Thursday, August 25, 2011

King Devick Test to Predict Concussions

I was reading an article online regarding current concussion management, and an interesting advertisement displayed on the side of my screen.  It read "King Devick Test: Eye Test for concussions!"   I hadn't heard of it.  So began the search. Unlike ImPact, or other assessment tools, it is designed to be administered directly on the sideline.  The big selling point to ATC's: it only takes 2 minutes to administer.
Basically, it begins with administering a baseline to the athlete prior to athletic competition (this is similar to others) to be sure you are directly comparing themselves with, well, themselves.
After that, when you have an athlete on the sideline you are concerned about, you can use a card (or an IPad or laptop) in which the athlete has a set amount of time to read a series of numbers which are connected by arrows in a left to right fashion, and then downwards.  To view a demo card,which likely shows you better than I can explain, click here.  A more detailed description can be found here:

Surprisingly, this test isn't all that new.  It has been used for the past couple of decades to evaluate eye movements and reading difficulties.  It was originally developed to evaluate  saccadic eye movement.  Saccadic basically means fast, voluntary eye movements.  For more detail on how this relates, check out this fantastic explanation .here.

Moreover, the test has some early applicable data attached to it.  The American Academy of Neurology recently published a study in which it was used on boxers and MMA fighters, and their study showed that it had a high accuracy rating.  Although, the authors fully disclose that in order for it to be utilized more widely in athletics by athletic trainers, both interrater and test-retest reliability need to be further examined.  It should also be noted that one of the researchers is Dr. Devick, a developer of the test itself. 

One last bit, it's not free. The test costs anywhere from $45-$1750 per year, which some may balk at.  I challenge this initial thought.  At what point is a test of this importance too expensive?  Think of how ImPact has revolutionized concussion assessment.  We are at a point where we need to start looking at preventative measures and diagnostic procedures closely, and weighing that against the more long term effects/costs of brain injury.

It will be interesting to see if/when this is integrated into current concussion management on the sidelines.  So check it out, and decide for yourself!

Wednesday, August 24, 2011

Ironman 70.3 Follow Up

Big congrats to Renee for finishing her first 70.3, and judging by the way she feels, I'm guessing it won't be her last.   We also got a great pic from a very gracious Chrissie Wellington, who won the women's race (and beat most of the men).  This was an amazing event to witness; approximately 2100 competitors in the field and a true testament to mind over body. 

Also of note, local triathlete Mike Caiazzo finished second overall in the men's race.  Check out his blog, located at

Thursday, August 18, 2011

Off to the Timberman Ironman 70.3!

Today we leave for the Timberman Ironman 70.3 in beautiful Gilford, NH.  My wife will be attempting her first half-Ironman, which is a 1.2 mile swim, followed by a 56 mile bike, and concluding with a 13.1 mile run.

We are partaking in all of the pre-race activities, and hope to meet up with 3 time World Ironman Kona champion Chrissie Wellington.   FMI on her, check out her website here.

So here's a GREAT VID that really captures the spirit of these amazing endurance athletes.  There are some incredible aerial shots in here as well.  Hope you enjoy.

Monday, August 15, 2011

Posterior Tibialis Irritation

This is an injury which continues to annoy me as a clinician.  At it's worst, it requires prolonged immobilization and/or surgery.  In the physically active population, it can be a nuisance for those who experience pain and discomfort, yet can still perform a portion of their activities.
The Posterior Tibialis Tendon (PTT) is an interesting structure which runs along the medial and posterior aspect of the lower leg.  It originates on the lateral aspect of the posterior component of the tibia, runs posteriororly just behind the tibia, and snakes down behind the medial malleollus where it inserts on the navicular tuberosity.  I should note here that most muscles/tendons have multiple attachment points, however I am listing the major areas of  attachment for ease.  This places it in the posterior compartment, along with the flexor digitorum longus and flexor hallucis longus (taught to many of us as the group acronym  Tom, Dick and Harry or TDH for Tib Post, Digitorum and Hallucis; get it?) Due to it's location, it has a notorious reputation for having a poor blood supply, thereby inhibiting it's ability to heal.  It's prime functions include providing medial ankle stability, inverting and plantaflexion.  The main concern here is a fallen medial longitudinal arch; and we all know that a "flat foot" or pes planus is associated with lots of other issues.  Avoid it at all costs.

The main issue for athletes here is that immobilization or surgery might not be an attractive option.  So how to manage?  Well, for this you can travel down several paths.
It's used for a reason; RICE.can work well.
Rest when you can; get off your feet for awhile.  You might be bored, but do you want to get better or what?
If effused, ice and elevate.  But do it the right way; after combining icing and elevating simultaneously for a period of time (a topic for another blog, lots of schools of thought on this, but 20 minutes is  a good starting point) take the ice off and keep the lower leg elevated for another 30 minutes.  That's right.  Lie down for an hour; keep the limb above the athlete's heart; remember that even while sitting effusion will have to work against gravity.  Repeat several times daily.
I have seen a variety of supportive taping and bracing options work; from kinesio tape running directly over the PTT, to a Low Dye arch taping technique, to simply inserting an over the counter orthotic with a slightly pronounced arch to help maintain natural foot shape. 
If NSAIDS are your thing, then they can take over the counter ibuprofen per the label; or see your team physician for something stronger.  I say this with the utmost caution though; it is a medication and should be used carefully.  I have seen an increase in the topical anti-inflammatories (Voltaren is one brand) recently, as well as the advent of Arnica Gel.
Lastly, if you have access to a walking boot; get your athlete in one.  They can wear it to help adequately rest the PTT, as the rigid or stiff sole will aid in limiting motion.  It's not uncommon to see athletes walking around in boots, in order to conserve for game day competition. A regimen of eccentric exercises can also help aid in balancing out immobilization and activity.
Remember to evaluate the other foot prior to making modifications.  As I remind students; Always compare bilaterally!

Wednesday, August 10, 2011

Intersection Syndrome or DeQuervain's?

I love it when former alums swing by my office to chat.  I really enjoy hearing the clinical cases they've come across as professionals and how they've handled them.  Last week, Rob Brookes, an ATC currently working summer camps in between his graduate assistant responsibilities, stopped by and during conversation mentioned how he came across a lacrosse athlete who suffered a direct blow to the forearm, and suffered consequent pain and "creaking" in his distal forearm.  The diagnosis: Intersection Syndrome.  While this condition can be caused by an acute trauma, it is often seen as an "overuse injury" (think rowers/weight lifters).   Now comes the interesting part...I searched through the index of my AT texts looking for this particular term, and could not find it. Anywhere.
Curiosity piqued, I turned to the internet.
Pain is exhibited along the "thumb line" on the lateral aspect of the distal wrist (remember lateral, because we're describing it in the anatomical position.  It can easily be confused for DeQuervain's Syndrome, which is usually diagnosed utilizing Finkelstein's Test, seen here.

The main difference between the two is location of discomfort.  In the case of Intersection Syndrome, pain is more proximal to the wrist whereas in DeQuervain's, pain would be a bit more distal to the thumb.  Anatomically, the difference between the two can be explained as follows:
Intersection:  Inflammation at the intersection of both the extensor carpi radialis brevis and longus, as well as the abductor pollicis longus and extensor pollicis brevis.
DeQuervain's: Inflammation of either/both abductor pollicis longus and extensor pollicis brevis.

This video, which seems to be shot in an ER, does and excellent job of briefly but accurately describing the malady as well is offering a clinical differentiation  between DeQuervain's and Intersection.
An interesting clinical differentiation which can help make us all a more effective health care provider!

Wednesday, August 3, 2011

Proper Bicycle Fitting

Fresh off a great trip to the Dominican Republic, I was greeted by my wife who is in the midst of training for the Timberman Ironman 70.3 in a few weeks.  My welcome back included a reluctant trip to the local bike shop, where she has been mulling switching from her Specialized road bike to a true tri-bike.  What an interesting trip it turned out to be. The staff at Gorham Bike & Ski, specifically Kyle and Greg, introduced us to some cool technology I didn't even know existed.

Renee was fitted  for her prospective tri-bike with a new technology called  Body Scanning.  It utilizes laser measurements combined with software to fit for each unique rider and body type.  What was really interesting to me was that it also took into account her style of riding for a highly individualized fitting recommendation.  A computer graphic is then generated with ideal measurements such as saddle height, aerobar placement, etc.  Greg then set up a bike for her and she took it for a spin.  After a couple of quick adjustments, she went off for a longer ride.    Switching from regular handlebars to an aero-bar promises improved

speed and faster times, but has to be carefully fitted to insure protection against nagging injuries which can occur while spending 2-3 hours in the saddle.  Even for shorter distances, relatively small adjustments to handlebar angle can drastically change both upper and lower extremity numbness/tingling which can occur.  She said it felt great, and likely my bank account will be taking a hit soon. So if you are a bicyclist, regardless of your fitness level, I recommend finding a dealer in your area which has this system. Who knows, maybe it will help turn riding into a pleasurable experience for you again.  It is quick, easy, and often free!