Ask The Doctor Answers

Answers for the 2010-11 Season


Question #3
Name: Karen
Question: What is the best treatment for a severely jammed thumb?

Karen,

Thanks for your question.  The injury treatment depends on the severity and type of injury.  If there is no fracture to the bone then the injury is likely a sprain of the collateral ligaments that stabilize the thumb at the attachment to the hand.  We call this the MCP joint.  The most common injury is a sprain of the Ulnar Collateral Ligament.  Sprains are graded on a scale of 1-3 with one being a stretch of the ligament, two being a partial tear, and three being a complete tear of the ligament. 

Grade 1 sprains are not serious but still take time to heal.  There is no instability to the joint and some rest and brief immobilization may be necessary.  Your doctor may also give you an anti-inflammatory such as Naproxin, Ibuprofen, Voltarin, or any number of other medications.  These can be either oral medications or topical creams.

Grade 2 sprains require a bit more care and protection.  Partial tears will require a bit more time to heal and should be immobilized to prevent further or re-injury while that healing process takes place.  Typically we may splint this type of injury for 3-4 weeks and then begin the rehab process.  Your doctor may keep you splinted longer depending on the severity of injury and how stable your thumb is after this initial time.  All in all you may need some sort of support for up to six weeks.  When returning to activity or sports I would also recommend some added support early on in the process.

Grade 3 tears are the most serious and indicate a complete rupture of the ligament that causes chronic instability, weakness, and eventually arthritis in the joint.  This type of injury would require a surgical fix in most cases.   The recovery time will range from 6-8 weeks.  Usually at around six weeks the splinting is removed and the rehab process begins with range of motion exercises initially and moving to strength exercises as indicated by the physician and therapist. 

For sports how we determine if a player can play again really depends on his sport and position.  If the athlete is a hockey player for example, is it his top hand or bottom hand?  Can we modify his glove to fit a playing cast?  Is he comfortable using it and playing with that limitation?  For others such as quarterbacks, is it his throwing hand?  These are all questions and variables that will be discussed with the athlete, physician, and athletic trainer to come up with the best plan on a case-by-case basis.

I hope this answered your question and as always consult your physician for continued help or come see us at Valley Orthopedic Associates and we will be more than happy to help you with your injury.

Sincerely

Dr. Michael Allison, MD, MPH
Phillip Varney, MA, ATC, AT/L


Question #2
Name: Laurie
Question: With the new focus on the dangers of recurrent brain injury, what is your protocol for returning a skater to play after concussion?

Laurie,

This is an excellent question and a very timely one with all the changes in head injury treatment in the last few years.  I think we can expand on this a little and hopefully make this a bit educational as well as practical without rambling on forever!  The first thing we need to understand is what a head injury is and what it looks like practically for a parent or coach as far as treatment and recognizing a problem.

A concussion is the result of trauma to the brain caused by direct or indirect impact.  Medical professionals do not universally agree upon the definition of concussion, however, the trauma to the brain causes in most cases more of a functional impairment rather than visible physical damage. What that means is that most concussed people show no damage on CT or MRI scans.  They, on rare occasions, can cause a bleed in the brain and this must be treated immediately to prevent or minimize serious damage or death.  Also, we have learned that repeated concussions over the course of a career can lead to the degeneration of the brain and cause what would be comparable to Alzheimer’s, cause chronic depression, or other mental health diseases.  There is also Post Concussion Syndrome which can result in the continuing of symptoms past the normal healing time, and Second Impact Syndrome which occurs when an initial injury is not treated or properly healed and another hit occurs causing severe damage and/or death.

What we should watch out for when diagnosing and treating concussion are those functional impairments both subjective (what they can describe to you verbally about what they feel) and objectively (what we can see and measure).  This will allow us to assess the severity and evaluate the progression of healing.

When injured a concussed person may display one or more of the following:

•           Headache
•           Drowsiness
•           Memory Loss
•           Loss of Consciousness
•           Irritability
•           Confusion
•           Balance Loss/Dizziness
•           Speech Impairment
•           Depression
•           Nausea/Vomiting
•           Change in Sleep Habits
•           Decreased Reaction Time
•           Dilated Pupils
•           General Slowness
•           Sensitivity to Light
•           Decreased Motor Function
•           Vision Problems

These are the most common symptoms and should help you recognize a problem.  Usually these symptoms go away within a week to ten days of the injury.  However, this is not always the case and these symptoms may last much longer.

In Washington we have a new law in place that requires any youth athlete to be evaluated by a physician or athletic trainer before being allowed to return to play when there is a suspected concussion.  When we evaluate a player on the sideline or in the locker room, we are looking at all of these things.  A symptomatic athlete may NEVER return to play.  If a player’s symptoms do not last more than 20 minutes we have them perform an exertion test to raise their heart rate and increase pressure in the head. If the athlete remains asymptomatic then they may return to play if we are satisfied that no injury is present.  If symptoms persist or return at any point the athlete is removed from play for the remainder of the competition and must complete the full return to play protocol.

To answer your question about what that process looks like for our team, we follow a graduated return to play protocol based on the latest research in concussions and is mandated by the league.  We do pre-injury testing to develop a baseline for evaluation using a computer program called Impact.

This data measures reaction time and mental processing and gives us a tool to evaluate the function of the brain that we cannot see.  This is evaluated by a Neuro-psychologist and our team physician and is done within the first 48 hours after injury.  This is treated as a symptom and must be comparable to the pre-injury test before they can return to physical exercise.

Once a player shows no symptoms and has passed his Impact test, he may start our return to play protocol.  This is a five day process that gradually increases the workload of the athlete to make sure proper healing has taken place and allows us to ease the brain into normal athletic participation. The first day is 30 minutes of biking at a steady and moderately stressful pace.  The next day is a conditioning skate by himself for about 30 minutes.  Day 3 involves the athlete participating in practice without contact.  If there has been no return of symptoms the athlete will be allowed to practice with contact.  If he is able to complete this task he may be cleared to play by the medical team.  If at any point he feels or we see a return of his symptoms the task is stopped and he will be allowed to repeat it the next day.  If symptoms remain present more rest will be required.

This is our basic treatment plan for an athlete with a head injury. However, we will change this based on the history and severity of the athlete’s concussion.  This would be a guideline for an athlete with a simple concussion with no history of injury previously.  Every athlete and injury is different and requires the care and attention of qualified medical professionals.  If you suspect that a concussion has taken place we go by a motto of “When in doubt, sit him out.”  Then get him or her to see a doctor who is familiar with concussions and the treatment of it.

Thank you for your question Laurie and we hope to see you at a T-Birds game sometime soon.

Sincerely,

Dr. Michael Allison, MD, MPH
Phillip Varney, MA, ATC, AT/L

 

Question #1
Name:
George
Question:  I have developed severe "lace bite" on both ankles.  I can't even tie my skates anymore it is so painful. What can I do? I am not able to play hockey anymore because of this.

George,

Lace Bite is a common problem for hockey players.  It is an inflammation of the extensor tendons of the foot.  Irritation also may occur over the ankle bones on medial and lateral sides of the ankle but this would not be considered a true lace bite injury.  The cause of the inflammation is usually related to your skates.  The tongue and/or ankle padding has worn down and the laces and/or boot rub on the tendons on the top of the foot and ankles bones.  This causes pain and swelling.  The treatment for this is usually ice and oral or topical anti-inflammatories.  I recommend icing for 15-20 minutes 3 times per day.  Your physician should be able to provide you with anti-inflammatories to reduce the swelling in the tendons.  The next step once it is calmed down is to address the skate.  Is the padding in good shape?  We use a product called a Bunga pad which has a silicone gel that covers the area to provide some cushioning and reduce friction.  Also look at the fit of the skate, especially if they are new.  Using un-waxed laces will also decrease how much the lace bites into the tongue.  If you have the ability, you can try a double thickness tongue that will provide more cushion.  Let your skates dry after each use because wetness can affect this injury.  This can take a couple weeks to really heal, but if you address all those issues you should see some positive results.

Michael Allison, M.D., MPH
Dr. Allison is committed to managing occupational and musculoskeletal problems, as well as preventive medicine. He is dedicated to helping his patients maintain superior health and fitness levels despite any injury or disability. Dr. Allison practices at Valley Orthopedic Associates’ Renton clinic. For more information on Dr. Allison click .