Category: Orthopedics
Keywords: hand elevation test, (PubMed Search)
Posted: 6/12/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Hand elevation test
https://www.youtube.com/watch?v=IO2qC5qHVFE
1) Ahn DS. Hand elevation: a new test for carpal tunnel syndrome. Ann Plast Surg. 2001
2) Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012 Nov;52(5):472-5.
Category: Orthopedics
Keywords: Epidural abscess, back pain, vertebral osteomyelitis (PubMed Search)
Posted: 5/8/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Both erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are highly sensitive (84-100%) for spinal infections and are observed in >80% with vertebral osteomyelitis and epidural abscesses.
ESR
Most sensitive and specific serum marker, usually elevated in both spinal epidural abscess (SEA) and vertebral osteomyelitis.
ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)
CRP
Not highly specific
Less useful for acute diagnosis since CRP levels rise faster and return to baseline faster than ESR (elevated CRP seen in 87% of patients with SEA as well as in 50% of patients with spine pain not due to a SEA)
Better used as a marker of response to treatment.
1) Colip CG, Lotfi M, Buch K, Holalkere N, Setty BN. Emergent spinal MRI in IVDU patients presenting with back pain: do we need an MRI in every case? Emerg Radiol 2018;25:247-56.
2) Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011;14:765-70.
Category: Orthopedics
Keywords: SEA, ESR, spinal infection (PubMed Search)
Posted: 4/24/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Erythrocyte sedimentation rate (ESR) for spinal infection
Sensitive for spinal infection but not specific
Elevated ESR is observed in greater than 80% of patients with vertebral osteomyelitis and epidural abscess
ESR is the most sensitive and specific serum marker for spinal infection
Usually elevated in acute presentations of SEA and vertebral osteomyelitis
ESR was elevated in 94-100% of patients with SEA vs. only 33% of non-SEA patients
Mean ESR in patients with SEA was significantly elevated (51-77mm/hour)
Infection is unlikely in patients with an ESR less than 20 mm/h.
Incorporating ESR into an ED decision guideline may improve diagnostic delays and help distinguish patients in whom MRI may be performed on a non-emergent basis
1) Davis DP, et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011;14:765-767.
2) Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000;23:175,204
Category: Orthopedics
Keywords: Concussion, mTBI, exercise prescription (PubMed Search)
Posted: 4/10/2021 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
A total of 367 patients were enrolled. Median age was 32 years Male 43%/Female 57%.
Result: There was no difference in the proportion of patients with postconcussion symptoms at 30 days. There were no differences in median change of concussion testing scores, median number of return PCP visits, median number of missed school or work days, or unplanned return ED visits within 30 days. Participants in the control group reported fewer minutes of light exercise at 7 days (30 vs 35).
Conclusion
Prescribing light exercise for acute mTBI, demonstrated no differences in recovery or health care utilization outcomes.
Extrapolating from studies in the athletic population, there may be a patient benefit for light exercise prescription.
Make sure that the patient is only exercising to their symptomatic threshold as we recommend with concussed athletes. Previous studies have shown that athletes with the highest post injury activity levels had poorer visual memory and reaction time scores than those with moderate activity levels.
Varner et al. A randomized trial comparing prescribed light exercise to standard management for emergency department patients with acute mild traumatic brain injury. Acad Emerg Med. 2021.
Category: Orthopedics
Keywords: Distal radius fracture, wrist, splint (PubMed Search)
Posted: 2/27/2021 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Home management versus PCP follow-up of patients with distal radius buckle (torus) fractures
A recent study investigated outcomes of patients with distal radius buckle fractures who were randomized to
Versus
Noninferior study
Torus/buckle fractures of the distal radius are the most common fractures in childhood occurring on average in 1 in 25 children
This is a stable fracture typically treated with removable wrist splint and very rarely require orthopedic intervention
Outcome: functional recovery at 3 weeks
Randomized controlled trial at a tertiary care children’s hospital
All radiographs reviewed by pediatric radiologist with MSK specialization
149 patients. Mean age 9.5 years. 54.4% male
Telephone follow-up at 3 and 6 weeks following ED discharge by blinded interviewer
Primary outcome was comparison of Activities Scale for Kids-performance scores between groups at 3 weeks
Outcomes: Home management performance score was 95.4% and PCP follow-up group was 95.9%. Mean cost savings were $100.10.
Conclusion: Home management is at least as good as PCP follow-up with respect to functional recovery in ED patients with distal radius buckle fractures.
Colaco et al. Home management versus primary care physician follow-up of patients with distal radius buckle fractures: A randomized controlled trial. Ann Emerg Med. 2021
Category: Orthopedics
Keywords: diabetes, exercise, weight loss (PubMed Search)
Posted: 2/13/2021 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
What time of day is best for exercise to achieve weight loss goals?
Working out in the morning has traditionally held the edge, especially if done on an empty stomach.
Upon walking, elevated levels of cortisol and GH will aid in fat metabolism.
Switching to a morning workout may also decrease appetite throughout the day.
Morning exercise may also induce significant circadian phase?shifting effects. Patients report feeling more alert in the morning and get more tired at night. This may “force” people to get increased rest as poor sleep quality and duration has been associated with weight gain.
Moderate intensity aerobic exercise has been shown to cause immediate mood improvement and mental productivity. These effects can last up to 12 hours and may be a simple aid to combat job stress.
However, a recent small study looked at this question with a group of men at high risk for Type 2 diabetes.
Those that exercised in the morning had better blood sugar control and lost more abdominal fat than those who exercised in the morning.
Study: 32 adult males (58 ± 7 years) at risk for or diagnosed with type 2 diabetes performed 12 weeks of supervised exercise training either:
In the morning (8.00–10.00 a.m., N = 12) OR
In the afternoon (3.00–6.00 p.m., N = 20)
Test: Graded cycling test with ECG monitoring until exhaustion
Results: Compared to those who trained in the morning, participants who trained in the afternoon experienced superior beneficial effects of exercise training on peripheral insulin sensitivity, insulin?mediated suppression of adipose tissue lipolysis, fasting plasma glucose levels, exercise performance and fat mass.
Conclusion: Metabolically compromised patients may benefit from shifting their exercise routine to the afternoon from the morning. Ultimately, any exercise is great in this population, but this study may be worth sharing to your patients.
Mancilla R, Brouwers B, Schrauwen-Hinderling VB, Hesselink MKC, Hoeks J, Schrauwen P. Exercise training elicits superior metabolic effects when performed in the afternoon compared to morning in metabolically compromised humans. Physiol Rep. 2021 Jan;8(24):e14669.
Category: Airway Management
Keywords: Myocarditis, Covid-19 (PubMed Search)
Posted: 1/23/2021 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Exercise and Covid-19
The majority of COVID-19 cases fall into the mild-to-moderate category, with symptoms lasting less than 6 weeks on average.
The disease presents a challenge for clinicians seeking to offer counsel for patients wishing to return to exercise.
A recent cohort study in Germany looked at 100 patients (avg. age 49, 53% male) who had recovered from Covid-19 infection.
Most had been healthy, with no pre-existing medical conditions, before becoming infected.
The group had cardiac MRI (CMR) performed.
Average time interval between Covid-19 diagnosis and CMR was 71 days.
Cardiac involvement was seen in 78% of patients and ongoing myocardial inflammation in 60%.
Evidence based return to activity guidelines being developed are more conservative than in the past with other viral infections
https://link.springer.com/article/10.1007/s11420-020-09777-1/tables/1
1) Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265–1273. doi:10.1001/jamacardio.2020.3557
2) Metzl, J.D., McElheny, K., Robinson, J.N. et al. Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete. HSS Jrnl 16, 102–107 (2020).
Category: Orthopedics
Keywords: tendon, antibiotics (PubMed Search)
Posted: 1/9/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
A recent retrospective observational study looked at the association of oral antibiotics (primarily fluroquinolones) and tendon rupture.
Outcome data is very interesting for our practice, deviates from traditional teaching.
Population: 1 million Medicare fee for service beneficiaries from 2007-2016 (>65 years old)
Antibiotics queried: Seven total oral antibiotics of mixed class:
Outcome measures: all combined tendon ruptures and 3 by anatomic site (Achilles, rotator cuff {RC} and other)
Results: Of the 3 quinolones, only LEVOfloxacin showed a significant increase in risk of tendon rupture (16% for RC) and (120% for Achilles) in a 1 month window. The others did not show an increased risk
Among the other antibiotics, cephalexin showed an increase risk across all anatomic sites.
The authors note that the risk with levofloxacin never exceeded the risk of cephalexin in any comparison!
Baik S, Lau J, Huser V, McDonald CJ. Association between tendon ruptures and use of fluoroquinolone, and other oral antibiotics: a 10-year retrospective study of 1 million US senior Medicare beneficiaries.
BMJ Open. 2020;10(12):e034844. Published 2020 Dec 21.
Category: Orthopedics
Keywords: Hip pain, snapping hip, tendon (PubMed Search)
Posted: 12/27/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Chief complaint: “My hip snaps when I exercise”
Both athletes and non-athletes may report a “snapping” sound with certain movements
This may affect up to 10% of the population
May be associated with activities than involve repetitive hip flexion
Symptoms may be due to an internal or an external cause
External causes are usually due to a tendon passing over a bony prominence
This can be felt as either an audible sensation and/or even a palpable snap
This may or may not involve pain or discomfort
This is most commonly due to a benign cause
During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.
Alternatively, the hamstring tendon may pass over the ischial tuberosity
There are several other causes with similar mechanisms
Symptoms are usually minimal and not serious
This can be reproduced on bedside clinical exam
Ask the patient to identify the area of snapping with one finger which will help with anatomic localization
First line therapy is physical therapy which focuses on:
Improving muscle length if muscle is too tight OR
Improving neuromuscular activation if problem is due to excessive muscle activation
Category: Orthopedics
Keywords: Balance, mBESS, concussion (PubMed Search)
Posted: 12/12/2020 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested.
This test is not very sensitive overall, but especially in concussed athletes.
Many concussed athletes are able to stand relatively stable despite their neurologic injury.
In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).
A) Romberg
B) Single leg stance
C) Tandem Stance
Have patient stand quietly with hands on hips
Have patient close eyes and start 20 second trial
If error occurs tell patient to return to start as quickly as possible
Examples of errors: opening eyes, lifting hands, falling out of position
Category: Orthopedics
Keywords: Shoulder, biceps, tendon (PubMed Search)
Posted: 11/28/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
A 25 year old athlete presents to the ED with right anterior shoulder pain.
Pain radiates into proximal biceps.
It is worse with heavy lifting and especially “pulling” exercises at the gym.
How do we evaluate for biceps tendonitis?
Pathology is often the long head of the biceps
https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg
Start by palpating this area and attempt to reproduce the discomfort
Speed’s test
Yergason’s test
Category: Orthopedics
Keywords: Elbow, dislocation, instability (PubMed Search)
Posted: 10/25/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Ulnar Collateral ligament injuries of the elbow
Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow
This can lead to valgus instability similar to what can occur in the knee
Overhead throwing places a significant valgus stress on the elbow
Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports
In the acute setting may be seen after an elbow dislocation
History includes a “pop” and medial elbow pain following throwing activities
In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.
The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion
One classic test for UCL instability is the milking maneuver
Patient may be sitting or standing
Patient’s forearm is supinated and elbow flexed at 90 degrees
A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line.
Instability, pain or apprehension at the UCL is considered a positive test
https://www.youtube.com/watch?v=gbn24X_qqn0
Category: Orthopedics
Keywords: Carpal Tunnel Syndrome, neuropathy (PubMed Search)
Posted: 10/10/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Carpal Tunnel Syndrome (CTS)
The hallmark of classic CTS: pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.
The symptoms of CTS are typically worse at night and often awaken patients from sleep.
Fixed sensory loss is usually a late finding
Involves the median-innervated fingers BUT spares the thenar eminence.
This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.
Consider a more proximal lesion in cases involving sensory loss in the thenar eminence
Example: pronator syndrome
Category: Orthopedics
Keywords: Elder abuse, bruising, trauma (PubMed Search)
Posted: 9/26/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Physical injury patterns associated with physical elder abuse
Elder abuse is both common and underrecognized
Between 5 and 10% of US older adults are victims of elder abuse annually
For many older adults, contact with a health care provider may represent their only contact outside the home
Differentiating physical elder abuse from unintentional trauma can be very difficult
A recent study compared these two groups with a case-control design
Study cases: 100 successfully prosecuted physical elder abuse cases from a single urban ED
Physical abuse victims were more likely to have:
Bruising (78% vs. 54%)
Injuries to maxillofacial, dental or neck region (67% vs. 28%)
Particularly the LEFT side
Neck injuries 6x more common is assault
Ear injuries occurred in assault but not in falls
Absence of fracture (8% vs. 22%)
Less likely to have lower extremity injuries (9% vs. 41%)
22% of victims had no visible injuries
Most common mechanism assault with hands or fists and pushing or shoving causing a fall
Take home: Consider elder abuse especially in cases of the above red flags
Rosen T, et al. Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Ann Emerg Med. 2020 Sep;76(3):266-276.
Category: Orthopedics
Keywords: Spine fracture, decision rule (PubMed Search)
Posted: 9/12/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
A recent study looked at thoracic spinal fractures in the era of the trauma panscan
NEXUS Chest CT Study from 2011 to 2014 at 9 Level I trauma centers.
Goal: To describe the identification rate and types of thoracic spine fractures.
Inclusion: age over 14 years, blunt trauma occurring within 6 hours of ED presentation, and chest CT imaging during ED evaluation.
11,477 subjects, 217 (1.9%) had a thoracic spine fracture
The majority of spine fractures in patients who had both chest x-ray and CT were observed on CT only (91%). 50% had more than 1 thoracic spinal level involved (mean 2.1). 22% had associated cervical fractures and 25% had associated lumbar fractures.
64% had vertebral body fractures
45% had posterior column fractures
28% had compression fractures
6% had burst fractures
Many patients (62%) had associated thoracic injuries such as
Rib fractures (45%)
PTX (36%)
Clavicle fracture (18%)
Scapular fracture (17%)
Hemothorax (15%)
100 patients had clinically significant thoracic spine fractures.
Thoracic spine fractures are relatively uncommon in adult patients with blunt trauma.
If thoracic spine fracture is suspected clinically, radiography is not an effective screen and clinician should consider CT. If not suspected, guidelines discourage ordering CT to screen for this injury because of effective screening instruments, the diagnosis of clinically insignificant injuries and radiation exposure.
All clinically significant thoracic spine fractures would have been detected by the NEXUS Chest CT decision instrument.
https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging
Bizimungu R, Sergio Alvarez, Baumann BM, et al. Thoracic Spine Fracture in the Panscan Era. Ann Emerg Med. 2020;76(2):143-148.
Category: Orthopedics
Keywords: Elbow, fracture, ultrasound (PubMed Search)
Posted: 8/12/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Diagnostic performance of Ultrasonography for detection of pediatric elbow fracture
Elbow fractures account for approximately 15% of pediatric fractures
Fat pads are traditionally taught as a marker of fracture
In a cadaveric study:
Elbow effusions of 1-3 mL could be identified with ultrasound
Elbow effusions of 5-10 mL could be identified with plain film
Pediatric plain films are sometimes challenging to obtain and interpret compared to adults
-More likely to be uncooperative in obtaining required views
-Non-ossified epiphyses
Ultrasound may be used to detect
-Cortical disruption and irregularity
-Growth plate widening
-Hematoma interposed between fracture fragments
-Elevated posterior fat pad
Absence of elbow fracture was indicated by
-Lack of cortical disruption
-Absence of posterior fat pad sign
Meta-analysis of 10 articles totaling 519 patients using ultrasonography to detect elbow fractures
Sensitivity 96%
Specificity 89%
False negative rate 3.7%
For comparison, plain radiographs
Interpreted by peds EM physicians (87.5% sensitive and 100% specific)
Interpreted by radiology (96% sensitive, 100% specific)
Consider using ultrasound as a noninvasive, radiation-free modality for accurate diagnosis of pediatric elbow fractures.
Lee SH, Yun SJ. Diagnostic Performance of Ultrasonography for Detection of Pediatric Elbow Fracture: A Meta-analysis. Ann Emerg Med. 2019;74(4):493-502.
Category: Orthopedics
Keywords: Peripheral neuropathy, median nerve (PubMed Search)
Posted: 8/8/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Pronator Teres Syndrome
A compressive neuropathy of the median nerve in the region of the elbow
The median nerve passes through the cubital fossa and passes between the superficial and deep heads of the pronator teres muscle.
Rare compared to other compressive neuropathies such as carpal tunnel syndrome.
More common in women and in fifth decade of life
May be seen with weight lifters, arm wrestlers, rowers, tennis, archery, professional cyclists, dentists, fiddlers, pianists, harpists
Also associated with well-developed forearm muscles
History:
Forearm pain – unlike carpal tunnel
Paresthesias in median distribution
No night symptoms – unlike carpal tunnel
Physical exam:
Sensory loss in medial nerve distribution.
Involves the thenar eminence!
Unlike carpal tunnel syndrome which doesn’t involve sensory loss in thenar eminence.
Pain may be made worse with resisted forearm pronation
Compression/Tinel’s sign over pronator mass reproduces symptoms
Treatment:
Splinting which limits pronation and NSAIDs
Steroid injection
Surgical nerve decompression is non operative treatment fails after greater than 6 months (rare)
Category: Orthopedics
Keywords: carpal tunnel syndrome, neuropathy, (PubMed Search)
Posted: 7/11/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Treatment for carpal tunnel syndrome (CTS)
The management of CTS depends of the severity of the disease
If symptoms or on the mild to moderate range, a trial of conservative treatment is encouraged.
Possible therapeutic approaches can include splinting in wrist neutral position. Some even extend to keep the CMP joints extended. Extreme flexion and extension can increase pressure within the carpal tunnel. Usually for nighttime use only. May be used during day based on work and activity demands.
Has been shown to improve electrophysiologic findings after 12 weeks of use in moderate CTS.
Formal hand physical therapy (by an experienced therapist) may also be of some benefit including carpal bone mobilization, ultrasound and nerve glide exercises.
There is small evidence for the benefit of prednisone (20mg/d) as it has been shown to be more effective than placebo with improvements lasting an average of 8 weeks.
There is no benefit to NSAIDs or diuretics.
There is poor evidence for therapeutic ultrasound and acupuncture.
While more invasive than the above modalities, steroid injections may decrease inflammation and pressure in the carpal tunnel. Patients randomized to steroid injection may do better than those randomized to nighttime splinting.
Early referral in those with positive electrodiagnostic findings is encouraged as they do best with earlier surgical release and have better recovery.
If however the patient has severe, progressive or persistent symptoms or there is known evidence of nerve injury on diagnostic testing, referral for surgical decompression is warranted.
Category: Orthopedics
Keywords: Sickle cell trait, exertional death (PubMed Search)
Posted: 6/13/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Sickle cell trait (SCT) is common and often overlooked clinically
-7.3% African Americans
-0.7% Hispanics
-0.3% Caucasians
SCT is a leading cause of exertional death in athletes who play football
The exact mechanism is unknown but likely involves a combination of high intensity exercise, dehydration, heat strain and inadequate opportunity for cardiovascular recovery leading to microvascular erythrocyte sickling.
This leads to hypoxia, cell death, hyperkalemia, and death from arrhythmia.
Presentation often involves rhabdomyolysis and exertional collapse.
In August of 2010 the NCAA enacted legislation requiring documentation of SCT status of all Division 1 athletes (2012 for Division 2 and 2014 for Division 3)
They also mandated education, counseling and issued guidelines for proper conditioning
Sudden death in athletes with SCT was first observed in military recruits in 1970.
Death in African American military recruits was 28 times more likely in those with SCT than in those without.
A 2012 study of football athletes found the risk of exertional death to be 37 times higher in athletes with SCT than in those without.
Despite game/competition situations being more intense, deaths occur almost exclusively during practice and conditioning drills.
Following the 2010 legislation, there has been a 89% decrease in death from SCT in NCAA D1 football.
Workout plans need to account for heat/humidity, the athletes level of conditioning and allow for adequate rest, recovery, hydration. SCT screening is only part of the solution.
Buchanan et al., 2020. Sudden Death Associated With Sickle Cell Trait Before and After Mandatory Screening. Sports Health.
Category: Orthopedics
Keywords: Concussion, musculoskeletal, injury, lower extremity (PubMed Search)
Posted: 5/23/2020 by Brian Corwell, MD
(Updated: 2/18/2025)
Click here to contact Brian Corwell, MD
Post concussion musculoskeletal injuries
Sport related concussion (SRC) impairs numerous functions of the CNS.
Traditional research has focused on risk of repeat concussion following clearance and return to sport
Several studies have shown a consistent elevated risk of lower extremity injuries from 90 days up to one year following SRC.
These include lateral ankle sprains and ACL injuries. Risk ranges, 1.3-3.4x.
This risk may be greater in those with multiple concussions.
This elevated rate has been seen in populations ranging from high school, college to professional athletes and has also been seen in the general population.
Persistent neurological deficits in cognitive and postural control, stability and gait deviations have been postulated as potential mechanisms.
These may be potential modifiable risk factors before return to play/activity. This may be a role best served by sport physical therapists to assist with sport specific rehabilitation post concussion.