 Welcome to the sports playbook where we discuss solutions to issues that impact sports. I'm your host, Angela Hazelett. Today's guest is Dr. Jessica Wertz, a specialty care physician for ANOVA sports medicine. We're here to discuss sports injuries and concussion, helping athletes return to play. Welcome Dr. Wertz. Thank you. Thank you for having me. We're excited to have you here. I know previously you have served as a team physician for Ohio State, McDaniel College, Mount St. Mary's, and you deal with the prevention and management of all types of sports injuries like concussions. I know you engage in osteopathic manipulation, musculoskeletal ultrasound. Talk to me a little bit, if you can, Dr. Wertz, about some of the types of sports injuries you encounter in your practice. Yeah, so we see a wide variety of sports injuries head to toe, literally. So any kind of injury that you can sustain, we see it, but not just sports injuries. We also see arthritis and concussions. We do procedures, ultrasound guided injections, orthobiologics, such as what we can talk about more later, using platelets and stem cells. I work with orthopedic surgeons, so if you need surgery, my colleagues are right here in-house. We try to streamline our care as well, just because everybody works together under one roof. So are you often one of the first points of contact for an athlete who comes in and has some kind of injury? Are you the first person they visit or do they often go to their primary care position and they get referred to you? That's a good question. So unless the patient is aware of our specialty, usually they're going to their primary care or the emergency department or urgent care. And those practices usually will refer to our office. And then we are usually the gatekeepers of the initial injuries coming in and making the diagnosis, evaluating them, making the diagnosis and treatment, and seeing if it is something that needs surgical evaluation or further care. And you're helping make those determinations as far as if they need more advanced special care, if they need to refer to a surgeon or any other kind of specialist. So you're sort of that next kind of thing. Exactly. Exactly. So that kind of decides is it something that I can manage and treat that conservatively without surgical management, or is it something that we need to kind of send on to our surgery counterparts to manage? Yeah, absolutely. And when you see patients coming into your office, how long are they with you? How much time does it take for you to provide a diagnosis and a treatment plan and get them back on their feet to return to play? So the initial visit for a new patient. I typically can take up to 30 minutes in my evaluation and coming up with a treatment plan for them. And it kind of varies injury to injury on how long they continue to see me back for. If it's a very straightforward injury, it could just be a couple visit. If it's something more significant, it could be drawn out over the course of a month. So it just kind of depends. Even though I'm not like your typical primary care position, I don't have regular patients per se. I ultimately do end up seeing patients back regularly because people continue to get injuries and sustain whatever it is, whether it's a degenerative disease like arthritis, I'll end up seeing them at some point down the road because I build that trust with them. And so they know to come back and see me. You mentioned earlier, orthobiologic injections, and I understand that this is really using a person's own biology to help heal them. Can you describe that in a little more detail? Sure. So one of the ones that I use most commonly is called PRP. So PRP is short for platelet-rich plasma. And so essentially what we're doing is we're drawing a patient's own blood and we're spinning it down in a centrifuge and we separate the platelets. We don't draw a lot of blood, which is usually about maybe 15 milliliters of blood. And we tend to get maybe five milliliters of platelets out of that. And we can use that to inject for arthritis, the treatment of arthritis or chronic tendon injuries. And it can also help speed up healing for a lot of patients, even though technically we can't quote that it creates this amazing healing process. We have seen some really great clinical results with our professional athletes all the way down to the elderly patient with arthritis who's trying to put off having a knee replacement. It does create a healing cascade of cell factors to help promote that kind of healing process. It's not going to fix your arthritis, but it may help improve pain and function and get you back to play sooner for those more acute injuries that we see. And then the PRP process is that often used for issues with arthritis and similar symptoms? Or is it a technology that's used for broader purposes? Definitely broader purposes. Like I said, we do even use it on our professional athletes to get them back to play sooner. It does help kind of improve pain and function when an athlete has sustained, for example, a muscle injury or a tendon injury. When we're trying to promote improvement in healing, that healing cascade, we can help kind of use this product in addition to physical therapy rehab to get them back on the field faster. And you also use ultrasound guided injections as well. Talk to me a little bit about this process and what purpose it serves. So using an ultrasound help guide your accuracy of making sure that you get whatever you're injecting or aspirating, making sure that you're not going to enter structures like vessels, nerves, making sure you get what you're trying to accomplish, making sure you get that needle in the right spot. Because if you don't have that ultrasound guidance, you kind of go off your surface anatomy, which is pretty good for the most part. But there have been studies that show using your surface anatomy versus using an ultrasound that obviously ultrasound is going to be more accurate because you can actually visualize the needle going where it needs to go. And you're putting, whether it's steroid or the PRP or your aspirating fluid out of a joint space or wherever, you make sure you're doing what you went into accomplish, and you're not going to injure any other surrounding structures. You can identify the vessels and nerves and make sure that you're not going to hit those structures. It's a pretty amazing, non-invasive process to use ultrasound to really increase the accuracy and reduce further injury and pain and suffering. So it's pretty incredible. Talk to us a little bit about the compartment syndrome. I know this is caused by injury or intense exercise. And it causes swelling and pressure in nerves and muscles, often sports with repetitive movements, like biking, running, and swimming are a particular risk. So how do you encounter compartment syndrome as a particular issue? And what do you do to solve this problem? So there's a difference between acute compartment syndrome and exercise-induced compartment syndrome. And I think the exercise-induced compartment syndrome is one that is commonly misdiagnosed, as, for example, shin splints or stress fractures or muscle injury. And people aren't really aware of it. So I see a handful of these cases every month in my clinic. And oftentimes, these athletes are coming to me with pain and their lower legs just with exercise. And they have been having symptoms for years. And it has gotten to the point where it has prevented them from being able to exercise because the pain is so significant, which can be life-changing for somebody who's young and wants to be active. So when they come into my office, they're usually very frustrated. And a lot of times, there's some to present as pain pressure that they describe as pressure that comes on, usually within 10 minutes, at the same time every time, usually with some sort of running-type activity. Sometimes if they continue to push through the symptoms, they'll get numbness and tingling or weakness in the legs. But it does prevent them from continuing to be active. So we can put them through testing, such as compartment testing, where it's a very large needle that we have to test their pressures in the leg because they get exertional compartment syndrome is, we don't know what causes it exactly. There are a lot of theories out there what causes it. But it basically pulls swelling into the compartment spaces. We have four compartments that house our vessels, nerves, and muscles in our lower legs. And so the fluid gets filled up and increases pressure that puts pressure on the nerves and the vessels and causes the symptoms in the legs. A lot of times, we find that people have tight fascia in the lower legs or large muscles. And it tends to occur in sports that are doing a lot of running-jumping-type activities. But there is a treatment. Ultimately, if people don't improve with physical therapy and retraining the running, sometimes you need surgery. And that's something that we call a fasciotomy, where they basically have to slice open the fascia and release that pressure. But people do really well with those surgeries. Unfortunately, you can have recurrence. But ultimately, a lot of these patients, when it does work, they're very thankful to get back to being active again. Absolutely. Especially if they've been out of commission for a long time and they probably see some relief. Is that relief immediate from this treatment that you provide? So not immediate. They do get some, they won't usually be able to tell for sure how well they will be able to feel until probably about three to four months out when they're able to start progressing back to their running exercise. But they're usually working with physical therapy for the first couple of months. And then they'll gradually progress them to that getting back to running. And they're able to generally progress back pain-free, which is our goal. And I imagine you have a lot of empathy for athletes since you were a Division I college gymnast at the University of Nebraska. A letter winner for the Huskers from 2000 and 2003. You were an All-American on the vault where you posted two perfect pens during your career. Pretty impressive. And I know you suffered some ankle injuries that impacted your ability to compete. So what can you tell us about this personal experience and how this influenced how you practice sports medicine? Yeah, I think the nature of gymnastics, there's a lot of overuse injuries. And unfortunately, I did sustain a lot of ankle tweaks and just wear and tear on my body. I think it kind of caught up with me my last year or two of college. And I had stained a lot of ankle sprains and developed some impingement and bony spurs and ended up having surgery. The nice thing about gymnastics, you got four events. So you can always swing the bars or do other things that are not as impactful. But I think I was happy with my career. And I think having that experience of having an injury like that that ended up in surgery, obviously it wasn't anything major. I think I got away pretty unscathed considering some of my other teammates who had more significant injuries. But just spending the time in the training room and getting to know some of the team doctors and knowing their role with us, really I think played a role in me deciding what I wanted to do as a career. And that influenced your trajectory. So it's interesting with sports medicine because you deal with a lot of things, a lot of injuries but concussions are also very important. And it sounds like maybe that you don't have any personal experience with concussions but you probably had teammates that experienced concussions and certainly you treat athletes who come in with concussions. So talk to me a little bit about how you treat these patients. I know concussion is a bump, blow or jolt that shakes the brain. It's really interesting that you don't even have to have a collision to the head in order to sustain a concussion. So how often are these things going undiagnosed and how do you diagnose them when they come to you for care? Yeah, I think you and I both, when we were athletes and competing I don't think I could tell you what a concussion was. And I think it was something that you could just kind of work through. But now I think the idea of concussion and identifying it and being hyper aware of it is becoming more and more common. And I think that it does go undiagnosed. And I think that it is more prevalent than what we're seeing because people maybe are not educated on what the symptoms are, that's the signs to look for. And I think we're becoming more aware because we are educating people. Obviously the old thought of sitting in a dark room and isolating yourself is, until your symptoms go away is not the best treatment. It actually can make things worse. When you kind of have an athlete who's used to being out there and being social and competing and being active for several hours a day and you put them in a room and you take them away from that environment obviously can create a lot of emotional distress. They feel that self isolation, their self esteem goes down, they fall into depression, they're falling behind in school maybe because they're being held back from school which creates a heightened level of anxiety. Maybe it affects their sleep because they're used to working out two or three hours a day and now they're not even able to exert that energy. So then they're not sleeping well and their mood is gonna be all over the place. So for us it's important to educate the athlete to try to regulate them and get them back to normal as soon as possible ideally within that right after 24 hours as soon as they can tolerate it getting back in a normal routine, sleep, hydration, eating well, starting to exercise and they tend to recover faster with that kind of approach. This is a real change in the way I think many people understand how to respond post concussion. You published an article about the importance of behavioral regulation following concussions. So are these some of the recommendations that you provide to athletes to continue to stay active, keep a regular schedule? What are the recommendations do you provide when they are seeking care post concussion? The, our evaluation and treatment of concussion is so comprehensive that we basically have a team and when you come in to see us for concussion you'll initially see an athletic trainer who will do all the intake of your symptoms and how your injury happened and basically go through all the basics with you of that behavioral modification after your injury, which includes that hydration and sleep and getting back on a normal schedule such as going to bed at the same time getting up at the same time and walking you through your symptoms to see if we need to do any further management such as vestibular therapy. Sometimes there's different types of concussions and there's no two concussions that are alike. So you have to take it on a case-by-case basis and we have a neuropsychologist on staff that comes in and evaluates the patient as well from a psychological aspect, a neuro-behavioral aspect. We do a lot of testing on these athletes and as a medical advisor, if a patient needs a referral for vestibular therapy, if they're having a lot of dizziness or headaches, we have a vestibular therapist on staff to help the patient work through some of their symptoms without using medication. But if it gets to the point where they may need medication, obviously as the medical advisor, I'll come in and kind of guide them through that process as well. So there's, again, every, there's no two concussions that are alike but we kind of take a multidisciplinary approach to kind of take that specific concussion and try to identify which trajectory it's following so that we can treat that specific trajectory, meaning whether it's like a neck and eye issue if there's a lot of mood involvement or vestibular abnormalities that are contributing to their symptoms so that we can kind of hone in on the cause of their symptoms as a result of that concussion. Because a concussion obviously is a very complex pathophysiological process. And it sounds like when a concussion happens, a patient needs to get in front of an educated doctor as soon as possible. But I imagine there are a lot of patients, particularly with a milder case of a concussion or those who live in more rural areas and don't have access to medical professionals, they may not get the care that they need. So what advice do you have for those who don't see a doctor within 24 hours, 48 hours of their initial concussion? What advice do you have for those individuals? So I think, you know, majority of mild concussion injuries actually don't need to be evaluated within that period of time, unless their symptoms are really escalating. For example, if they're really starting to get, you know, significantly nauseous, vomiting, severe dizziness, headaches that are worsening, you know, maybe not controlled with an initial pain medications, although we tend not to recommend long-term pain medications for concussion management. But if the symptoms overall are escalating, then yes, that could be something that's an emergency. We can't rule out like a brain bleed or something like that. And that should be evaluated at the emergency department. But if the symptoms are pretty steady, you know, and that maybe they're just not feeling well, but they're not like getting a worsening headache, you know, or they're not vomiting and feeling just completely miserable, it's certainly something you can kind of sit tight, like, you know, try to get your rest, hydrate, eat well. And generally we like to see them within, you know, a couple of days and not necessarily right away because we kind of want those initial symptoms to kind of calm down, to kind of see where they're at, because sometimes it's hard for us to do the testing we need to do when they're not feeling so hot. And we don't want to make them feel worse by putting them through some of our testing. So I think a general rule is just to kind of see what your symptoms are initially and if they're really getting significant and getting worse, then yes, it's always important to get evaluated at the emergency department. We are fortunate enough to have a concussion hotline so that patients can call that hotline and speak with a nurse or speak with an athletic trainer if they're not sure whether they need to go to the emergency room. And we can walk them through that process. Wow, and is that hotline available 24 hours a day or do they operate during normal business hours? So it is available 24 hours a day. However, during the nighttime hours, I think it cuts off like around nine o'clock. You leave a message and somebody will get back to you first thing in the morning, usually around seven a.m. Even on the weekend, they're available. Wow. I know around 12% of youth athletes sustain concussions and this is a really critical time for youth when their brains are developing. Some of the sports that cause the greatest risk of concussions are ice hockey, tackle football, lacrosse for boys and soccer for girls. Do you notice a trend for certain sports where you treat athletes with greater frequency for concussions? Oh, absolutely, yeah, definitely. I would say football, soccer, wrestling, these are generally the more common sports lacrosse in this area because we see a lot of. So definitely those higher impact contact sports that are going up against the defender, people are being very aggressive, especially in a game situation, we tend to see more of these contact and even non-contact injuries that can occur. Do you notice a pattern for any kind of injuries, not just concussions, but a pattern with males versus females, other types of sports, certain ages? Are there any patterns that you've been able to notice as far as people who are more susceptible to injuries or concussions that you've witnessed in your practice? Yeah, I would say in terms of male versus female, I think we tend to see more female athletes. And I always question why that is, there has been some research done in that area. The thought is, are females more susceptible? Is there a hormonal component or something like that? But also, if you have to take in consideration, females might be more likely to report their symptoms than a male. So, is it just the fact that they're reporting more often their symptoms than a male who might be trying to be tough and push through those symptoms? Cause that's what is expected in our culture. So I think we have to keep that in mind as well in educating, again, athletes and coaches and letting them know that the importance of not continuing to play through symptoms and how it could prolong recovery. And you mentioned that mental health can be impacted through injuries, through concussions and you may have to refer patients out for additional care for their mental health. This multi-care approach can be really, really important in your practice. So, I would imagine that female athletes maybe are more comfortable often making reports of mental health issues as well. Have you noticed that in your care that you've provided? Absolutely. Yeah, I think there's still a stereotype around about mental health. And I think people are used to living in a society that's very high anxiety. And so sometimes people don't recognize the symptoms and sometimes it comes out in a very physical somatic way. And so we have to kind of identify it for them. But I think the trend has been that, you know, not always, but I think females tend to be more attuned with that emotional side and being able to identify what their feelings are. Or at least when we pointed out be more open to that, what they're experiencing and how it might be contributing to how they're feeling. So definitely. And then, you know, using a multi-team approach and managing the symptoms and making sure that you haven't again an educated staff of athletic trainers and coaches and sports psychologist and even a sports psychiatrist, you know, which is an upcoming field of medicine and having a psychiatrist dedicated to just athletes because it is a huge area of mental health that kind of has gone unrecognized. And I think it's coming more to the forefront recently. Absolutely. So either the mental health can impact and increase the injury or the injury can cause the mental health problem that makes it complicated as well. And I know it can be even more difficult for coaches who, when maybe athletes are participating in multiple sports and so they have different coaches, different teams and the coaches aren't aware of the frequency in which they are engaging in training and activity. How complicated is that of a factor if athletes are playing in all these different sports in different places and they may not have that kind of unified team, if you will, that are helping support them and recognize when there's some kind of issue? Well, obviously that can cause a breakdown in communication and as an athlete participating in multiple sports and, you know, nobody's on the same page in terms of their, you know, training and I think the athlete could get lost in the shuffle, you know, and that can create issues for making sure that that athlete has time to recover. It can contribute to burnout, depression, anxiety because they're trying to meet the expectations of all these different coaches and areas of sport because everything in our culture is focused on winning in competition versus, you know, just the skills itself and skill development. And I think that's the key here is that we focus on skill development and not focus always on winning for these athletes and making sure that, you know, everyone who's involved with that athlete, whether it be a multi-sport athlete or an athlete on various levels that we again educate. It's all about education for the athlete and the coaches and everyone involved in the athlete's care. Communication, education, those are all definitely important things. So what final tips would you provide for someone who maybe has sustained some kind of injury? How do they know when they need to seek intervention from a medical professional? So obviously that varies on the injury, but I think if you, for example, sustain an ankle, sprain injury or roll your ankle, obviously if you've tried some icing and rest and elevation and you have a significant amount of swelling, you can't bear weight on it, that certainly should be something that should get evaluated. So things are not getting better in a reasonable time, which I would say if you give it a few days and you don't notice things are heading in the right direction, it's always best to get it evaluated. But again, it depends on the severity of the injury. If you have some significant trauma, obviously you should get that evaluated sooner and not sit on it versus something that may be more minor and you're, you know, give it a few days and if it's not getting better, obviously get it evaluated. Great advice. Thank you, Dr. Woods, for your insight into sports injuries and concussions and helping athletes return to play. Thank you to our viewers for joining us today on the Sports Playbook. In two weeks' time, our guest is Ryan Fitzgerald from Indiana University Bloomington who will discuss collegiate intramural sports. We will see you then. Thank you so much for watching Think Tech Hawaii. 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