I want to ask, as I introduce the legends, to come forward and grab your seat here with a microphone. I have collected four of the greatest and experienced minds the world has ever seen in this room right now. You have collectively probably about 80 years of sideline experience. Let's start with big George Mowerman. George was a two-way starter, lineman at Vanderbilt. That was 60 years and many steroids ago, right George? Many steroids. He went to Columbia Medical School, Campbell Clinic. He's a captain of the US Air Force. He's the Tulsa team doctor since 1970, before I was born. There's a George Mowerman sports complex named after him. He's a fixture at not only Aston, but also at Anna. He's a winner of the Brady Award. Let's bring it up for George Mowerman. Next, we have Irish Pat Smith, Michigan Medical School, Michigan Ortho. Look at his pedigree. Houston Clinic. He's been the head team physician for Mizzou for 28 years. He's in the Missouri Sports Hall of Fame. He did the first all-inside ACL. Let's bring it up for Irish Pat. Next, another legend. We all know Buddy. LSU Med, Mississippi Ortho, Cascari Fellow, AO Fellow, Microvascular Fellow, Mayo Clinic. He's the chair and professor at Tulane. He was a former president of ASES and Anna. He's been the head team physician for Tulane for several years. To me, he has always been Mr. Innovation in arthroscopy, Buddy Savoie. And finally, I'm humbled and honored. This is my mentor, Ray Moyer, Lafayette College All-American Baseball. He signed with the Chicago Cubs, decided medical school was more appealing. He went to Penn Med, Temple Ortho. He was a Marine Corps flight surgeon in Da Nang, thank you. Team physician for Temple Athletics for 38 consecutive years. He's in the Temple Hall of Fame. He will always be my mentor, Ray Arlen Moyer. Let's hear it for Ray. We're going to have a lot of fun today, and the first disclosure is, men, there are no lawyers present, and nothing you will say will be used against you in a court of law. Are we clear with that? Ray and I are used to Philadelphia practice. We get sued TID. All right, let's start with injections. Men, what is fair game injection, say at halftime? Do you frequently, George, inject an AC joint? Honest answer. Microphone. If it's a fresh injury, I'll do it at that time, yes. And I'll not only use the steroid, but I'll use the local anesthetic. All right, so any other comments? I'll ask the panel. What AC joint would you not inject and say, showers, buddy? Well, clearly, if there's a fracture associated with it, I'm not going to inject that one. And so one of the things we'll do is, if it's a one or a two, and there's no bony issues, I'm just like George. I'll inject it at halftime with anesthetic, and then reassess in the second half if the player wants to play. Our two-lane guides don't always, they think it could be risking permanent injury with an AC separation, but most of the time, we'll inject it, let them play the second half, and then reassess. If there's significant crepitation, and I think it's bony, usually we'll try to get an X-ray at halftime. We have X-rays there. Most of our schools in the AAC have X-rays. So we'll get a quick X-ray, and if it looks good, and there's no fracture, just a separation. But if there's a fracture, we won't do it. By the way, sidebar, if you haven't read Buddy's work on AC separations with taping, please do. I've tried it. It's been a miracle for me. I agree. I will inject them, and actually, it works pretty good in the thrower. We've had a couple of our quarterbacks at halftime that have made a recovery afterwards, so I would not hesitate to do it. I know you inject, Ray. Are you going to add some steroid? Are you just going to do lidocaine, marcaine? What do you do? Separate his AC. One thing that Buddy said, which is a criterion for doing the injection, is if the player is willing to get it done. I had one of our players at halftime during one of the few bowl games that Temple has been in. He was very reluctant to either get the injection or play as well. He ended up playing pro ball, but that day, he wasn't going to do it. I actually ended up injecting more things pre-game than during the game, but I've injected other joints as well as the AC joint at halftime. Most commonly, if the player was willing to play. A great comment. In my asylum experience, I look at the player's eyes and I can say, do they really want to play? If I get that read that they're like, great point, Ray. How about knees and draining effusions to play? Fair game, Ray? Do you have any knees before games injected? I think before games is the appropriate time to do it. As far as what you do at halftime, I always tell guys, if you can practice, you can play, which usually, I think, for any injury at all, that if they have something that occurs during the first half or an expectation to play in the halftime, I try to see if they can do the functional things that would be equivalent to what they're going to do when they're playing. If they can't do it, then they can't play. If they have an effusion, I would be willing to take that out, would not inject it, but see if that would enable them to be a little more functional. Again, I go through the same thing. I give them some functional tests. If they can do the functional tests, they can play. If they can't do them, they can't. Are you worried, men, about the effusion? You just could have, like, making them feel better, cause more damage? Buddy, will you still, and George, will you still do that? Yes. Again, they have to be able to go back. If they don't want to go back, you don't do it, but most of them will ask you to do it before you even approach them. Do you use steroid, Buddy, or George? I do not use a steroid for a knee. Maybe if it's pre-game, yes, I'll drain a knee, and occasionally put a steroid in. Just one, if it's repetitively, week after week, no. Okay. We have a three-day rule for knees. We'll aspirate and inject, but you have to have three days ahead of time. We'll do it right before the game, and we'll do it at halftime. Cause coaches need to know that they're functional and able to play. So it can't be a last-minute decision on the coaching staff. Oh, can he? Maybe, maybe not. So for us, it's certainly by Thursday at the latest, but preferably Wednesday, we'll aspirate, inject, and that can be a steroid injection once every three months. So basically, pre-season and maybe one time during the season, and that's it. And if it doesn't resolve, then we don't do it again. And I grew up injecting knees for junior college players when I first started. We don't do that anymore in terms of playing. I think the subsequent consequences of additional damage are too high to numb it up and let them play. Pat? I guess I'm a little different. I look at the joint. If it's got a diffusion, it's like you're sick and you've got a fever. I mean, the knee's not well. And to me, I kind of draw the line there. I haven't done my job. If they're coming Saturday and they've got a diffusion, if it's post-surgery or a previous injury, so I don't let them play. So for me, I do a lot of injections, but I don't aspirate the knee and I don't inject any steroid. All makes sense. So how about ankle sprain or hamstring tears? I think, let's see, Dan Cooper had a nice series on hamstring injuries, injecting them with steroid. Do you guys do that? Buddy? So we have a hamstring protocol, and it's based on both Dan and Jim Bradley's work. So grade 1s, the little ones, we just rehab them according to what we've always done, try some different medications and stuff. Grade 2s, where there's some disruption in hematoma, we'll do a steroid shot, wrap them up, and then do all the treatment along with the one injection. And then if it's more than that, then it becomes PRP injections, and the PRP are once a week until they're well. The key there, as we all know, is you just don't let them play until they have their isokinetic strength back, otherwise they'll just re-injure themselves. So if we do inject them, they've got to sit out. We'll do water, we'll do water running, we'll do cycling, but we won't do sprinting until that hamstring recovers. And lastly, ankle sprains, Ray, fair game, second half? I actually probably inject more things about the foot and ankle than I do anything else, and it's pregame, and I use Marcane, and I'm very careful not to get into the joint and just almost kind of do a regional block. That's probably the most thing I do, and it's pretty impressive. Even for your kind of moderate high ankle sprains, you can kind of inject up through the syndesmosis, and that's been very effective for me, actually. I know you, Ray, you've injected quite a few ankle sprains over the year, haven't you? I have injected the ankle as well as the foot, and again, I think it depends on the player that you're taking care of. At Temple, we had limited reserves, so the front guys, you wanted to play as much as they could, and I always found that a lot of times when I did inject guys to play, it seemed like they were so critical. It never seemed like it made a lot of difference at the end of the game, whether we won or lost. There was one instance with Todd McNair. We were playing Tulsa where George was, and so he had one of his mid-foot sprains, so I injected it at halftime so he could keep playing, and we lost the game. The next week we were playing Army, and he would like to have his foot injected, so I said, can you hop up and down? He couldn't do that, and I was very reluctant to inject his foot, to let him to play, because in my mind I thought this kid had a future and I didn't want to compromise that, and I can't say our head coach, that was Bruce Arias, he was severely pissed off. I didn't do it because we had a second-team running back who gained about 190 yards that game, but he wasn't fast enough to make it to the end zone. We would have beaten those guys for sure if Todd would have played, but as far as injecting, I usually both injected in the joint as well as on the surface, but sometimes some of the limited motion was because of the swelling of the lining of the joint, which caused what you call impingement, and I thought if you inject it in the joint as well as out of the joint, it would shrink that down and enable him to play a little better. One little pro Ray taught me, one of many, was limited casting, ankle sprains, we'd cast the player one day. Amazing. Let's get some cases. Thank you, man. This is the defensive back. He tackles and he gets a subluxed shoulder, and it goes back in, and you go to the locker room. He's nerve-raspy intact. This is real-world stuff. Weak abduction. He has apprehension, 90-90. His x-rays are normal, but, buddy, he's a senior. He's got two more games, and there's a bowl appearance on the line. What are you going to do? If he wants to play, then we'll start rehabbing him. We'll put him in a Sully brace, and if he can hold his arm up and play safely, then we'll let him play as a defensive back, so he's got to go up. If he can't reach up, even with the brace on, then he can't play. He's got to pass that test. We use the Whipple test as a determining factor. If we take him down, cross him over. By the way, the Whipple test, Terry Whipple is sitting in the front row, so if any of you see him, you should come say hi. I use that test every day. Every day. It's the best test for compensating for instability. It's a rotator cuff test, but when they dislocate, they become diskinetic, and so the scapula sits forward, and they can't hold up because they'll pinch the front part of the cuff. So if you do that test and they can't hold up, then they can't play safely, and they can't get on the field. But if we rehab him quickly, most of these guys, within a week, two weeks at the max, if you put them in a good brace, then they'll be able to play the rest of the season. So Ray, he's in the locker room, but he has decent motion, no apprehension. You're going to maybe consider injecting him, play ball. You're going to tape and brace, play ball. You're going to call his agent. You're going to call the colonel, Dr. Tokish, for phone a friend. Or you're just going to give him more steroids. How many times have you had a person, Ray, sublux during a game and went back to play? I've seen it. Again, I basically use a functional test. I always say if they have the strength to protect themselves, then they can play. If they don't have the strength to protect themselves, then they can't. And as far as the range of motion, the brace that we most commonly used to use was that Denison wire harness brace. The Denison wire harness would really restrict your motion severely. And for a guy who was playing defensive back where you need the abduction, external rotation position, if he's your best player and he still has the strength to protect himself, he's probably better than the guy below him, so I would still let him play. I never really injected those shoulders ever. George, 50 years experience here. I do not inject the shoulder to play. Usually it's an offensive. Hold your microphone, George, so we can hear you. It's usually a lineman in our hands, and we will let them play in a harness. But if the defensive back has the range of motion and the strength and he can be braced and he wants to play, we'll let him play. But it's mostly, as I say, the majority of our patients are the linemen who get hurt as far as the dislocated or subluxated shoulders. Pat, you're sitting there quiet. What do you think? I don't know if you're going to talk about, in general, anterior instability, first-time dislocator. I've changed my philosophy, and I'm actually at Mizzou. If somebody has an anterior dislocation or a major subluxation and I scan them and they have labor involvement, I actually do not let them play. I fix them all. And the reason is, and this is kind of a little bit maybe the voice of experience, one year after a bowl game, I operated on six shoulders, and five of the six had grade 4 chondral changes, and it wasn't just a heel-sax lesion. These changes get centrally located. The glenoid was grade 4, and these are young men. And I think what happens to them is they tell you that they're fine. They tell the trainers they're fine. They're subluxated in practice all the time. They don't say anything because they want to play. But what happens, they go in the weight room and they keep lifting, and they've got a disconnected shoulder because of their instability pattern. So, you know, I changed philosophy, and at the time our coach, Coach Pinkle, who brought us back to some degree of success at Mizzou, and I went into his office and I said, Coach, listen, I just got them. Here's some pictures. I'm going to show you. I'm going to fix them all. So he goes, Okay, I'll support you. So the next season, first game of the season, we were in the Big 12 at the time, all Big 12 linebacker, subluxes, first game, first quarter. And so I said, Coach, I'm going to fix his shoulder, and he gave me this long look. Oh, really? We did talk about that, didn't we? So I fixed his shoulder. The kid came back and was all Big 12 the next year. But, you know, he redshirted. Personally, I don't subscribe to the philosophy of rehab, embrace, and get them through the season. So for me, because of what I've seen, my first-time guys, like this guy, depending on how irritable he is, I'd probably scan him, and if he's got the pathology, I'd say, Listen, I think you need to be fixed. So I'm a little bit probably different than everybody that way, but that's what I do. Buddy, hold your thought, because I know what you're going to say, but I have a question for you particularly. Do you mind, before we get to the next slide, what is your thought on braces? Anybody believe they don't work? Literature has been pretty uncertain about bracing, but I'm sure all four of you use them, correct? Is there any downside, buddy? So that's a Sawa, S-A-W-A. Trying to keep commercially pure. It's a static brace, and static braces don't work. They're designed to be motion-limiting, and they can still dislocate no matter how tight you strap them. The elastic braces work. We've gone to a Sully because it's front and back strap, so you get some tactile feedback. The whole idea is that you're just trying to teach the shoulder to stay in place. If you do just an anterior elastic strap, what we found was that it still pulls the scapula forward, so although it helps, it doesn't help as much unless they have good scapular control. So we do the Sully instead. It's not a miracle. It's not going to keep the shoulder in place. I think Pat is probably 100% correct with our football players, and that's a 180-degree turn in my thinking right now. I still leave it up to the child and the parents, because those are late-night calls to the parents and everybody, and you kind of leave it up to them, and you give them the options. But if they want to play, I'll let them try. But I tell the trainers, and the hard part is, as you said, they don't necessarily tell you, but I tell the trainers, watch them. If they start subluxating in practice, they're out. They can't keep playing if they're subluxating. So, Buddy, you're the one that taught me don't operate on disability. Are you saying that these people are a little different animals? So what I'm saying is that if they're – because some of them you pop back in, and they feel great. They got their strength back in a day, and it's kind of hard to operate on those, regardless of what the MRI says, because they're doing fine. But if they're symptomatic and they can't regain their strength and they're still slipping, and they have symptoms, and you just got to watch them. Because most of the kids want to play. And at Tulane, we don't have any depth. So if we lose our first team player, it's a big drop off to our second team. I mean, huge. And so the coaches want to play. The kids want to play. But they all subscribe, because we're a big academic institution, that if you're hurt, we don't want you on the field. If there's anything permanent. So you just got to talk to the young man and say, these are the risk factors. This is what's going on. If you're not safe to play, I don't want you to play. And sometimes you win, sometimes you lose. So it comes down to the man skin. Let's just get to the treatment, because you all have all this 100 years or so of experience. He comes back to the office. Four days there, his MRI shows minimal glenoid bone loss. He has an impaction marrow edema, really, on the superior head. No real significant hill sacks. And he has, again, on the anterior axial view, minimal glenoid bone loss. So he's got full motion now four days. Good abduction, slight weakness in exhalation. His relocation test is positive. Forgot to mention his Whipple test is still positive. So now what? Right with this information, what are you thinking? He says, you know, Doc, I really want to play. Well, this could be sacrilege now, but I have never operated on a first-time dislocator. And I still think that the indication whether they can play or not is based on what they call their functional disability. I go back to the fact that if they have the strength to protect themselves, and they can reasonably do some resistance testing, that relocation test, I always think if you can stabilize it, and then they can throw against that motion with stabilization. I think some kind of physical stabilization that you could supply for them would be at least a reasonable thing to give them the same opportunity to play. George, he comes in in his exam at this point four days later. Not bad. What are you going to tell him? I'm as much as Ray. Microphone, George. I'm much as Ray. His feelings in it. I'm probably the oldest guy on the panel here. But I've never. I have no question. I've never operated on a first-time dislocator. And if they want to play, they have the strength, depending what position, I'll let them play. OK. So let's get to the treatment, particularly to Buddy and Pat. I elected to get him through the season with a brace. And I arthroscoped him at the end of the season. He actually did pretty well. He had a couple of misadventures, no dislocation. But he said, Doc, I didn't really trust my shoulder, but it didn't come out. And so Buddy gets to the OR, and he has minimal bone loss. He has a Kym lesion. And Pat, he has a Bancart lesion, minimal bone loss. What are you going to do, Buddy? Are you going to do an open Bancart? Are you going to do a scope Bancart remplissage? Are you going to do a latourgerie? Are you going to do a thermal shrinkage? Are you just going to call yourself? So what are you going to do? You're asking me? Yep. OK. Don't call yourself. You can't phone a friend. I'm going to do a Bancart and a remplissage. Our success rate, scope Bancart and remplissage, I know what some of the guys are saying about combined bone loss. And I agree that you have to look at it very carefully. But our return to play rate in that patient population in the 13 years, 14 years I've been at Tulane has pretty much been, we've not lost a player to recurrence of instability. And so that has worked really, really well in my hands with a good shift. You start in the back, work your way up, all the things we know. And that works very, very well in our contact athletes. So I don't think, at least for me, that's a good operation. I wonder if Dr. Tokus is in the audience hearing this. He's right over there. JT, did you hear what he just said? Pat, what are you going to do? I didn't see the heel sacks on that picture. With small. Yeah, first time dislocator, I'm not doing a remplissage. I'm doing an anterior stabilization. I'm going in the back and putting a couple in anchors. And I'm pulling up the posterior band to recreate the sling. I want the anterior band and the posterior band. So in all my contact athletes, even if they don't have a Kim lesion, I make one. And I always pull up the posterior band when I'm doing a contact athlete arthroscopically. So I'm fixing in the front, in the back, and pulling the sling up. But first time, I wouldn't have done a remplissage. He's not just a knee surgeon, folks. Look at that. All right, Ray and George, the traditional guard. George, what was your go-to operation in a contact athlete who failed rehab? Did you do open bank card or did you do a scope? Again, being the age I am, I did an open bank card. OK, Ray? I did both, and I had equal failures in both. An honest man. Oh, thank you. So we have a couple more cases. I appreciate your honesty. No lawyers in. So George, this is your star quarterback. He gets his bell rung. JT. Oh, JT. Sorry. Rebuttal. No, I'm just asking a question. So buddy, you, with the remplissage, it's a- Yeah, sorry. Oh, there it comes on. Buddy, with the remplissage, that's now a cuff repair. So you're going to, how are you going to rehab that? Or will you rehab it like a cuff or a capsule? So we, so with the, to me, a remplissage is also a posterior lateral shift. So what Pat said about recreating the poster band is absolutely critical. So when I do my bank card, I put my bottom anchor in first. And if the poster band is reconstructed, and it looks normal with that amount of shifting, then my remplissage is just a tuck. And then, so they're held for four weeks while the cuff heals. We ultrasound them at four weeks, because these are young guys. And they, and for our volleyball players and other things, we get into that. And so they can rehab after four weeks, and the infraspinatus is healed, we start working on it. So normally, if there's no stitches in the cuff, we start active motion pretty much right away. Whereas with the remplissage, we wait four weeks before we start any type of external rotation or external rotation abduction active exercise. So you can do some isometric abduction for the deltoid, but you've got to keep the infraspinatus out of it. So it's a different rehab, not as fast. Thanks. Thank you. Let's get to the case. Again, we have your star quarterback, Ray. He's on the sidelines. He gets his bell rung. He's got a normal neck exam. He's feeling a little wifty. Now, again, there are no lawyers present. The doors are locked and sealed. Hey, come back in. You examine, unless you always do, 15 minutes later, he says, I feel great, Doc. To your exam, there's no scat or any of those things. Short-term, long-term memory appears intact. Ray, Moira, what are you going to really do? We're down by one touchdown. Again, in our earlier years, we had the liberty of making a diagnosis and examination without the TV watching. And I know that I let guys play, but nowadays, you would never let them play. As I shared that story last night, we had our star quarterback. With one year, we were 1 and 10. The next year, with one guy playing, same team except for the quarterback, we were 7 and 4 come last game. He was knocked out on the field. And like my wife reminded me, I put my hand under his face mask to make sure he was breathing. And he was out for about three or four minutes. The opposing team physician came over and said, do you need help? We'll be all right. He missed one series because, in my mind, I knew that if he doesn't play, you don't win. And by the end of the game, he was questioning how we got all the points. We did win the game. But nowadays, you do all the different tests for balance and coordination and time, place, and person. And if they're clear with that, I give them some running tests and see if they can do that. I don't necessarily use the length of time as to when they go back to play. I will say that the two things that usually end up being the most compromising factor of concussions is either headaches, which are pretty obvious, or they do those tests now, the SCAT test. And those things, which determine whether a kid can go back to school or not, are the things that seem to linger the longest. And I think that the exam that you have oftentimes does correlate with what that exam shows. But back to that issue, I think that you determine what his functional capabilities are, like the kid who was knocked out. And he was clear as a bell in all his plays, at least until the last five minutes of the game. And he had no issues after that. He's not old enough to know whether he has any CTE yet. And my own feeling as far as I think the CTE also is an uncertainty as far as who gets it and the severity of it. May I just add one more thing? I would think that CTE in a way is almost like a stroke, in that how somebody's brain is affected by a stroke depends on what part of the brain is affected. I think the same thing is true as far as the lesions that you get in the brain from the concussions. George Maur, you told me as a player you don't remember an entire second half. That is true. Do you wish your doctor held you out? Well, again, I didn't have much choice. But I was held out, yes. I ended up in the other huddle. But back then, you had one bar in front of you. And they could always get in with a fist. But today, if there's any indication there's been a concussion, some brain function problems, we'll hold them out. And the trainers are usually the first to check this out. But everybody, when they come to school now, it's a cognitive as well as a balanced test. So we have a baseline. And again, if you've had the concussion, you make the diagnosis of the concussion, you're done for a minimum of a week, you start off not in class. They're in practice. They're in the locker room with no lights on. Once they're asymptomatic, then you've got to work back over a week period of time before you can go back to contact. So Buddy and Pat, let's be more pragmatic. Let's deal with a simple bell rung. You can get a little shot, a little, you know, just wifty for seconds. No lawyers present. Pat, if he comes back 15 minutes later and he feels totally fine, you do your memory, short term memory. He knows a time orientation place. Do you ever bend the rules, kid? Well, actually, I would say to you that this part of our life, I think, is a lot easier now because of the NFL. Because this is, bar none, he's done. I mean, we got guys up, you know, I get beat from the guy up in the SEC. He has the SEC. They beat me. If somebody's got a hit, they've got to look. It's just like the pro thing. In the old days, I struggled with this because I did let these guys go back and play, you know, and probably wrong, you know, in retrospect. But now it's so easy. They don't fight you anymore because they see what happens on Sunday. When we say you're done, they go, OK, I'm done. I mean, they don't. I have seen a change in the athletes, too, where they don't fight us anymore because of all the CT publicity, the NFL, the way it's all gone down. So to me, this has made my life a lot easier on the sideline. This was hard 15 years ago because I made some wrong decisions. I put some kids back that I probably shouldn't have. Now it's like you're done. It's case over. And that's probably the right thing to do. One more case, man. This is a great wisdom. Your star quarterback takes a shot to his left knee. He got a valgus injury. He's got point tenders to meet up a condom. He has pain with valgus stress. You examine the locker room on the sideline. No gapping. He has slight pain with cutting. So, buddy, what are you going to do? You're going to say, you know, he's our star quarterback. Let's send him to the showers. You're going to tape and play ball, brace and play ball. Are you going to inject him? What are you going to do? So I can I can tell you, I had a running back that did. He actually dislocated his elbow, popped it back in, put a brace on him, went back out, did this exact same thing to his MCL. So I sent him in at halftime and halftime. He comes over. He says, you know, I don't feel that bad. I think I can play. So you just talk about your elbow. You hurt your knee, too. No, my knee feels really good. And and so the coach says we really could use him. So I put him in a brace. I did not inject him, but we taped his knee because you need to figure kind of a crisscross to stabilize that side and then put him in a brace. And he played the second half. He's five years in the NFL now. He's a tough, tough kid. So he played that game and never missed another. I mean, he missed like the second quarter. So for me, if they want to play and they can run, I'll put him in a brace and then we'll do some stuff at halftime. But I don't I don't just pull him on the sideline, put him in a brace and let him go. The vast majority don't play because they're too sore. Ray, you're going to inject an MCL ever? No. George? No. Patrick? No. So let's just look at this video. What is your criteria for function? Do you have to do cutting? Could we just play that video again? Did you make him do elaborate cutting drills, Ray? What's your algorithm? You just say, hey, just run. Absolutely. Yeah. Have him run straight ahead first, then do some carryovers, backpedaling. It looks like he can do it sufficiently, efficiently. But I feel like a buddy has said, though, I think he was able to take the shit out of me. But to take that meat, I'm just trying to say that. Take the shit out of the meat. That's a scientific term. That means three bundles. All right. So lastly, we got our star quarterback. It's a burner. And his spinati are slightly weak, but his neck exam, George, is totally normal. What are you going to do? No lawyers present. Star quarterback. Don't say again, if if he has his strength, he wants to play and. He functions well, I'd let him play. Any dissenters on that, Pat? No, I'd let him play. Boy, this is wonderful. We're going to finish up and a cowboy collars or horse collars, right? And neither. But he's shaking his head. That was a standard thing that we used to have for somebody that have a burner like as far as the burners. I always thought the determining factor, whether you could play or not, plays their neck examination. Strange how you have these people have these varicose plexus injury, varicose plexus, wherever the hell they are. But they oftentimes have significant pain and their strength is almost never abnormal. You get a burner and they're hurting like a son of a gun for about 15 minutes and their strength to be a little deficient. As long as our neck examination is normal, like you sit on their head and it doesn't, they don't shrink away from it. And their strength is sufficient to play than they can play. But you're shaking your head with the collars. Tell us why. So the originally the collars, they had a big bump in the back that push your helmet forward that loaded your C-spine. And so if you wear one, you're trying to prevent either compression or stretching injuries to the lateral neck like you're showing there. And the problem is that in the back, especially at high school level, nothing fits right. I mean, in college, we're fitting their shoulder pads better. We're trying to do this. But when you do that, you got to be really cautious that you're not going to the back part of it. It's not going to push the helmet down and load your C-spine for a direct impact injury. So to me, I really don't want to play with it. And even when they come in and use it in high school, we try to get them to not use it because of that problem. I don't want to load the C-spine. We have a few seconds. I just want to, for the audience's benefit, choice of ACL graft, BTP across the line. Consensus, Ray, you're a hamstring guy still? Well, you know, I was a hamstring maven for many years, and then when you changed, I thought it was not a good reason for changing. So I used most of the bone at the end. That's just two more, because we're running out of time. What is your best rehydrating solution, George, at halftime? What do you use? Saline, lactated ringers, any pearls? We usually go lactated ringers. That's what Ray does. Pat? Yeah, same. Wow, lactated ringers. And do prophylactic knee braces work? Do you give your alignment that, Pat? Are you a fan or not a fan? I'm a fan. Everybody has them, and we brace everybody from the first teamer to the to the walkouts, brace them all. Looks like we have a consensus. Finally, Pat, if you had one game coverage pearl for audience, what would it be? Well, I think you need to be decisive in your decision making. I mean, I think you need to do as quick exam as you can and make your decision and stick to it. You can't waffle with the athlete and you've got to make your call and because you've got to be responsible to the trainer and the head coach and you just got to act on your best judgment and experience. But you have to be decisive. Buddy, one pearl for our young physicians out there. Do a good assessment and remember that the player's health comes first. You're his doctor. Doesn't matter what the coach, the athletic director, the president of the university or any of the fans think, you're responsible for that kid and you have to take care of him. George, one pearl for our young. Well, again, as Buddy said, patient first. Everybody else second. My mentor, Ray Moyer, the wisdom of Solomon, what is it? Well, I think like Buddy was saying, I agree with that, that you want to be as honest as you can with your assessment. And I think you're the one that protects the athlete. You always have to protect him against all his friends, his teammates and against himself a lot of times. Let's bring it up for these legends. What a wonderful session.

sports medicine

injuries

treatments

injection techniques

athletes' well-being

braces

ACL grafts