Saturday, January 18, 2014

David Clarkson's Elbow

A few weeks back, HBO's lauded series 24/7, which was following the Toronto Maple Leafs in the weeks leading up to the Winter Classic, highlighted a nasty injury suffered by David Clarkson against the Carolina Hurricanes on December 29th. On an awkward body check, Clarkson's elbow split open as can be seen below.


The wound required 18 stitches and a little cleaning up but that didn't stop Clarkson from returning to the ice later in the game. However despite returning and playing in nearly every game since the injury (missed 1/7/14 against the Islanders with a foot injury), Clarkson was placed on injured reserve Friday. Clarkson will miss at least a week.

When asked about the injury, Maple Leafs coach Randy Carlyle said:
"He split his elbow two weeks ago, and it was well along its way to healing, and then it re-opened with a body check and it has been draining here for the past seven or eight days. Doctors made a decision that it wasn't going to be favorable for him to continue playing with that and made a decision to treat it now." 
 So it sounds like Clarkson's elbow was fine but after a body check, the stitches split open, aggravating the injury.. Also since his elbow has been getting drained, it sounds like Clarkson has elbow (olecranon) bursitis.

THE INJURY

Olecranon bursitis is the inflammation of the bursa sac located on the tip of the elbow. Bursitis can occur for a number of reasons but is mostly attributed to a hard blow to the elbow or prolonged pressure at the site.

Bursae are thin, slippery fluid-filled sacs of tissue that are located throughout the body wherever skin, muscles, or tendons need to slide smoothly over the bone. A bursa is lined by synovial membrane (soft tissue) and filled with viscous (synovial) fluid, providing a cushion between the bone and tendons/muscles/skin around a joint. Bursae are crucial because they help reduce friction and allow free movement of the joint.

The olecranon bursa is located between the top of the elbow (olecranon) and the overlying skin. Normally the bursa is flat but when it becomes inflamed, fluid accumulates in the bursa.


A direct blow to the elbow may damage or tear the tissues and blood vessels of the bursa, causing bleeding into the bursa sac which swells. If the bursa is filled with blood, it can cause an inflammatory reaction, causing the walls of the sac to thicken. The thickening and swelling of the bursa sac is what is referred to as bursitis. 

Bursitis causes painful swelling in the area at the tip of the elbow and the area is so tender, it's even tough to rest your elbow on a hard surface. Over time, the bursa sac can fill with fluid (pus) and swell up.

TREATING BURSITIS

After diagnosis of bursitis (usually obvious from physical examination by a doctor), the fluid may be drained to make sure there is no infection. Luckily, bursitis is an injury that usually goes away on its own as the body will absorb the blood over a few weeks. An elbow pad will probably be placed to cushion the elbow and the patient should avoid direct contact to the swollen elbow. Ibuprofen or other anti-inflammatory medications may be used to reduce swelling. 

However, if swelling and pain in the bursa is not responsive over the course of a few weeks, a needle may be inserted to drain the blood and fluid and speed up the healing process. During the draining, a small amount of cortisone can be injected into the bursa to control inflammation. Corticosteroid injections usually work well to relieve pain and swelling as they are a strong anti-inflammatory drug. The doctor will take all steps necessary to avoid infection. 


Clarkson's injury shouldn't be too serious as long as his elbow isn't infected. No surgery is required and Clarkson just needs to rest and hope his elbow's inflammation goes down. The fluid-filled sac isn't a problem unless it causes pain. Still, Clarkson should avoid direct contact to his elbow which is difficult for a player of his nature. This probably explains why the Leafs and their doctors are recommending he stay and rest and recover this week.

Sunday, January 12, 2014

2013-2014: Year of the groin injury?

Groin injuries have been extremely prevalent in the NHL this season, especially amongst goaltenders. NHL goalies have always been prone to hip and groin injuries due to the butterfly style of play, but it's insane how many netminders have missed time this season due to an injury of the groin. 17 out of the 30 NHL clubs have had at least one player miss time this season due to a groin injury, totaling in 37 players overall. This doesn't include players that missed time with undefined or undisclosed 'lower-body injuries.' Listed below are prominent NHL players have have missed time this season due to a groin pain or a groin strain:

Team
Player
Games Missed
Anaheim Ducks


Boston Bruins
Adam McQuaid (D)
8
Buffalo Sabres


Calgary Flames


Carolina Hurricanes
Anton Khudobin (G)
Cam Ward (G)
32
10
Chicago Blackhawks
Corey Crawford (G)
Nikolai Khabibulin (G)
10
8
Colorado Avalanche


Columbus Blue Jackets
Sergei Bobrovsky (G)
Matt Calvert (F)
14
Day-to-day (N/A)
Dallas Stars
Ray Whitney (F)
Kari Lehtonen (G)
5
5
Detroit Red Wings
Stephen Weiss (F)
Jonas Gustavsson (G)
Darren Helm (F)
Pavel Datsyuk (F)
Danny DeKeyser (D)
Daniel Alfredsson (F)
Gustav Nyquist (F)
6
4*
N/A
2*
1
5
3
Edmonton Oilers
Richard Bachman (G)
Corey Potter (D)
Justin Schultz (D)
Ryan Smyth (F)
Dennis Grebeshkov (D)
16
6
8
6
8
Florida Panthers
Tim Thomas (G)
Scott Gomez (F)
Sean Bergenheim (F)
16
8
N/A
Los Angeles Kings
Jonathan Quick (G)
24
Minnesota Wild


Montreal Canadiens
Max Pacioretty (F)
N/A
Nashville Predators


New Jersey Devils
Cory Schneider (G)
Patrik Elias (F)
7
N/A
New York Islanders
Evgeni Nabokov (G)
11*
New York Rangers


Ottawa Senators
Jason Spezza (F)
1
Philadelphia Flyers


Phoenix Coyotes


Pittsburgh Penguins


San Jose Sharks


St. Louis Blues


Tampa Bay Lightning


Toronto Maple Leafs
Joffrey Lupul (F)
7
Vancouver Canucks
Roberto Luongo (G)
Dan Hamhuis (D)
David Booth (F)
3
N/A
8
Washington Capitals
Brooks Laich (F)
14
Winnipeg Jets
Zach Bogosian (D)
Mark Stuart (D)
15
1
* - Currently on IR or injured
N/A- Unable to obtain



GROIN STRAINS - THE INJURY

Groin strains are a common sports-related injury. Treatment depends on the severity of the strain. 32% (12/37) of the groin injuries that have occurred in the NHL this season have been sustained by goaltenders which can be attributed to the butterfly style of goaltending. In the video below, Tim Thomas of the Florida Panthers injures his groin on a right pad save, most likely due to an over-extension.


A groin strain is it's simplest form is a partial or complete tear of the small fibers of the adductor muscles. The adductors are a group of muscles located on the inner side of the thigh, attached along the femur. The adductor longus, adductor brevis, and adductor magnus are three powerful muscles of the adductor group which originate at the pubis (lower portion of the pelvis) and terminate in attachments at the inner side of the knee. These ribbonlike muscles' primary action is adduction of the thigh, which is essentially the movement of pulling the legs back towards the midline. When you're walking , your adductor muscles are used in pulling and swinging your lower limbs towards the middle to maintain balance. Adductors also aid in actions such as squeezing the thighs together, and rotation and flexion of the thigh. The adductor muscle group is pictured below: 

A groin strain can be caused by a variety of actions. There are also several factors that may increase an athlete's chances of developing a groin strain. These factors include a previous strain or groin injury, muscle fatigue, and tightness in the groin muscles due to not stretching properly. 

A rupture or tear of the adductor muscles usually occurs when sprinting, rapidly changing direction, or in swift movements of the leg against resistance (kicking a ball, making a kick save, etc.). This occurs because the adductor muscles are being stretched past a threshold or  beyond the amount of tension they can withstand. Additionally, if the groin muscles are suddenly put under stress when not prepared or if they receive a direct blow, the muscles can be damaged. 

MRI image showing partial-thickness tear isolated to the right pectineus muscle. (Koulouris)

Overusing the adductor muscles over time can result in adductor tendinopathy, a common but infrequently recognized cause of chronic groin pain. Muscle strains tend to occur at the myotendinous junction, or the site of connection between tendon and muscle. Muscle strains typically occur after a single traumatic event. However, tendinopathy injuries don't occur after a single event, it is a chronic but progressive pain that a consequence of overuse and aggravation resulting from athletic activity. Physicians should suspect adductor tendinopathy in cases of going pain with localized tenderness, weakness, and unilateral pain and when the patient complains of groin pain with quick bursts of activity. The diagnosis of adductor tendinopathy is made after a physician/speciliast has reviewed the patient's history, examined their muscles, and then confirms it via MRI (shown below). 

Arrows point to an intense bright signal within the bone marrow. 
This signal is indicative of focal marrow edema, an indication of inflammation. (Avrahami and Choudur). 

DIAGNOSIS 

Diagnosing groin pain can be extremely difficult. Below is a table depicting pathological diagnoses of muscles and their related symptoms.


Symptoms of a groin strain include but are not limited to:
  • Pain, stiffness and tenderness in the groin area
  • Weakness of the adductor muscles
  • Bruising in the groin area
  • Popping or snapping sensation as the muscle tears
To diagnose a groin strain, a doctor will need to complete a physical exam. If severe damage is suspected, the doctor may order MRIs to accurately diagnose the strain. During the physical exam, the doctor will complete three steps shown in the video below:
  • Observation and palpation: taking a close look at the affected area, observing for swelling and bruising, also if the patient has postural abnormalities when standing or walking. 
  • Range of motion: during this step, the range of motion at the hip join, into abduction (moving the leg out to the side) and adduction (moving the leg inwards) will be tested. This provide information about the tightness of the muscles and if stretching the muscle causes pain.
  • Resisted muscle tests: adduction will be tested against resistance, causing the muscle to contract. If the patient has a groin strain, it will be painful. 

The doctor will also need to determine the severity of the injury. There are three grade of groin strains:
  • Grade 1: A minor or micro-tear with some stretching with less than 10% of the fibers of the muscle being damaged. Grade 1 strains may only appear once an athlete stops exercising, the groin will feel tight and tender to touch.
  • Grade 2: a moderate or partial tear of the muscle fibers, ranging from 10 to 90% of fibers torn. The patient will feel a sudden sharp pain in the groin area during exercise and the muscles will tighten. 
  • Grade 3: the most serious form, involves a partial or full rupture of the muscle fibers (complete tearing). The patient will feel a severe pain and be unable to contract the muscles or squeeze their muscle together. Swelling and bruising on the inner thigh will occur. 

RECOVERY

Recovery time depends on the severity of the strain. The first thing a doctor will recommend is rest, the muscle needs time to heal. Additionally, an ice pack should be applied to the affected area for up to 20 minutes, four times a day. Some doctors will provide pharmacological treatment, including prescription pain relievers or anti-inflammatory medications (ibuprofen). 

Once the athlete is ready to return, stretching is imperative along with heat packs. Before stretching, athletes should apply heat to the affected area to help loosen the muscle. Stretching should progress in levels, from gentile stretching to more active stretching. Athletes should stop if they feel any pain. Once the pain starts to go away and the doctor clears the athlete, strengthening exercises will begin to help recover the muscles back to their baseline strength. 

DISCUSSION

Groin pain in elite athletes is a common yet challenging diagnostic dilemma for physicians. Groin pain accounts for approximately 5-18% of all athletic injuries and is estimated to account for 10% of all hockey injuries (Syme et al.). Groin injuries are often very difficult to manage as well, as they are often disabling, not allowing an athlete is exercise or walk very much. Recent discoveries in diagnostic imaging has helped the ability to diagnose groin injuries accurately. 

So why the increase in groin injuries this season? Anti Raanta, the Blackhawks backup goaltender, said the smaller pads in the NHL this year may be a cause. He was quote saying "Maybe a little bit, you just have to try to put the knees so tight together, try to block all the holes that you have, it's a little bit harder now." This is an interesting theory, as the butterfly technique is prone to groin injuries to begin with, but with the smaller padding, goalies might be overextending themselves to cover the 5-hole. Bill Ranford, a former NHL goaltender and currently the goalie coach for the Kings said he's noticed the increased amounts of goalie injuries this season but doesn't believe it's due to the smaller sized pads. Ranford believes the compressed Olympic schedule is a bigger culprit. 

Both the compressed schedule and limited pad sizing can definitely be factors or contributors to the increase in groin injuries. However, it's impossible to say for sure. In fact, many goalies (who got injured) did not change their pad sizing. However, it's understandable that it is something that goalies think is affecting them. Several goalies believe it's affected their play and the amount of goals they've allowed, however, there hasn't been much of an increase in goals-per-game in the NHL this season. Team physicians and trainers should explain the importance of stretching, and should also pre-screen players before the season starts to see if they are susceptible to groin injuries (injury history, skating strides, etc.). 

SOURCES

Avrahami, Daniel and Choudur, Hema. Adductor tendinopathy in a hockey player with persistent groin pain: a case report. J Can Chiropr Assoc. 2010 December; 54(4): 264-270. 

Koulouris, George. Imaging Review of Groin Pain in Elite Athletes: An Anatomic Approach to Imaging Findings. American Journal of Roentgenology. 2008; 191: 962-972. 

Syme G, Wilson J, Mackenzie K, Macleod D. Groin pain in athletes. Lancet 1999; 353:1444. 

Wednesday, January 8, 2014

Why Brayden Schenn's seemingly harmless skate cut could have been disastrous

It's kind of crazy how quickly we forget that hockey is an intense, physical game played at a high velocity on ice with players wearing sharpened skate blades. It's almost amazing how few injuries occur directly related to skate blades. However, some still occur, the most famous of which are:
Last night, during the second period of the Philadelphia Flyers/New Jersey Devils game, Brayden Schenn suffered a cut after an errant skate blade from Zubrus when across his lower body. Schenn went for the hit on Zubrus who fell to the ice, making his legs and skate blades come up and cause contact to Schenn's body. Video of the incident below:

Schenn went to the bench and the trainer was lucky to find just a cut across his lower stomach/oblique area. Schenn was bandaged up and was back only a few minutes later. Schenn ended up scoring the winning goal in overtime for the Flyers.

The scary (but lucky) part is where Schenn was cut. Schenn was cut in a pretty vulnerable area, had the cut been any lower, key arteries and ligaments could have been damaged.


"Just clean that puppy up and get me back on the ice"

Luckily, the cut wasn't deep enough or close enough to some really important areas. The cut appears to be slightly above the inguinal ligament. This ligament supports the region around the groin, containing soft tissues. The inguinal ligament also prevents an inguinal hernia (most common type of hernia), which is a protrusion of an organ into the muscles of the groin (outside the organ's cavity wall which contains it). Additionally, several structures pass deep to the inguinal ligament, including: 

  • Muscles such as the Psoas major (hip flexor group, contributes to flexion and external rotation in the hip joint), iliacus (important for flexing the femur forward), and the pectineus (hip flexion).
  • Femoral nerve, artery and vein
  • Lateral cutaneous nerve of thigh (innervates the lateral thigh skin)
  • Components of the lymphatic system


One of the most important things to remember is how close the cut was to the external iliac artery which connects to the femoral artery further down (both under the bone). Had the skate cut at an awkward angle or much deeper, Schenn would have been in serious trouble. The external iliac artery and it's associated vessels supply blood to the pelvic organs, gluteal region, and legs (the iliac arteries terminate in the femoral artery supplying blood to the legs). The affected area also contains testicular vessels and other components. Had they been cut, let's just say Schenn wouldn't be having kids any time soon.



Schenn is lucky, good to see him right back out on the ice and score the GWG. Sometimes it's easy to forget how dangerous skate cuts can be though. All hockey fans should be grateful they don't happen more often. 

Sunday, January 5, 2014

Concussions in the NHL

CONCUSSIONS AROUND THE NHL

According to TSN, there are currently 100 players injured in the NHL across all 30 teams. There are currently 6  players injured due to concussions (with an additional 3 due to post-concussion syndromes), making head injuries a major topic around the hockey world. This is evident by the increased focus on hits to the head by the Department of Player Safety.

Earlier in the season, New York Rangers forward Rick Nash was diagnosed with a concussion and placed on IR after a high hit by San Jose Sharks defenseman Brad Stuart. As shown in the suspension video below, Stuart makes significant head contact by launching himself up into Nash. As the primary point of contact (PPOC) was the head and Nash was injured, Stuart was suspended three games for the hit.

At the time, this wasn't good news for Rangers fans since it wasn't Nash's first concussion. Nash reportedly suffered a concussion after a hit by Lucic just twelve games into last season and missed four games. Nash has since returned and has 16 points in 26 games on the season.

Of the other NHLers sidelined due to a concussion, all were caused due to contact with the head (Update: Backstrom, Josi and Kronwall have returned. This article has been in the process of writing since October so not all are up to date, sorry!).

WHAT IS A CONCUSSION? 

Also known as a mild traumatic brain injury, the concussion is the most common type of traumatic brain injury. At the 4th International Conference on Concussion in Sport (Zurich, November 2012), a panel discussion took place to obtain a consensus-based definition of a concussion. The Concussion in Sport Group (CISG) defined a concussion as follows:
Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include: 
  1. Concussion may be caused either by a direct blow to the head, face, beck or elsewhere on the body with an "impulsive" force transmitted to the head.
  2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
  3. Concussion may result in neuropathological changes but the acute clinical symptoms  largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.  
Boy, that's a pretty long definition. In essence, a concussion is a head injury with a temporary loss of brain function that may result in a variety of physical, cognitive, and emotional symptoms.

DIAGNOSING A CONCUSSION - SIGNS AND SYMPTOMS 


Concussion is considered to be among the most complex injuries to diagnose in sports medicine. The majority of concussions in sport occur without a loss of consciousness or frank neurological signs and the symptoms can be difficult to recognize (McCrory et al.). The aforementioned Zurich 2012 consensus panel agreed that concussion "is an evolving injury in the acute phase with rapidly changing clinical signs and symptoms, which may reflect underlying physiological injury in the brain." Additionally, there is no perfect diagnostic test that physicians can rely on for an immediate diagnosis of  a concussion, especially in a sporting environment. Most concussions also cannot be identified or diagnosed by advanced neuroimaging techniques, such as a CT scan or MRI, unlike other neurological injuries/diseases.

Right now, a concussion is a clinical diagnosis based largely on the observed injury mechanism (point of contact, force on head area, etc.), signs, and symptoms. The first step towards a diagnosis of a concussion is actual recognition of the injury. As always in the NHL, a huge hit will garner the most attention, however it's important for team trainers, coaches, and physicians to be vigilant of smaller hits or multiple hits in a short period of time. The combined effects of multiple hits over a short period of time may be worse than just one large hit. This is largely due to the unknown mechanism of the injury. For example, a recent study evaluated the relationship between the force of impact and clinical outcome, finding that magnitude of impact did not correlate with clinical injury (Guskiewicz et al.). The study showed that despite the fact that the impact magnitude of the hits sustained by concussed athletes ranged from 60.51 to 168.71 g (!), no significant relationships between those impacts and symptom severity/neurocognitive functioning were found.

Sport-related concussions are very difficult to diagnose. This is especially true when the injury is 'mild' or when the symptoms or subtle or masked by the athlete. It's quite common for athletes (at all levels) to assume that "having your bell rung" is part of the game, and don't recognize the significance or consequences of playing with concussions. A study of high-school football players, only 47.3% of players with a concussion reported their injury (of the cohort that didn't report, 66.4% didn't think their injury was serious enough, 41% didn't want to be held out of play) (McCrory et al.).

The symptoms of a concussion are just one component of making a diagnosis, but important to note. The hallmark signs of acute sports concussion include:

  • Loss of consciousness (LOC)
  • Problems with attentional mechanisms
    • Manifested as (but not limited to): slowness to answer questions and follow directions, easily distracted, poor concentration, vacant stare/glassy eyed. 
  • Memory disturbance
  • Balance disturbance
Over the course of the first 24 hours following a concussion injury, other signs and symptoms may manifest. However, it's important to note that there is a large range of these symptoms and they often vary, not all of these symptoms are seen in every case of sports concussion. The most common symptoms reported in concussion literature include:
  • Somatic symptoms such as headache
  • Cognitive symptoms such as feeling like in a fog
  • Emotional symptoms such as lability
  • Physical symptoms such as LOC and amnesia
  • Behavior changes such as irritability
  • Cognitive impairment
  • Sleep disturbance (insomnia)
  • Dizziness and balance problems
  • Blurred vision
  • Fatigue

If any one or more of these symptoms is recognized, a concussion should be suspected and a management plan should be implemented.

Since concussions are often hard to recognize and to diagnose, the McCrory et al study as well as the Zurich Consensus on Concussion in Sport proposed diagnostic criteria for sideline evaluation:
An athlete shows any of the following, they need to be removed from play and assessed.

  • Initial obvious physical signs consistent with concussion (LOC, balance problems)
  • Teammates, trainers, coaches observe cognitive or behavior changes in functioning consistent with concussion symptoms reported
  • Any concussion symptoms reported by the athlete injured
  • Abnormal neurocognitive or balance examination
Following a removal from play:
  • Physician evaluated the player using standard emergency management principles, most notably to exclude  severe head trauma or cervical spine injury
  • Once first aid issues are addressed, assessment of the concussive injury should be made using the SCAT3 or other sideline assessment tools (NHL uses ImPACT concussion testing, read here: http://www.impacttest.com/about/)
  • The player should not be left alone following the injury and serial monitoring for deterioration is essential over the initial few hours following injury (as seen on 24/7, Abdelkader was driven home by his parents following several hours of testing at Joe Louis arena)
  • A player with diagnosed concussion should not be allowed to return to play on the same day. 
    • It has been unanimously agreed that an athlete should not return to play on the same day of the injury. Studies have shown that athletes allowed back into play following a concussion may demonstrate neuropsychological deficits post injury. 
THE SCAT3 CAN BE FOUND HERE: http://bjsm.bmj.com/content/47/5/259.full.pdf

The SCAT3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older.

CONCUSSION MANAGEMENT AND RECOVERY


As stated in the International Conference on Concussion in Sport, the consensus panel agreed that the "cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and a return to play."

However, current research related to advances in the management of sport concussion is sparse. There is not much evidence for concussion therapies, including how much rest is optimal, different physiotherapy treatments, etc. There is a need for studies which evaluate the effects of a resting period, pharmacological interventions (many doctors will prescribe pain medications as well as anti-inflammatory medications), rehabilitative techniques and exercise (low-levels) for players who have sustained a concussion. 

The graduated return to play protocol following a concussion is a stepwise process and is outline below: 



In this stepwise progression, an athlete only proceeds to the next level if they are asymptomatic at the current level. Each step should take at least 24 hours, making the minimum amount of time to proceed through the full rehabilitation protocol one full week. Athletes should never return to play on the same day as an injury.

Persistent symptoms (>10 days) are reported in 10-15% of all concussions but may be higher in populations such as hockey players and younger aged athletes. Each case should be managed effectively and not rushed.

One thing to consider, especially in the case of NHL concussions, is the role of pharmacological therapy. Drugs may be applied to managing a concussion in two different ways. The first is managing specific or prolonged symptoms such as anxiety, insomnia or sleep disturbance, and post-concussive headaches. The second is using pharmacological therapy as a way to modify the underlying pathophysiology of the condition, with the aim of shortening the duration of concussive symptoms. However, this approach is still only used by experts and involves drugs such as anti-inflammatory medication.
One of the most important considerations in the management of a concussed athlete, is that not only should they be symptom-free, but they need to be symptom-free when off of their pharmacological therapies, so that they don't mask or modify the symptoms.

Management of a concussion is different in each case. Some studies now believe that concussion/TBI is a disease process, rather than an isolated self-limited event (Masel and DeWitt) with post-concussive symptoms, especially post-traumatic headaches reflecting persistent, potentially progressive brain dysfunction.

CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)

A few of the most covered topics regarding concussion in the media right now is the phenomenon known as chronic traumatic encephalopathy (CTE). There is a growing awareness that repetitive minor TBIs may lead to persistent cognitive, behavioral, and psychiatric problems and, rarely, to the development of CTE, a progressive degenerative disease which can only be definitively diagnosed postmortem. CTE results in a degeneration of the brain tissue an an accumulation of tau protein. Media outlets report that CTE may show symptoms of dementia (memory loss, aggression, confusion, depression) years after the initial trauma.

However, while clinicians need to be mindful of the potential for long-term problems while managing their athletes, several studies disagree with the media hype of CTE. First and foremost, the International Consensus agreed that CTE represents a distinct tauopathy with an unknown incidence in athletic populations. There has yet to be a proven cause and effect relationship demonstrated between CTE and concussions or exposure to head trauma in sports. CTE has yet to be related to concussions alone and at present, there are no published epidemiological, cohort or prospective studies relating to CTE. The speculation surrounding concussion exposure to CTE is unproven but doctors still need to proceed cautiously and address the fears of parents/athletes from media pressure related to the possibility of CTE.

When meeting with a premiere neuropsychiatrist, he explained to me that there is an absurd amount of hype and lies in some of the articles dealing with CTE. Essentially, no brain that has been autopsied, screened, and diagnosed with CTE has actually been a good brain to diagnose or relate solely to concussions. For example. every single brain that has been diagnosed in the media studies you may have read about is one of a person with distinct underlying neurological problems, or has taken a large load of medications (thinking of Boogard who died of an accidental drug and alcohol overdose). The extent to which age-related changes, psychiatric or mental health illness, alcohol/drug use or co-existing medical or dementing illnesses contributed to the process is unaccounted for in the published CTE literature. The sample size (hey advanced stats guys) of brains diagnosed with CTE is so small and more good brains need to be autopsied and compared. Additionally, the doctor said that second-impact syndrome is a complete myth, but more research needs to be done.

NOTE FROM THE WRITER

Hopefully this clears things up with NHL fans regarding concussions. They are a serious issue in the game today, and there is serious effort by the NHL to invest in new research.

If you have any questions, please let me know! Hopefully I will be writing more concussion-themed articles soon!


SOURCES:

Masel BE, DeWitt DS. Traumatic brain injury: A disease process, not an event. J Neurotrauma. 2010;27:1529-1540. 

McCrory P, et al. Br J Sports Med 2013;47:250-258.

McCrory P, et al. Br J Sports Med 2013;47:268-271.

Guskiewicz KM, Mihalik JP, Shankar V, et al. Measurement of head impacts in collegiate football players: relationship between head impact biomechanics and acute clinical outcome after concussion. Neurosurgery 2007;61:1244–52.