Explore a complex case of Thoracic Outlet Syndrome, double crush, & triple crush injuries. Learn about diagnosis, treatment, & patient support.

Q: Overview of Neck, Nerve, or Both?

A: My wife experienced numbness in her upper extremities. As an athletic trainer (AT), I initially suspected Thoracic Outlet Syndrome (TOS). She eventually sought medical attention and was diagnosed with TOS. Conservative treatment, including medication and a home exercise program, was recommended. However, therapy seemed to worsen her symptoms. An MRI of the vascular system came back normal, except for a benign thyroid mass. A cervical MRI revealed stenosis in C5, C6, and C7, which, when combined with her other symptoms, provided clarity.

I consulted a spine surgeon, who advised exhausting conservative options before considering surgery for insurance coverage. My wife, who has a fear of anesthesia, opted for pain management and received injections. An EMG to rule out carpal tunnel syndrome indicated 70% carpal tunnel involvement. An upper extremity specialist diagnosed a double crush injury, meaning nerve compression at two sites. She underwent left-side carpal and cubital tunnel release, followed by a two-level cervical fusion. Post-surgery, she regained sensation in her pinkies. The right side was subsequently treated.

She experienced relief for about a year before numbness recurred. Another round of CT, MRI, and EMG scans returned normal. Pain management suggested a shoulder issue, leading to an MRI of the shoulder. While the report mentioned a slight rotator cuff tear, a physician who reviewed the scans deemed her shoulder pristine. This doctor’s examination of her neck, however, exacerbated her symptoms, leading to a diagnosis of lower brachial plexus TOS.

Despite my initial concern about the previous treatments, the doctor affirmed that the cervical fusion was necessary. A C8 nerve block did not provide relief but offered further diagnostic information. We were then referred to a specialist in Dallas, where a diagnostic nerve block in the scalenes provided immediate relief. Months later, Botox injections were administered for extended relief. The doctor’s words, “How does it feel to not be crazy?” significantly validated her experience.

She then underwent a first rib removal on the left side, which resulted in an 11-day hospital stay with complications including two chest tubes, a needle aspiration, and 100cc of fluid in the pleural cavity. Upon returning home, she began physical therapy but developed shortness of breath with deep breaths due to a costochondral fracture, likely from the chest tube or aspiration. She is currently awaiting a consultation for ultrasound injections to address this. The journey continues.

Q: What inspired you to share this story?

A: The primary motivation was to share the complex journey and its takeaways. This case involved a “triple crush” — compression at the first rib, cubital tunnel, and carpal tunnel. A key takeaway is the importance of acknowledging when you “don’t know, but know the next step.” In healthcare, we often focus on obvious issues, but a broader perspective is often needed before returning to specific concerns. It’s also crucial to acknowledge the psychological toll on patients without answers, highlighting the profound impact of chronic pain.

Q: You mentioned how emotionally draining the journey was. What advice do you have for clinicians to support patients?

A: Remind patients that recovery is an “ultramarathon, not a sprint.” Reinforce this message, as other healthcare professionals will likely echo it. Sometimes, when my wife is in pain, she doesn’t want to discuss it, and that’s acceptable as long as I am there to support her. The doctor’s validation, “How’s it feel to not be crazy?” significantly improved her emotional well-being. Supporting patients in seeking further opinions is also vital.

Q: Overlapping issue on a personal level, how did you navigate the multiple diagnoses?

A: My ability to navigate this well stems from my access to top medical professionals through my profession. My connections as an athletic trainer allowed me to consult doctors and seek referrals. While they may not know specific TOS treatments, they can guide us to the appropriate specialists.

Q: Any difficulties separating the Athletic Trainer (AT) role from the husband role?

A: There were no difficulties in separating the AT from the husband role. My wife knew me as both from the beginning of our relationship, so there was no separation or conflict.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

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Expert insights on athlete nutrition timing: GI issues, RED-S, PCOS, and fueling strategies. Learn about tailored snack recommendations.

A (Dr. Curtis): While not a typical GI condition, amenorrhea and RED-S require a multidisciplinary approach. Often, medication is prescribed to induce a period, but this does not resolve underlying hormone imbalances or decreased bone density. These conditions frequently arise from an athlete’s energy deficiency, such as a marathon runner not increasing fuel intake to match activity, leading the body to prioritize survival over non-essential functions like menstruation.

A (Poole): It’s a myth that athletes should not get their period; it is not normal. Addressing overall energy intake is crucial. In severe cases, decreasing activity while increasing fuel might be necessary. We often work with athletes who are injured or returning to sport, which provides an opportune time to address their fueling needs.

A (Dr. Curtis): The culture of sports often pressures athletes toward specific body images or weight classes, which is unhealthy. We must educate athletes that a balanced diet is acceptable and that restrictive diets are not always necessary. Coaches also play a role in fostering a healthier environment.

A (Dr. Curtis): As a former pediatric sports medicine doctor, I learned the importance of creating a trusting and safe environment. While it’s harder to have parents leave the room now in full sports medicine, fostering trust is key.

A (Poole): We focus on the athlete’s performance goals, as health often isn’t the primary motivator for adolescents. We seek out what truly motivates them to achieve their best performance through proper nutrition.

A (Bri Poole): Snack recommendations are highly individualized based on what works and what an athlete enjoys. Simple, easily digestible options like GoGo Squeez are generally safe choices.

A (Dr. Curtis): I don’t have specific go-to snacks; the focus is on what an individual athlete likes and what doesn’t cause GI distress. Suggesting foods they are unwilling to eat can lead to non-compliance.

A (Poole): Simple carbohydrates are typically easy on the GI system around exercise. It’s best to stick with foods the athlete has consumed before. Liquid carbohydrates can be a good option as they may sit better for some. While many believe “sugar is bad,” simple sugars are the body’s preferred fuel source during exercise.

A (Poole): Some athletes have higher or different energy needs, even if they aren’t playing intensely. Athletes generally have elevated caloric demands. It’s perfectly fine for them to eat snacks, especially when readily available, such as on the sidelines.

A (Poole): Always approach with an open and curious mindset. Ask questions to understand cultural practices better, especially regarding fuel timing within non-fasting windows. Work closely with the athlete to create a tailored plan.

A (Dr. Curtis): Meet athletes where they are; you cannot simply forbid them from fasting. I am willing to write letters to coaches if training times need to be adjusted to accommodate an athlete’s practices, ensuring they can continue to play safely.

A (Poole): Many runners prefer not to eat before a run. For shorter runs (e.g., 5 miles or 3k), it can be acceptable if the athlete had sufficient fuel the day prior and will refuel adequately post-run. However, for exercise lasting 50-90 minutes or longer, pre-exercise fuel is essential, particularly for running due to its impact on bone resorption. The specific goals of the runner (e.g., marathon training) also influence recommendations.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

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Athletic Dry Needling – Save up to $100 when registering through our link.

Learn about emergency preparedness in youth sports, focusing on cardiac safety, the Project Adam initiative, and the status of the “Heartsafe” program with Tom Woods.

A: Review statistics on sudden death in young athletes. Sudden cardiac arrest is the leading cause of death. Target the most likely areas where incidents occur and prioritize time and equipment-sensitive responses.

A: Some may falsely believe youth athletes are inherently safe because a highly prepared incident was effectively managed in the NFL. However, youth settings lack the extensive resources and numerous providers available in professional sports. This incident highlights the need to increase effective response capabilities and empower more individuals to provide care.

A: When including grassroots sports, the financial investment in youth sports is substantial. It is crucial to make reasonable investments in equipment, procedures, and policies that maximize safety and efficient use of time to ensure overall safety.

A: This is a critical point; clubs should invest more in youth safety. Efforts like Bob Marley’s network aim to bring ATs to these settings. More needs to be done beyond large tournaments, extending to daily operations, especially given that larger clubs may have many teams practicing simultaneously.

A: Project Adam and recent legislation offer programs specifically designed to make youth sports cardiac safe. These initiatives provide a framework for clubs to enhance their emergency preparedness.

A: Our school became involved with Project Adam after recognizing areas needing attention in our setting. It offers a systematic approach to achieving cardiac safety. Texas Children’s Hospital (TCH) is an affiliate site for Project Adam, providing numerous resources.

A: The exact reason is unclear. However, presentations like this provide an opportunity to spread the message. Discussions with directors at TCH and Cook Children’s indicate that some areas, like Dallas-Fort Worth (DFW), are more involved. We need to disseminate this information, especially with increased requirements for cardiac responsiveness.

A: Achieving “Heartsafe” status involves a step-by-step process through Project Adam. Organizations register, complete a checklist, and consult with directors and affiliate contacts for questions. Upon completion, they receive “Heartsafe school/program/district” designation.

A: Yes, it is similar to SafeSport and is an ongoing process.

A: House bills have been passed and are expected to take effect on September 1st, following the governor’s signature. This legislation aims to enhance cardiac responsiveness.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

MedBridge Education – Use “TheSMB” to save some money, be entered in a drawing for a second year free, and support the podcast.

Marc Pro – Use “THESMB” to recover better.

Athletic Dry Needling – Save up to $100 when registering through our link.

Explore expert tips for post-operative ACL rehab, including avoiding pitfalls like lacking extension & recommended biofeedback units.

A: Phase 2 is a favorite because the athlete is getting off the table, which is exciting both mentally and physically. During this phase, significant gains are made, and progress continues toward returning to running.

A: Consistently checking and actively feeling for extension daily is crucial. Make it a habit and an integrated part of the treatment flow to catch any issues early. Even a little bit of load when athletes start doing more of their daily activities can affect extension, so early detection is key.

A: It is not necessarily a red flag, but it should definitely be noted. This observation prompts consideration of what might have changed between sessions that could have caused the lack of extension. For example, it might indicate that too much activity was introduced.

A: No, one should not immediately jump to using fibular head mobilizations. However, they can be a successful intervention in certain cases.

A: The framework of this ACL rehabilitation program can definitely serve as a guide for other knee surgeries. However, modifications are necessary based on the specific structures that have been surgically altered. For example, a meniscus repair would require avoiding weight-bearing, unlike an isolated ACL reconstruction.

A: I recommend Mtrigger. It’s an app-based unit with an easy setup, and it can be used more functionally beyond just table exercises. Additionally, it is versatile and can be applied in various other post-operative cases.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

MedBridge Education – Use “TheSMB” to save some money, be entered in a drawing for a second year free, and support the podcast.

Marc Pro – Use “THESMB” to recover better.

Athletic Dry Needling – Save up to $100 when registering through our link.

Get insights on chest injuries & emergencies from ER physician Dr. Dacia Ticas. Learn about red flags and vital info for athletic trainers.

A: I liked everything and wasn’t sure what to commit to. Emergency medicine allowed me to experience a bit of everything, including a wide range of chest injuries.

A: Pulseless children are concerning. Severe cases with children, such as swelling or edema of the airway where a cricothyrotomy might be necessary, are also very serious.

A: Being out of shape typically presents as shortness of breath without actual struggle or severe chest pain. Red flags for chest injuries include pale or cyanotic appearance, complaints of severe chest pain, and a visible struggle to breathe.

A: A physician would be required. While we wish it were seen more often, on-field ultrasound has tremendous value in clarifying life-threatening chest injuries.

A: We will conduct our routine workup regardless. Key information includes what actually happened—e.g., getting hit in the throat versus the chest—whether they collapsed or lost consciousness, and how the patient initially presented and communicated their complaints.

A: Cardiac and pulmonary contusions can take time to develop. Life-threatening issues are typically identified through labs on the day of the incident.

A: Commotio cordis involves the ventricles going out of whack due to a flux of ions being disrupted, which is a chemical issue. This happens in a fraction of a second, as highlighted by the Damar Hamlin incident, which brought athletic training to the forefront for chest injuries.

A: Often, if you ask an athlete if they can return to play a few plays later, they might indicate they cannot or develop a specific spot of noticeable pain. Lingering pain for a few plays, rather than generalized pain, may be a sign for removal due to a bigger issue, particularly with chest injuries.

A: There are many stories. Early in my career, seeing a 4×4 through a chest wall, yet the internal organs were intact, was shocking. As I progressed, medical mysteries became more enticing. DJ Harden’s aortic injury after a chest hit, and assessing patient consciousness and bilateral pulse equality, are all crucial in emergency medicine for chest injuries.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

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Athletic Dry Needling – Save up to $100 when registering through our link.

Guided practice was the theme for Chris Greenleaf and Mary Williams as they joined Ben and Jeremy at the Sports Medicine Update. Being a preceptor is a growing experience, and the best way I know to grow is to ask experts how they do it.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

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Learn about facial injury red flags, CSF identification, EAP essentials, and return-to-play guidelines for athletes from Dr. Rehal Bhojani.

A: Protocols from SCAT6 and other guidelines for hematomas or hemorrhages emphasize watching for loss of consciousness (LOC), altered mental status, and vomiting. Quickly identify these signs to avoid missing late concussions or other critical issues. Ensure the mechanism of injury (MOI) aligns with the trauma; diagnosis is challenging if it doesn’t.

A: The halo sign, also known as the ring sign, remains the best indicator for identifying cerebrospinal fluid (CSF). CSF is distinct: it has a clear-to-mucous color, is super thin, lighter than water, and does not mix with other fluids. For instance, a soccer player initially diagnosed with a concussion showed a bloody nose and consistent halo sign post-game, necessitating immediate emergency room referral.

A: EAPs are becoming more comprehensive, focusing on three key areas. First, ensure resource accessibility by including contacts for ENTs, dentists, and eye doctors. Second, review the EAP regularly, two to three times a year, rather than just annually, using past injury knowledge to proactively improve it. Third, if using AI to draft EAPs, meticulously verify all listed resources.

A: For eye and tooth injuries, kits should include 4×4 gauzes, an otoscope, a “Save a Tooth” system, eyedrops, nasal tampons, and Afrin. Physician-approved medications should also be added, along with an ENT kit, which is available online.

A: On-field suturing depends on the location and type of laceration, with the cause (e.g., metal object) being crucial due to potential tetanus considerations. Athletes often return to play the same day with sutures. For facial lacerations, specific types and sizes of sutures are used, but caution is advised near the eye. Eyebrows and the skull are generally suitable for suturing if no underlying fracture exists. Control bleeding and inform athletes of the risks associated with playing with sutures; safety is paramount.

A: For primary (baby) teeth, if no secondary tooth injury is suspected, return to play (RTP) is generally straightforward. However, secondary tooth injuries involving complex factors can lead to lasting effects. It is important to document whether the injury involves primary versus permanent teeth. For younger children, involve parents to understand the mechanism of injury and the potential for future crown and root fractures.

A: Sports medicine is constantly evolving, with increased pressure for accurate decision-making. Recent graduates need to be proficient in current literature and comfortable with shared decision-making and escalating care. As athletic trainers often serve as primary sports medicine providers, they require broad skills across various domains.

A: Teaching these competencies is challenging due to the need for comprehensive exposure. Educational methods vary by setting, and the field has expanded significantly. Training provides a broad scope, so it’s important not to be narrow-minded. Past experiences remain relevant, and post-training, continuous reading and skill refinement are crucial. In a controlled educational environment, students should learn as much as possible, as quickly as possible, to prepare for real-world practice.

A: Today’s breakout session focuses on facial injuries, incorporating practical eye, ear, and nasal examinations. The session emphasizes that history-taking accounts for 80% of a diagnosis, with the physical examination comprising the remaining 20%.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

MedBridge Education – Use “TheSMB” to save some money, be entered in a drawing for a second year free, and support the podcast.

Marc Pro – Use “THESMB” to recover better.

Athletic Dry Needling – Save up to $100 when registering through our link.

Dr. Dominic Maneen shares insights on OMT in sports medicine, covering his AT to DO transition and OMT applications for common conditions.

A: I transitioned to practicing sports medicine without surgery, as that field didn’t align with my interests. I explored osteopathic medicine, identifying the core difference between DOs and MDs as a dedicated course in osteopathic principles. I maintained my athletic training certification to foster understanding and collaboration with ATCs, and a second course focusing on the musculoskeletal system further ignited my passion. During medical school, I also pursued an MBA, gaining insights into medical billing.

A: I completed my undergraduate studies at UT, then worked as an ATC for baseball and softball at HBU. I entered the profession serendipitously, drawn by the phrase “sports medicine.” It required rapid maturation, as I assumed an adult role despite being only slightly older than the athletes. I collaborated with Richy Valdez and several GAs, and student athletic trainers were indispensable since it was impossible to simultaneously oversee both baseball and softball. I recall an incident involving twin softball players: one sister not playing, the other on deck, with an accidental practice swing hitting the sister, necessitating a golf cart ride to the adjacent facility.

A: Low back pain is the second most common reason people visit the doctor, with depression being the first. Patients typically present with symptoms that indirectly lead to a depression diagnosis, rather than overtly stating “depression.” A sedentary lifestyle is often termed “the new smoking” in medicine, leading to tight, unused muscles. Hands-on manipulation therapy can be beneficial, and simple exercises like push-ups can improve posture by strengthening the neck muscles that support the head. Many individuals struggle with core muscle activation; focusing on proper technique and guiding them to engage their core will lead to increased strength over time.

A: Patients often present with concurrent back and knee pain. Structural analysis can reveal the cause, leading to recommendations for inserts or corrective devices for arch support, rather than immediate surgical intervention. Subsequent efforts focus on improving knee mechanics to alleviate symptoms.

A: Myofascial release may sometimes require trigger point injections. However, most concussion cases can be effectively managed with muscle energy techniques. In older patients, some form of osteopathic manipulation may be necessary.

A: It is crucial to understand that the neck’s complexity extends beyond superficial muscles like the scalenes and deltoids; smaller, deeper muscles also play a significant role in neck function.

A: Prioritize hands-on manipulation therapy and muscle energy techniques with athletes, rather than solely relying on stationary bikes or treadmills for warm-up.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

MedBridge Education – Use “TheSMB” to save some money, be entered in a drawing for a second year free, and support the podcast.

Marc Pro – Use “THESMB” to recover better.

Athletic Dry Needling – Save up to $100 when registering through our link.

Learn how to optimize hamstring recovery for peak performance with insights and key Q&A from Brian Duncan, PT, DPT, OCS, SCS.

A: Fascial length is not necessarily more important than strength, but the body adapts from training, loading, and sprinting. However, sprinting alone is insufficient for optimal hamstring recovery.

A: Currently, there is no way to palpate fascial length. It can only be observed on MRI or ultrasound as imaging techniques improve. An NFL-funded trial is ongoing, examining hamstring injuries and investigating various factors with imaging across several colleges.

A: Varying the amount of knee flexion or extension can increase hamstring length and load depending on the specific area of the hamstring. Training hip extension can place more load on the proximal hamstring tendon. Most hamstring injuries occur at the myotendinous junction (proximal), while injuries within the muscle belly tend to heal better.

A: The higher the level of competition, the more complex the situation becomes, often involving “more cooks in the kitchen.” This raises questions about collaboration between different coaches and the athletic trainer. Communication and planning can be challenging in these scenarios, impacting hamstring recovery.

A: High-intensity sprinting is considered most important, but a lack of planning may be an issue. There is a significant load difference between an 80% sprint and a 100% sprint, with a substantial increase in eccentric load at maximum effort. The length the hamstring travels between 80% and 100% sprint is no different. A gradual progression back into previous activities is often necessary for effective hamstring recovery. Running more than nine sprints in a session can lead to further hamstring injury.

A: AI is only as effective as the user and the questions asked. For example, it can build a maintenance program. When asked to include high-speed running and eccentric loading, it then asked if a weekly microcycle was needed. Hopefully, it will not replace athletic trainers’ jobs but instead help them to excel at them, especially in optimizing hamstring recovery.

A: Athletic trainers should start eccentric training early (at a pain level less than 4/10) and incorporate sprinting (running) as soon as possible. It is also crucial to communicate with coaches to target at-risk position groups with maintenance plans throughout the season and to incorporate banded Nordic hamstring curls to maximize range of motion.

A: Maintenance programs are vital throughout the season to prevent recurrences and soft tissue injuries. During SAC camps, the key is to prevent overtraining and identify athletes who don’t self-regulate. Sprint training should occur early in SAC camp or during the day’s workout before lifting. For in-season maintenance, hamstring work should be incorporated on match day and two days after, ideally 3-4 days before the next match day.

Jeremy Jackson

Benjamin Stephenson

Layci Harrison

Mark Knoblauch

Ashlyne Elliott

Leslie Bennett

Frio Hydration – Superior Hydration products.

Xothrm – Best heating pad available – Use “SMB” or email [email protected] and mention the Sports Medicine Broadcast.

Donate and get some swag (like Patreon but for the school)

HOIST – No matter your reason for dehydration, DRINK HOIST

MedBridge Education – Use “TheSMB” to save some money, be entered in a drawing for a second year free, and support the podcast.

Marc Pro – Use “THESMB” to recover better.

Athletic Dry Needling – Save up to $100 when registering through our link.