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Guest post by:

Shane K. Woolf, MD
Chief, Sports Medicine
Department of Orthopaedics
Medical University of South Carolina

Fall is a great time of year for sports! Major League Baseball postseason is heating up. College and Pro football is getting interesting as the dominant teams start to distance themselves from their competitors. High School and college sports are in full swing as a regular part of the fabric of community life.

And for local leagues, colleges and the pros, hockey season is underway! That means excitement on the ice as well as potential for injuries. Given the pace, frequent collisions and contact, and hard surface on which the game is played, head injuries are not uncommon. Shoulder and knee injuries are fairly common as well. The hip experiences unique stresses in hockey, so these injuries warrant consideration and are the topic of this week’s MUSC Health Sports Medicine blog.

When do injuries, especially to the hip, happen in hockey?

A study of collegiate male hockey players showed injury rates are 8 times higher in games compared with practice during the season and usually involve the lower extremity. Knee injuries occurred most frequently during games (14%) while hip and pelvic muscle (groin) strains were most common in practice (13% of injuries). (1)  A similar study of female hockey players showed game injury rates 5x that of practice but with hip/pelvic injury rates (12%) in practice second only to concussions (13%). (2)  Clearly, hip and groin injuries are important to consider and to avoid in hockey players.

What are the usual hip and groin injuries in hockey and what can be done about them?

Evidence exists to suggest that a muscle imbalance of hip abductors (this group moves the hip/leg outward) compared to adductors (they move the leg inward) can be predictive of groin injury. (3)  Groin injuries (adductors) are most common. This finding would support the need for strengthening and conditioning both muscle groups to maintain balance in both offseason and during the season. Another study of youth hockey players suggested an ‘at risk’ position for the hip to experience a condition called femoroacetabular impingement. This condition happens when the femur contacts the socket (acetabulum) abnormally at extremes of motion. The study showed that the sprint start with flexion and internal rotation of the hip pushing to abduction and external rotation initially places the hip in a position of impingement and risks development of overuse injury patterns.  Goalies also find themselves in similar positions of extreme hip rotation.

The diagnosis of femoroacetabular impingement has become more prominent in recent years among athletes with hip pain. Hockey players tend to be at particular risk given the extreme positions their hip joints endure.  Indeed, it has been shown that elite level youth players have a higher incidence of cam deformity on their femoral heads and also associated hip pain. (5) In this condition, the edge of the ball (or head) of the hip develops a bump of extra bone over time. This extra bone can contact the edge of the hip socket more easily during hip rotation and can actually enlarge over repeated contact with the socket. This contact can ultimately damage the labrum, which is a gasket of sorts on the edge of the hip joint, as well as the cartilage within the joint as well. Youth basketball and soccer players seem to have similar risks for femoroacetabular impingement. (6) In most cases of new onset hip pain, a conservative approach of rest and rehabilitation is enough to settle down the underlying condition. Chronic and persistent pain deserves a more thorough evaluation by a specialist.

Other possible causes of hip pain

Two other conditions should also be noted when a hockey athlete complains of hip pain. If the mechanism of injury is a fall to the ice or perhaps a hard check into the boards, it is possible for a fracture of the hip to occur. While rare, an athlete who cannot bear weight immediately after a hip injury should have a radiograph obtained to rule out fracture. Another condition called ‘sports hernia’ can occur in hockey and other sports that involve regular twisting, pivoting, and hip rotation. In this case, the inguinal wall is weakened and a herniation of abdominal tissue can occur. Deep groin pain is usually present with activity, resolves with rest and does not typically respond to the rehabilitative techniques used for other hip injuries. Surgery is often necessary for these affected athletes to be able to return to play.

For the competitive hockey athlete, maintaining hip strength and flexibility is important. Hip pain that does not respond to rest or is progressively worsening should be evaluated by a sports medicine specialist like those of the MUSC Health Sports Medicine Team.

  1. Agel et al. J Athl Train. 2007 Apr-Jun;42(2):241-8.
  2. Agel et al. J Athl Train. 2007 Apr-Jun;42(2):249-54.
  3. Dallinga et al. Sports Med. 2012 Sep 1;42(9):791-815.
  4. Stull et al. Am J Sports Med. 2011 Jul;39 Suppl:29S-35S.
  5. Siebenrock et al. Am J Sports Med. 2013 Oct;41(10):2308-13.
  6. Nepple et al. Am J Sports Med. 2015 Jan 13.

Here are three basics to guide you in choosing a health insurance plan.  Two you probably have thought of, and one you might not have.

1. The premium

Like auto loans and home mortgages, the “monthly” is usually the first thing health insurance purchasers focus on.  “Can I afford a comprehensive $500 a month policy? Or should I take the low cost plan?”  Of course, you must have the cash flow to cover the premium.  And if you can buy your insurance with pre-tax dollars, that will be a big help.  However, the real cost of health care is not the premium.

2. The out-of-pocket costs

Co-pays, co-insurance, deductibles and stop loss ceilings can drastically affect what you pay for health care.

Co-pay is the fee you pay for the initial appointment with your primary care doctor, usually around $25.  The co-pay for a specialist such as a dermatologist or urologist is often higher, typically $35-50.

The co-insurance is the portion of the costs for a procedure or operation you share with your insurance carrier.  For example, if an operation costs $10,000, and you have an 80-20 coinsurance, the insurance pays $8,000 and you have to pay the other $2,000.

The deductible is the amount you have to cover before the insurance carrier pays anything.  Many insurance plans will let you chose different amounts or your plan may specify the amount.  For example, you have a $300 personal deductible and a $1,000 family deductible.  If you increase that deductible to $1,000 for yourself and $2,500 for the family, your premium would be lower.

So the real cost of health care is the total of your premiums, the deductible, the co-pays and the co-insurance.  The stop loss is the total amount you would have to pay, even if your actual costs go beyond that.

3. The network

The number of insurance plan options has risen dramatically.  The Affordable Care Act has created insurance exchanges that add to the already numerous private, employer-based and government plans (Medicare and Medicaid).   More insurance carriers are offering bronze/silver/gold plans with low cost-high risk and high cost-low risk options.  If you are a 20-something in good health, you might want to roll the dice.  If you are 50 with a chronic health problem requiring frequent doctor visits and expensive prescriptions, you might choose a plan with a higher premium, but potentially lower out-of-pocket costs.

Insurance carriers are also offering plans that while they may lower the cost, also limit your options.  There was a time that you might have thought that if you had a policy with Blue Cross Blue Shield, you could go to any doctor and any hospital you wanted – and that the insurance would cover your cost.  Don’t be so sure.  Of the many Blue policies only five are accepted at the Medical University of South Carolina.  A major employer in Charleston offers four plans, but two of them require participants to get their care at just one hospital system.

Be sure the doctors – and the hospitals – you prefer are in the network.  Or you may be offered only partial coverage, perhaps 50-60 percent of the costs instead of 80 percent (referred to as out-of-network benefits) – or even denied any coverage at all if you went to another physician or hospital emergency room.

It’s open enrollment season and a good time to check what a new plan or your current plan covers.  And make the choice that’s best for you and your family.

Guest post by:
Michael J. Barr, PT, DPT, MSR
Sports Medicine Program Manager
MUSC Health Sports Medicine

As I am standing on the field after the Charleston Battery’s last regular season match of the 2015 season, thousands of fans are rushing the pitch to talk to their favorite players, get autographs, and find their own little spot of grass to watch the post-game firework; the historic moments from this season are running through my thoughts.

We started off the year back in February with the Carolina Challenge Cup which included two new MLS expansion teams New York City FC and Orlando City SC in addition to the Houston Dynamo and our Charleston Battery.  The CCC was a great kick-off of the season with international stars (Kaka and David Villa) and US national team players (DaMarcus Beasley, Brek Shea, and Mix Diskerud)  playing on our pitch in-front of sold out crowds.

The Battery then catapulted into the regular season starting with a 5-0-2 record before experiencing their first loss at FC Montreal.  Their outstanding play extended in to the US open cup where we won our first 2 matches and then eventually losing to Orlando City SC in pentalty kicks, however taking the MLS side to a 4-4 draw through regulation and overtime was a feat in its own.

As if having MLS teams coming to Charleston was not enough, it was announced that West Bromwich Albion from the English Premier League, was coming to town to play an exhibition match against our Charleston Battery on July 17th.  The West Brom match was played in front of another sold out crowd and all around was just an amazing event.

July 30, 2015, the Charleston Battery and MUSC Health announced the re-naming of Blackbaud Stadium to MUSC Health Stadium, which was then unveiled at a tough 0-0 draw against FC Montreal on August 1st

So over halfway through the season, the Battery announced a new stadium name, MUSC Health Stadium, has played MLS teams, an EPL team, and is fighting for one of the top 3 places in the eastern conference of the USL.  As we enter our last regular season home match, our fate and playoff position is in our own hands, a win means we finish 3rd and host a first round home playoff match.

The Historic Moments Continue:

In front of a crown of 4,543 at MUSC Health Stadium, the Charleston Battery go into the locker room up 1-0 over the Charlotte Independence at halftime.  At the start of the second half, in the 48th minute, Dane Kelley struck a phenomenal volley, scoring what eventually will be the winning goal of the match.  This was Dane’s 42nd career goal in the USL, putting him at the top of the all-time USL leader board.

The Attendance of 4,543 at MUSC Health Stadium broke the season average home attendance record for the Battery, setting the new record at MUSC Health Stadium to be 4,079 beating the previous record of 3,991, set in 2008.

The WIN, in front of this monumental crowd: increased the Battery’s home unbeaten streak to 24 matches at MUSC Health Stadium; claimed the 2015 Southern Derby Cup;  Solidified our third place regular season finish including hosting a first round home playoff game.

This was my eighth season working with the Charleston Battery as their team Physical Therapist and coordinating all of their sports medicine needs.  With everything that has happened this year, it was definitely a historic season, and one that I will never forget.

However the season is not over yet, there is one more historic feat that needs to be achieved to truly top off this historic season.  The Charleston Battery will start their playoff run, hosting the Richmond Kickers on September 26, 2015 at MUSC Health Stadium; you are not going to want to miss this match!

Shane K. Woolf, MD
Chief, Sports Medicine
Department of Orthopaedics
Medical University of South Carolina

Many people ask about the responsibilities and routine of those of us in sports medicine who serve as ‘team physician’ for high school, college, or even professional level organizations. Some might think of the role as glamorous and exciting. After all, we get to interact and watch the action among the athletes and get All-Access passes to the field/court as well as other restricted areas. Others might not even realize that a physician specializing in the care of athletes is even present at many games. Most of the time, we are quietly at work on the sidelines or in the training room collaborating with the team athletic trainer (AT) and staff.

The MUSC Health Sports Medicine program is composed of 4 sports medicine physicians (3 orthopaedic and 1 primary care) as well as other medical subspecialists, an experienced and talented group of ATs, and sports medicine dedicated physical therapists. We also are fortunate to have a ‘point guard meets quarterback’ program manager who helps to coordinate everything from practice/game coverage schedules to appointments for follow-up visits on injured athletes. This group is the core of what makes up a complete sports medicine program.

What are the Team Physician’s tasks besides providing medical coverage on game day?

The role of the team physician in all of this is more than just providing acute medical care and preventative recommendations to the athletes and coaching staff.

  • Reviewing the team/stadium emergency action plan or EAP (ie what to do in the event of a major on-field injury or a mass injury incident at the site)
  • Staffing team preseason physicals and reviewing medical care plans with the ATs and coaches. The physicals involve screening for potential medical issues such as asthma, heart disease, previous bone and joint injuries that need to be followed or worked up further.
  • Documenting pre-participation physical exams in the athlete’s record
  • Reviewing noteworthy issues to determine whether an athlete is cleared to participate or train
  • Performing physical exams on all new players picked up during the season
  • Exit physical exams for our professional affiliates to document health status of the athletes at the end of the season
  • Review injury updates from our ATs, in some cases with daily reports as we do with the Charleston Battery.
  • Training room visits are also a part of our responsibility when necessary or if an athlete cannot be worked into our regular office hours.

What about game day? What does the Team Physician have to do during the competition?

On game days, the team physician is usually asked to arrive an hour ahead of time to assess potential issues and help the AT prepare for the event. During the game, most of our focus is on what could go wrong or whether the athlete on the ground is injured, not on the action that most spectators are enjoying. The team AT is usually the first medical person to attend to the injured player while the physician evaluates on the sideline or in the training room. Clinical judgment guides whether the player is finished for the event or needs to be transferred to a hospital. In our role with the Women’s Tennis Association Family Circle Cup and the Charleston Battery, additional documentation is needed for an athlete who retires from an event or who has a significant injury. These athletes are professionals, so injuries may necessitate extra documentation for workmen’s compensation and insurance purposes.

What about after time expires?

After the event ends and the crowds leave, the AT and team physician usually spend another hour or so clearing the medical equipment from the field/court and examining lumps, bumps, bruises, headaches, and other medical complaints. The medical staff for the opposing team is met to make sure none of the other players need medical attention. Care plans are coordinated, and then we finally get to go home for the night. Often, this is well past 10-11 PM for evening games. Most events span about 3-4 hours once or occasionally twice per week. We are not paid for that time and typically have regular work duties the next day or attend injury clinics on weekend mornings as well.

So, the daily routine of a team physician involves a lot of extra work and effort beyond our ‘day job’ with very little glitz and glamour. Yet, most of us have been athletes at some point or at least understand the special concerns in caring for athletes whose goals are to stay healthy and remain in competition. We tend to seek out the extra duties of team coverage and want take care of these athletes.

How does a physician get to enjoy the privilege of taking care of a team or a sporting event?

In most instances, special training beyond residency called a fellowship is a starting point, although in many communities, the team physician may not have had such training, but has skills and experience to provide medical and emergency care to athletes. In addition to orthopaedists and primary care sports specialists, some pediatricians and emergency medicine physicians have special interest and experience in the care of athletes. Physicians who complete an additional year of training in orthopaedic or primary care sports medicine and are actively involved in team coverage are then eligible to sit for an examination and achieve a Certificate of Added Qualification from their respective national board organization.  This represents the pinnacle of qualification for team medical coverage.

For national and international competition, such as the Women’s Tennis Association, US Ski and Snowboard team, USA Boxing and others that our physicians affiliate with, additional credentials, references, training, and background checks are required to be able to get that ‘All-Access’ badge and have the opportunity to work with these elite athletes. But the common goals, regardless of the competition level are:

  • Keep the athletes safe from potential injury and medical issues
  • Document and manage the medical issues of each athlete
  • Advocate and educate on the best medical options for each athlete treated
  • Maintain privacy and dignity of the injured athlete
  • Provide high level medical care, often outside of a normal clinic setting
  • Communicate with care-givers, coaches, and other medical staff to optimize treatment and return to play plans
  • Lead in the assessment, management, and stabilization of injury during competition.

This ‘after hours’ responsibility is one in which each of our physicians, as well as all of the other sports medicine team members, excels as we strive to enable MUSC Health Sports Medicine to provide the same world-class care to our athletes that we give to our regular patients every day.

deep brain stimulation imageDeep Brain Stimulation or DBS can be a highly effective therapy for patients in advanced stages of a movement disorder. Patients with movement disorders have dysfunctions in the circuits in the brain that control movement – by placing a small stimulating electrode in these circuits, we can normalize the electrical activity and restore function. Learn more about Deep Brain Stimulation from our Health Library.

Candidates undergo a thorough movement disorder evaluation, followed by neurosurgical and neuropsychological evaluations with experts in the MUSC Health Movement Disorders program. Each patient’s case is reviewed by our full interdisciplinary team to ensure the patient is a good candidate.   

MUSC Health neurologists use highly sophisticated imaging to identify relevant circuit structures. This ensures proper placement of the DBS stimulating electrode through live mapping of the relevant structures and allows for testing and examination prior to permanent placement. Following the surgery, patients are monitored closely by our team to program the device, tailor the stimulation and monitor medications to account for the changes in stimulation. The MUSC Health DBS program has more than 12 years of experience in caring for DBS patients, including many of the most complex cases in the Southeast.


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