike Patrick: Yeah. And what is that treatment look like typically with the you know, ankle gets twisted, it gets some swelling, some tenderness. Like how long is the player out or typically do for it particularly if it is a sprain?
Dr. Jonathan Napolitano: Sure. So big spectrum on those and I hinted briefly that there's grades of ankle sprain depending on how much of that ligament tearing happens and how much swelling is around that.
And it really does very based from that severity. Someone can have mild great one ankle sprain that feels good in a couple of days and his back to activity.
Where some of this higher grade ankle sprains where complete tearing or chronic bruising and swelling of the ankle takes a little bit more time to get back.
And so, our treatment can varies based on that the old adage of RICE – resting, elevation, icing, compression, etc., can really help our treatment of this. But a lot of information that we have on those modality is really outdated.
And really the treatment from the beginning should be focused on that return to play and that strengthening of the ankle. When we look at ankle injuries as well as most injuries is our focus is mainly on prevention.
So after someone has one ankle sprain, the risk increases exponentially have multiple injuries since we wanna prevent that 2nd injury as well.
Dr. Mike Patrick: Yeah.
Gail Swisher: Can I jump in –
Dr. Mike Patrick: Yeah please.
Gail Swisher: – for a second on the ankles. I think working in a school setting, one thing I hear from families frequently is they're unsure if they can take care of this at home or if they need to go urging care, see a physician.
So, there's a few easy guidelines. I think a big one is the athlete who can't put weight on that ankle or walk on the ankle after 24 hours or something or so would be a time to go and see a physician or in urgent care.
As well as things that just aren't getting better. When it kind of stagnates, and the swelling is continuing, and then there's not making any progress, that's a big sign that it's time to go be seen.
As well as kids who seem to have reoccurring chronic ankle sprainers? That the kids that'll say "I roll my ankle all the time". There's a reason that's happening. So the only way to fix that is to go and seek treatment and see the appropriate medical provider.
Dr. Mike Patrick: Yeah, yeah. For folks who have more interest in ankle injuries because we could really do, you know an entire show just on ankle, which actually we have done.
And folks who are interested can head back to the archives and check out PediaCast 364. Dr. Tom Pommering, Kate Weale actually Ashley Minnick, both of them athletic trainers.
And we not only covered basketball but also talked about dance and gymnastics. So if you want more details on ankle injuries, be sure check out PediaCast 364 again in the archives over PediaCast.org.
Let's kinda move up a little bit to the knee now. Again, what sort of knee problems are typically seen in basketball players?
Gail Swisher: There's 2 main varieties of the injuries that we see. And the 1st one is acute injuries. So those are injuries that happen to an athlete who was otherwise healthy, doing well, pain free, and then they have an incident.
Either someone runs into them or they have a fall where they land wrong and something pops so they happen quickly.
The other category is overuse injuries. So those are injuries that occur overtime. Maybe it's a little sore the first couple of days. And then a week later, it starting to hurt when they're walking around at school.
And those injuries don't have a specific moment or mechanism of injury, they occurred over time. So jumping back to the acute injuries, the big ones there, we see that the dreaded ACL tear where you land wrong, or you're trying to change direction and cut and pivot and you feel a pop and the knee gives way.
We see that both in male and female athletes, although the female ACLs tend to get a bit more notoriety. And that can come along with other things like a meniscal tear, like an MCL sprain, other damage.
As well as just kind of people can do what's called patellar subluxation, whether knee cups or it slides out of place when they land wrong.
So really, anytime an athlete has a description where they land, or they're pivoting, or cutting and something goes wrong, they're probably need to be seen by a physician.
Jumping back over the overused or the chronic injuries, we see a lot of anterior pain which is pain in the front of the knees.
So patellar tendonitis, jumper's knee, in our younger population, pediatrics, skeletally immature kids, we see Osgood–Schlatters which is very common.
There's another thing we call Sinding-Larsen-Johansson which is similar variety. So you need to be aware of that. Those in that younger kids that needs to be treated differently versus an adult where it's gonna be unlikely to be a boney growth plate issue.
Dr. Mike Patrick: Yeah. So if you have a student-athlete who's complaining of knee pain, particularly there wasn't an acute event that happen but it's just that hurts all the time during basketball season really get to see someone who knows about kids knees because there are all sorts of things that can go wrong, Osgood–Schlatter, you mentioned.
Think we have talked about that but it's really been a long time ago. As for the patellar tendon that connects the knee cap to the shin bone, as starts to come up of the bones. So you get sort of micro fractures that the tendon's side. Am I right on – ?
Gail Swisher: Yes, that's correct.
Dr. Mike Patrick: Yeah. But there are other things that can happen to the knee and kids so you definitely wanted to have pediatric person taking look at the knee.
So how are those problems treated, particularly the overused ones I think those are the most common.
Gail Swisher: Yeah. The overused, since we see it so often and oftentimes people will let it go thinking "Oh my knees were just sore because I'm playing basketball".
For many of these kids, particularly those who've had a recent growth spurt, their flexibility is inadequate. Because their bones are lengthening too quickly or so quickly that their muscles and tendons don't stretch out to keep up with that.
So we need to address the flexibility deficits in the quads, in the front of the thigh, and the hamstrings in the back of the thigh. As well as, sometimes it's the way the athlete moves.
So perhaps they're landing wrong, other not landing efficiently and that's putting undue stress on certain parts of the knee.
Sometimes that's the flexibility issues. Sometimes that's a strength issue. So overall, rehab is key. That's sort of the main point that I'm getting at here is that in order to prevent these things and fix them in the first place, strengthening, stretching with in appropriate medical provider is gonna be the key.
Dr. Mike Patrick: Yeah. And so really, it's not just during the season itself but pre-season conditioning is gonna be important too, correct?
Gail Swisher: Yes, very much so.
Dr. Mike Patrick: And where can folks can kinda connected into program? I guess that's where the school-based athletic trainer might really be a great resource.
Gail Swisher: Yes. So I think the school-based AT is a great resource as well as the strength coach, if you have one available to you in the school setting.
Sometimes parents seek that, that sort of strength training for their young athlete. Dr. Napolitano, did you wanna touch on?
Dr. Jonathan Napolitano: Yeah. There really are a lot of consequences on this knee injuries.
Dr. Mike Patrick: Yeah.
Dr. Jonathan Napolitano: We're seeing a huge, almost epidemic, global ACL tears. In Canada and US along, we see over 25 million of those per year.
They require a lot of time missed from sport. They require a long prolonged recovery, at least 6 months to a year to get back to sport. And so, lot of the focus has been on this prevention.
I think you're right about that Dr. Mike in saying how can we prevent these injuries 'coz there are so many consequences of down the road arthritis within the knee, etc.
So these young athletes, we want to prevent that injury after that. So the school AT and the strength coach, as Gail was talking about, are really great ways to get started in such programs.
But ACL prevention programs are kinda sweeping the country and really the world. One of the better ones is put up by the International Soccer Federation, FIFA.
And that's really a program that we want to everybody be able to do. That starts with the pre-season but then also continue in through. And it involves strengthening, proper reception, neuromuscular control. All of these different steps in there. But it has to be easy to implement and comply with and so that's really a big step.
Dr. Mike Patrick: That is sounds like something that would be difficult for a family just a sort of do on their own. So this really does take a team effort in terms of athletic trainers in the school or sports medicine program if you have one in your location that sort to get plugged in that get back conditioning and training done correctly.
Dr. Jonathan Napolitano: That's correct. We do work with a number of athletic trainers and strength coaches at the schools but not all of our athletes that we seen in clinic have those resources.
And so there are different programs that we offer here at Nationwide with both our functional rehab programs and physical therapy to really work on prevention as well as treatment.
I see a number patients in my clinic who are concerned about an injury. And I count those as near-misses after working them up and see no acute injury. However, I watch their mechanics in a way that they're able to control their knee.
And they are at high risk of injury. The reason why Gail mention really the female athlete kinda stands on this category is 2 fold – one is an anatomical variation, meaning there's a different structure to their body.
But also the control of neuromuscular ability use of their knee. And while we can't change their anatomy, we can't change that strength in a way that they control their knee to really put that strength and demand more on the muscles and less on these fine ligaments that are at risk of tearing.
Dr. Mike Patrick: Yeah. Seems there are some set of kids who are kind of sedentary on the couch, not really all that active and you get this wake up call that "Hey, I need to be more active, I need to lose weight".
Parents may be pushing them "Hey, do sports". And so they try-out for basketball. And so they suddenly are in game or practices and they just aren't used to doing this. So those can be more prone to injury, right?
Gail Swisher: Yes.
Dr. Mike Patrick: So what advice do you have for families who maybe thinking about sports in a not too distant future who may not have access to the real structure conditioning program? Or there some things that they can do at home just to get ready.
Gail Swisher: Yeah. And the situation that you described is a common recipe for an overuse injury. The athlete that goes from really doing next to nothing and then going full-boar out on the basketball court, that sets them up for an overuse injury. So –
Dr. Mike Patrick: And failure in terms of "I don't wanna do this anymore".
Gail Swisher: Yes. 'Coz they're in pain and that's not fun –
Dr. Mike Patrick: Yeah, yeah.
Gail Swisher: – and they're not able to keep up with their teammates. So a lot of teams, frequently at the high school level, have open gyms, they have open workouts, potentially with this strength coach or with the team that allows them to get a ball on their hands, start doing sport specific movements, slowly build up their body to where they're ready for the demands of the sport.
I think another really, really good way to pre-season condition is to play another sport. And there's a lot of information out there about early sport specialization right now.
But athletes who play multiple sports are gonna be in shape all year round and while it's different movements, it's gonna help to prevent some of those overuse injuries because different sports require different motions, different muscle groups to function. And that helps to kind of change things up for the body.
So you know, there are programs out there. We do have some resources on our website in terms of the athlete trying to get started for the first time. But I would definitely encourage kids to seek out other sports, in addition to basketball.
Dr. Jonathan Napolitano: And I think really the other thing is it doesn't all have to be structure. You know, gym classes are great start to teach, you know, sports specific movements and really control but also free play.
You've hinted in the athlete where the young patient is not been involved. But there's also the patient who is over involved –
Dr. Mike Patrick: Yeah.
Dr. Jonathan Napolitano: – and they're getting time away from normal gym class or normal exercise out on the playground.
And so the ability to give a variety of what you're up to and what you're doing truly allow your body to rest but also to learn new skills.
And I have fun doing it. And that's really the key. There's also, you've mentioned, other resources within the sports medicine department for those patients who have no experience in sports and are looking to get interested.
We have a program specifically tailored to them. It's called the Playstrong Program. And patients can get involve in that program with referrals from their primary care physician or their pediatrician.
Dr. Mike Patrick: In terms of during the basketball season itself, how can players maintain their healthiness, good technique obviously. What sort of things should they be doing during the season itself to stay healthy?
Dr. Jonathan Napolitano: Yeah. I think early on in the season, you wanna make sure that you're gradually working up to things.
Coming from the football season and then in the basketball season we see a lot of this multi-sports athletes that we absolutely encourage to play multiple sports.
However, there needs to be a rest period in between or whether your taking at least a week off, preferably more than that. But when you're getting into it, I think it's a different activity, it's a different motion so gradually get into things.
So a lot of these overused injuries are from that rapid progression. And do expecting to join in basketball where you ended last season in April.
And then that's a gradual progression. And we've throughout this podcast today, we've talked a lot about the warm-up and the stretching programs.
Dr. Mike Patrick: Yeah.
Dr. Jonathan Napolitano: Having that as a part of your routine and really been invested in it. It's not just a time to kill but before you actually hit the court, you really need to be focused on that just as you are going through the place and the drills.
Because you are, there's a benefit there. And we wanna prevent those athletes and those athletes from getting injured and that's a great way to get started.
Dr. Mike Patrick: Yeah. And the younger age of the player that you kinda start instilling that "Hey, stretching and flexibility, these things you know, warming up, are really important".
The more likely the importance will get it to your high school years.
Gail Swisher: Yeah. And one thing tend to find with younger athletes and our instinct gratification, a lot of times kids are interested in investing the time in the stretching and preventative care of their bodies during the season.
Because it does take time. It may take 20 or 30 minutes a day to that preventative care and they may not see the payoff to that. Until they get injured and then we can look back and say "Here's why you're injured".
So I think doing the proper warm-up, stretching, doing things the right way, starting at early age really helps.
Another thing Dr. Napolitano mentioned was rest in between seasons but rest during the seasons is also very, very important. I always encouraged my athletes take at least one day off per week.
And that doesn't mean go out on a run and do other things. It means take one day off per week to let your body heal, repair itself. And along with that is sleep.
More and more, there's research coming out that athletes who don't get enough sleep are more injury prone, different sorts of injury as well as there's academic components.
So I really strongly encourage my athletes sleep 8-9 hours at night which may sound like a lot and it may be hard, but it really does pay off in terms of sport performance and injury prevention.
Dr. Mike Patrick: Yeah, yeah. That's really, really good point that sleep is important. One of the questions that I think people are gonna ask is shoes.
Does it matter what kind of shoes that the player uses with when they play basketball?
Gail Swisher: Yes. So number 1, if you're playing basketball, you need to be in a basketball shoe. I tend to see ankle injuries in the beginning of the season with maybe kids who haven't played before who where in a running shoe.
And that's not designed for athletes who cut and pivot and change direction quickly. So basketball shoes are important with the higher top.
I know there's a new of variety out there that they don't have quite as high of a top. Sometimes ankle braces can be helpful there but I think the shoe is very important as well as you need new shoes each season.
And for some of these athletes depending on how much they play, they may need more than one pair of shoes per season. Because when I start to see kids with knee pain, these overused injuries, that's one of the first questions is how old are your shoes.
Dr. Mike Patrick: Yeah.
Dr. Jonathan Napolitano: There's a lot of science that goes in the shoes too I mean when kids are looking for a new basketball shoes, they got up in stand and pick the coolest one off the shelf.
But a basketball specific shoe as supposed to a running shoe has a lot of sciences to why that's used in different pressure points, different support, you know, especially you gonna mention starting of with running shoes.
That's even become a bigger problem now because all running shoes aren't the same. And if you're having an extremely flexible running shoe with one of these barefoot running shoes, transitioning in a hard wood court you'll realize setting yourself up for a lot of pain and other injury.
Gail Swisher: One other thing with basketball shoes that I see frequently is kids don't use all the lace holes. So they will only lace them up around foot and leave the top few open and that really defeats the purpose of wearing a high top shoe.
So i would encourage all the parents out there to take a quick look and see if their children are actually using the top couple holes of the shoe.
Dr. Mike Patrick: Yeah. Great advice. What type of injuries that result from a contact, so especially when we think about upper body. What kind of problems can you see with basketball?
Gail Swisher: There is a lot of contact in basketball. Sometimes with diving on the floor, as well as body-to-body, person-to-person contact.
So we got the famous contusion which is a fancy name for a bruise. I've actually seen fair number of elbow contusions from kids who go down hard on the floor, taking a charred and it well get pretty big and swollen sometimes.
And turn into something we called bursitis. So there's that sort of thing . There is a contact variety of the ACL tear. They can happen, perhaps of another player dives into your leg when you're on the floor, diving for lose ball or you get knocked off balance and roll your ankle coming down from getting a rebound.
But another big one for contact injuries are concussions unfortunately.
Dr. Jonathan Napolitano: You know one other thing, before you jump in the concussions which is a whole big topic, but finger injuries. We see a lot of you know, basketball as a hands on sport where you really get in your hand and steal the ball or to go up and so.
We see a lot of finger injuries so swelling within the finger. Really the key there for what you're looking at is you wanna look at normal motion.
When Gail is talking about those contusions, another bruises that are less severe, you have a normal elbow range of motion. The important thing with that finger is you should be able to use that normally.
If you're not able to bend or extend that finger completely, that definitely warrants further evaluation because a lot of damage can be done to the tendons or ligaments of that finger after really seemingly mild contact.
We used the term kind of generically "I jammed my finger" which isn't necessarily a medical term. We need to know more specifically what exactly happened there.
Dr. Mike Patrick: And more than just being able to move it but maybe you can move it but it hurts a lot. And that sorts of counts as was not being able to move it.
'Coz we see so many finger fractures but that "I'm moving it, it's just fine" but it hurts you know, you're grimacing as you're moving it. And really, the only way you can tell the difference between the contusion or bone bruise and a fracture for sure is with an X-Ray.
Dr. Jonathan Napolitano: That's correct.
Dr. Mike Patrick: And so you would need the further evaluation for that.
Gail Swisher: With some of these finger injuries also, it's important to seek early evaluation because if they're not treated correctly early on, it can be a lot more difficult to treat them.
A month, six weeks, down the road, and I think it's easily missed sometimes by saying "Oh it's just a jam. My fingers doesn't straight now because it's swollen".
And then here we are a month out and now you have a more significant soft tissue injury that needs potentially something more extensive like a brace or surgery or things like that we caught early on, it could've been treated much more easily.
Dr. Mike Patrick: Yeah, yeah. Absolutely. And the other one is lacerations. So sometimes you know, we have contact and we see cuts and those are, you know, if it's keeping, obviously you need stitches and so you gonna have a medical attention at that point.
So let's move on to the head injury which can occur in basketball player, player-to-player contact, player-to-floor contact.
How can we tell if the head injury has resulted in a concussion?
Dr. Jonathan Napolitano: Yeah. Thanks for bringing this one up Dr. Mike. Concussions are out there in the literature, in the media as a very big topic. And I'm sure we've covered it extensively in other ways as well.
But within the basketball, what we look at for a concussion and not just injury to the head is we combined 2 things and it's really quite simple.
The process of the injury is complex but the diagnosis is quite simple. When we look at contact to the head either direct or indirect.
Meaning as you said head to player or head to floor or even in indirect where you have a whiplash type of injury. That injury followed by an outline of a combination of numbers symptoms.
Our symptom scores or our symptom logs have 22 different things that we're looking for from somatic to vestibular and balance and headaches, and sleep difficulties, concentration difficulties.
If you're experiencing those symptoms, and you can trace them back to the single head injury, that's how we use for diagnosis of a concussion.
And the reason why that is, is because it's not a structural injury. It is a functional injury. And so while, as we talk before about the fingers that I need to get an X-Ray to see if that fingers broken, no image in modality right now is gonna tell me whether or not you have a concussion. It comes down to your symptoms.
Dr. Mike Patrick: What kind of symptoms would be typical for concussions?
Dr. Jonathan Napolitano: Sure. So we see headaches, nausea, vomiting, dizziness, blurred vision, difficulty concentrating when getting back to the classroom, difficulty remembering certain things.
Down the road this can lead to emotional liability where you're more anxious, more nervous about certain things. And then that sleep routine, we talked about that early in athletes.
That sleep is all off, as far as difficulty falling asleep, tired throughout the day and you just wanna sleep all the time. We combine all of those symptoms in to diagnosing a concussion.
Dr. Mike Patrick: Yeah. And you mentioned the difficulty in concentrating, judgement can be impaired, slow response time.
And so one of the difficulties then, if you have a concussion, your turn to play too soon is then you're at risk for another injury because you are not necessarily at your best at that point.
Dr. Jonathan Napolitano: Yeah. 2 different types of injuries there. There has been some data. And you're right, you're not concentrating you are at higher risk of landing on that ankle or that knee awkwardly having that significant injury.
But really the more severe concerning injury a plain with a concussion is something that is describe as Second-Impact Syndrome and while it's very rare and we don't see it often, it is quite serious and that's the reason why we protect you from participation.
That's when an injury goes from a functional injury to become structural. So if you have a head injury that's diagnose as a concussion, and while still some thematic you sustain a second concussive blower, second injury to your head, your brain is at risk of swelling, bleeding, and having really bad consequences which include paralysis and death.
Stroke-like symptoms a whole list of things. So that's really why it's important to stop playing when you are experiencing those symptoms.
And not just to scare you but the other reason why we report these symptoms is because we have new literature up there that showing to laid, reporting or continuing to play with these symptoms actually makes for prolonged recovery, a longer time away from sport.
So really speaking up and saying that you're not feeling quite right when this happens gives you the best chance to get back to the sport and to get to feeling yourself.
Dr. Mike Patrick: And helping you get back in terms of timeline, you know, when it's okay to start again and what sort of activities you had to do in the beginning after you coming are back from the head injury.
It's really something that your regular doctor, your sports medicine doctor, your athletic trainer you really want sort of return to play program that supervise by a healthcare professional.
Dr. Jonathan Napolitano: Yeah. That's really important. And that's something that has been agreed upon by a number of medical societies in both sports medicine, and pediatrics.
As well as international communities as well. Those the same organizations that are coming up with this need prevention programs have agreed upon return to play programs.
But it now, it's even political. Where this is their state and laws throughout the country which are requiring a standard return to play, to get back to sport safely as supposed to just go on for when you're feeling a lot better.
Dr. Mike Patrick: As you mention, there's a lot on concussions out there including here in PediaCast. So if you want more information on concussions, open some links in the Shownotes.
Episode 177 it was an early one but still relevant, lots of details on concussion with Dr. Tom Pomerring. We also did one on concussions in mobile apps with Dr. Jason Mohalic, at the University of North Carolina Chapel Hill and that was on using mobile apps to help diagnose and manage concussions.
And then more recently, Dr. Kevin Walcher from the Children's Hospital of Wisconsin stopped by the studio and discuss some of the latest research surrounding concussions and returning student-athletes to play. That one was Episode 362.
So lots of resources for you in the archive over PediaCast.org and I put links in the Shownotes for this Episode 392 so you can find them easily.
Over on the CME site, which is our Podcast for the medical providers, where we offered free Continuing Medical Education credit. We did one on refining the sport physical, that was our 5th Episode of PediaCast CME.
And we talked about concussions, also the female athlete triad, cardiac screening including when to get an EKG. And that was with the Dr. Stacey Fisher, a sports medicine and Dr. Naomi Cortez of Pediatric Cardiology and I'll put a link on the program for you in the Shownotes as well.
And then later this month we're gone into a concussion update for CME with Dr. Stephen Cuff. He's a sport medicine doctor also here at Nationwide Children's Hospital. So stay tuned for that very soon over PediaCastCME.org.
Alright. Dr. Jonathan, tell us about sports medicine at Nationwide Children's.
Dr. Jonathan Napolitano: You know that the department here has really continue to grow, to meet the needs of our community. I'm now the 9th provider within our group, the 9th physician. And we make up a number of different specialties.
Dr Mike, you'd mentioned that my clinical or academic appointment is in Department of Physical Medicine and rehab where I'm trained with other physicians in our group but pediatricians, medicine providers, internal medicine providers.
We give them a wide variety of care for our patients based on our backgrounds. And then to meet those needs, we've really reach the far regions of Columbus.
Where have clinics all the way from Mary's Ville back down Canal Winchester. Everything in between. We have the largest centers in both Westerville and Dublin. But if you check out our website, we have locations really close to home for just about the everybody.
And we've continue to expand and offer variety of clinics. We just touch upon the importance and the difference of concussion compared to most of what we see in sports medicine.
So have concussion clinics at most of those locations where we can treat the athletes. But then we also expanded into other realms as well. We now have sports nutrition program.
We have, our latest endeavor is a adaptive sports medicine program. And that's really pioneering and that's new for not only the region, but it's really nationally gaining a lot of popularity.
And what adaptive sports medicine it is it's a program for athletes with physical disabilities to get involved and to be treated in a sport medicine center.
So we have a lot of athletes in our community who play both wheelchair basketball. We spend a lot of today talking about the lower extremity injuries in a wheelchair, I'm sorry, in an able body basketball player but wheelchair basketball has a whole another host of injuries.
And that need focused care. And with my background in physical medicine and rehab in training patients with physical disabilities I bring that and combining with my sports medicine knowledge really gave tailored care with these athletes.
So sports medicine really continues to grow here at Nationwide and it's really exciting program.
Dr. Mike Patrick: Yeah, really great stuff and we open some links to the sports medicine program at Nationwide Children's, the concussion clinic as you mentioned.
And also there's concussion information page through Nationwide Children's sports medicine. We'll put a link to that as well in the Shownotes page for this Episode 392.
And the adaptive sports medicine clinic, that's something we gotta show on in the future just in terms of delving into the specifics of that, what kind of injuries occur. I think folks will be really interested in hearing more about what you do in that particular clinic.
Dr. Jonathan Napolitano: Yeah I'd love to. It's a passion of mine and I'm eager to share with as many as I can.
Dr. Mike Patrick: Yeah. And then Gail, talk a little bit about the role of the athletic trainer within the sports medicine program here in the schools just, you know someone who's interested maybe in her career, being an athletic trainer. So what's the schooling look like in your day to day?
Gail Swisher: So within our department, we have over 40 now athletic trainers, I couldn't give you the exact numbers but we do a lot of different things. There's folks like me who work in a school setting and with high school and middle school athletes at the school.
As well as alongside our physicians in the clinic doing things like finding out about the injury, asking questions, we do casting, we do brace-fitting, we teach exercise programs.
And some of our athletic trainers actually specialize in functional rehabilitation. So whether that's helping facility or concussion return to play safely in our sports medicine buildings or helping an athlete come out in an injury and making sure that they can jump again and rebound things like that.
So they specialize there. But overall, athletic training, our educational process is actually changing. It's in the midst of transitioning between requiring bachelor's degree and then you sit for your certification exam to where now you're gonna have what's called an entry level masters.
In which you do the 4-year undergraduate degree and then do the entry level masters after which you can sit for certification exam.
So some of the programs at the college level have started to change and make that transition. And some are still sorting out when they're gonna switch over.
But long story short, I would encourage you to reach out to an athletic trainer or someone well-versed in that area if you have interest in you know, young person wanting to pursue a career to make sure that they kinda don't get lost in that shuffle at the educational change.
Dr. Mike Patrick: Yeah.
Dr. Jonathan Napolitano: We do have you know, a program over in the summer time that for young people who are interested in becoming an athletic trainer too.
That you know, we can emphasize enough what a great resource those forty plus individuals are within department. So it's a great field to get into.
Dr. Mike Patrick: Yeah.
Gail Swisher: I would strongly encourage the high school student program in the summer grade. That's the grade introduction, all the different skills and a way for kids to kind it try on for size and see if it's something they might really wanna pursue as a career.
Dr. Mike Patrick: And how can folks find that more about that program?
Gail Swisher: It's on our website which is nationwidechildrens.org/sports-medicine. And I believe it's the High School Student Workshop is the title of it so it would be there at the along the left hand column.
Dr. Mike Patrick: Okay. I'll try to find that and put the link in the Shownotes as well. Lots of links as we, great resources for everyone. So be sure to check out the Shownotes for Episode 392 over PediaCast.org.
Alright. Well thank you so much to Dr. Jonathan Napolitano and Gail Swisher, really appreciate both of you stopping by and joining us today.
Dr. Jonathan Napolitano: Thanks so much Dr. Mike.
Gail Swisher: Thanks a lot.
Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time out of your day, making the PediaCast a part of it. I really do appreciate that. Also thanks to our guests this week, Dr. Jonathan Napolitano a Sports Medicine Physician and Gail Swisher, Certified Athletic Trainer, both from Nationwide Children's Hospital.
Really do appreciate them stopping by and sharing their expertise with us as relates to basketball conditioning and injuries.
Lots of links for you as I mentioned in the Shownotes. Also don't forget that it's cold, it's January. And we're having a really cold beginning to the winter with the temperature's below 0, wind chills 10-20 degrees below 0.
And so we did talk in the beginning of this program about hypothermia and frostbite. And I wanna remind you there are some great links for you in the Shownotes to healthychildren.org with the cold weather safety, winter safety tips, extreme temperature exposures. So make sure to check those out and to keep your family safe in the cold weather this winter.
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Speaking of those shows, you might wanna check out is the Nourished Child Podcast. We talked about good eating for kids and the healthy nutrition. Host Jill Castle is a registered dietician in Child Nutrition Expert.
She's the author of "Eat Like A Champion: Performance Nutrition For Your Young Athlete". Also "Fearless Feeding: How To Raise Healthy Eaters From High Chair To High School". Both of those highly reviewed on Amazon.
And she has a podcast – Nourished Child. Available on parentsondemand.com. I put a link to it in the Shownotes PediaCast.org Episode 392 so you can find that podcast and check out the other podcast as well all really geared toward moms and dads and families.
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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.