Search for tag: "injury"

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen.

Interviewer: According to the Centers for Disease Control and Prevention, more than two million Americans experience a brain injury each year. While some of these injuries result in relatively short-term impact on a day-to-day function, others can lead to long-term challenges or even a permanent disability.

Today, we'll be speaking with Zoe, a young woman who experienced a traumatic brain injury after an accident and the long journey of her recovery and the daily experience of overcoming the long-term challenges of life after an accident like this.

And to help us better understand the medical side of a traumatic brain injury, joining us is associate professor of neurosurgery at University of Utah Health, Dr. Ramesh Grandhi, the doctor who helped stabilize Zoe after her accident.

Zoe, why don't we start with what kind of led to your traumatic brain injury in the first place? What exactly happened?

Zoe: Yeah. Well, interesting story. I had just moved to Salt Lake City in August of 2020, and this occurred . . . or rather, my accident occurred December 5, 2020. So I had just shy of five months in the state, really.

So I hadn't experienced a lot, but a friend and I really wanted to ski together. I bought a season pass at Alta, was really excited to get up there. And it was day one, in fact, of the ski season that this happened. So really did not get any other skiing in, obviously, but this was day one.

Yeah, I mean, I don't remember a whole lot about the day itself. I have spotty memories of the drive up to Alta, getting to Alta. I actually have some spotty memories of being on the lift up to the first run. After that, I don't remember anything. I remember a bit of skiing, and that's really about it in terms of the day.

And then subsequently, upon waking up, I have absolutely no memory of the remainder of December. My memory is really spotty from about Thanksgiving up to December 5th. So Thanksgiving, I would say, is the last clear memory that I have and everything else is kind of spotty. It appears in my head almost as if I made it all up.

I've had to ask a lot of people, especially family members, "Did this really happen? Can you describe this thing to me or remind me who was at Thanksgiving again?" I never would have guessed something like this when I first started skiing with my dad 10-plus years ago.

And I was maybe 500 yards behind several of my friends, so I was alone during the actual collision. I ran into this group of trees that sat right in the middle of the run that I was on at Alta.

In this tree well, it was icy. I slipped on the snow evidently and collided with some trees in the tree well. What I would assume happened at that point is I was knocked unconscious by the collision and then fell and was hidden by this tree well and this group of trees. And then because I wasn't found until about four hours later, I had become buried or covered by snow by people skiing by, obviously.

Interviewer: Sure. So you're spotty memory-wise from Thanksgiving to . . . When did you start to remember things again?

Zoe: Right. So really, my lucidity, I would say, started to come back right around January 6th, 7th, 8th, right in that area. This is purely what I was told, is that I woke up somewhere mid to end of December. The rest of December went by. I was then transferred to a long-term care facility outside of Salt Lake City. And right around that, again, 6th, 7th, 8th of January is when I have memories that I'm able to go back on and say, "Oh, yeah, that was right in the beginning of January." Before that, though, I have no memories.

Interviewer: Wow. So, Dr. Grandhi, I want to go to you at this point. When did Zoe come into the care of you, your team, the University of Utah Hospital?

Dr. Grandhi: As I recall it, I didn't find out about Zoe until Sunday morning first thing. I know that she presented as a transfer to our hospital, and clearly, she had traumatic injuries. And the first principle of what we do is just stabilize the patient. The trauma surgeons and a number of other services are super important and are our partners in making sure that a patient is appropriately stabilized.

And then my partner was actually on call and received the first call about her. He then got in touch with me. We do a really nice job within our department about communicating about patients with traumatic brain injuries, and specifically, patients with severe traumatic brain injuries.

So I remember that Sunday morning very well because she was downstairs in our surgical ICU. I went and saw her and just looked at her images, and then went out and talked to her dad who was sitting in the waiting room all by himself.

I remember the exact seat he was seated in early on that Sunday morning, probably around 8:00 a.m. or 9:00 a.m. And he was just by himself. I just walked up to him and told him what my assessment was of the situation based on looking at her head CT and things like that.

And at that point, it was just me trying to tell him that we're going to do our best to take care of her, that she presented with what we call a severe traumatic brain injury, and what the principles of managing patients with that are, and also, honestly, giving him hope.

Interviewer: When we talk about traumatic brain injury, is it a lot of skiing injuries, sports injuries? What is the most common type of traumatic brain injury?

Dr. Grandhi: Traumatic brain injury is a significant burden in the Western world. It's the number one cause of death amongst young folks in the Western world.

Traumatic brain injury falls into three buckets: severe traumatic brain injury, moderate traumatic brain injury, and mild traumatic brain injury. And oftentimes, patients with mild traumatic brain injuries don't even come into the hospital. We call it a concussion. And oftentimes, a patient may stay at home after hitting their head, or being involved in a sports injury, or a motor vehicle collision, or falling and hitting their head.

The burden of traumatic brain injury in the United States today is about 2.5 million patients per year. So many patients don't even come into the hospital. Many patients are discharged from the ER.

Interviewer: Zoe and her accident, of those three buckets, what did hers fall into, and why?

Dr. Grandhi: Zoe had a severe traumatic brain injury. And the way we diagnose severe traumatic brain injury is quite simple. We just gauge it in terms of what their neurologic exam is when they come in. So are they able to open their eyes? Are they able to speak? Are they able to follow commands?

Interviewer: And Zoe was unable to do those things?

Dr. Grandhi: Correct.

Interviewer: Wow. Zoe, do you remember any pieces or parts of the story? How did you feel when you were first, I guess, coming out of it?

Zoe: Yeah. Again, like I said before, the first memories I have are really in the long-term care facility that I was transferred to after leaving The U. I think it was sort of a slow realization.

And then since then, I would say I've noticed things that are sort of side effects or fallouts from having a severe traumatic brain injury: getting frustrated much more easily, being able to jump to anger much more easily, having very little patience, amongst many others. So it was very much a slow realization and slow rollout. And then still to this day, new things come up.

So it was much more slow. It wasn't similar to if you broke your arm and someone said, "Oh, you broke your arm," and then they casted it up right then and there. It was much more prolonged than that and slow realization.

My initial thought, honestly, was because I was awake and lucid and conscious, "Oh, my brain is fine. Well, everything is good. I can speak. I can see. I can hear. I can eat. I have my motor functions." And so, initially, I didn't think too much about the effects on my brain, and that did come up much later and still continues to this day.

Interviewer: Dr. Grandhi, when it comes to treatment of a case like Zoe, what was done to help Zoe get from the accident to where she was stabilized and in, I guess, a longer-term facility to kind of monitor her?

Dr. Grandhi: Well, I think we need to kind of dial it back a little bit to understand the management principles of patients with severe traumatic brain injury. And it starts, honestly, in the pre-hospital setting in which those who are on the first line understand how to manage a person, particularly with a pathology as significant as severe traumatic brain injury.

So first things first, getting the patient stabilized in the field, making sure that people are very cognizant of taking care of the patient, immobilizing their neck. Again, we don't know if a patient has had an injury to the cervical spine. Zoe clearly hit trees, so she could have very easily had damage to her neck, to the bones of her neck, spinal cord, etc. So getting a patient stabilized at the point of injury, then making a decision of where the patient goes.

There is data to show improved outcomes in patients who have a severe traumatic brain injury who are taken to Level 1 trauma centers. So understanding where to send the patient when the patient comes in.

Again, we have a huge bevy of services that are there in the ER, in the trauma bay awaiting a patient, because there's pre-hospital notification. And so if a person is coming in as a Level 1 trauma to a Level 1 trauma center, we do have orthopedics right there. Neurosurgery is right there in the trauma bay. Obviously, trauma surgery, the ER doctors, a number of different services and specialties are there awaiting the patient.

Airway management is important, worrying about circulation, blood pressure, ensuring that there's no intra-abdominal injuries. After that, there are a lot of scans that are ordered inclusive of CT scans that are literally performed head to toe to make sure that we're not missing significant injuries that need actionable treatment, such as rushing a patient up to the operating room for an intra-abdominal injury.

That being said, once that is done and there's nothing imminent that needs to be treated emergently, the patient is generally taken up to the ICU. And in Zoe's case and a patient with a severe traumatic brain injury, they're ventilated, and then there's a lot of management that occurs then predicated on blood pressure management, good oxygenation for the patient.

And for patients with severe traumatic brain injury, when we know a patient has a severe traumatic brain injury, we place particular monitors in the patient's brain because we're obligated to make sure that we have good control of intracranial pressure. So we want to make sure that we know what a patient's intracranial pressure is, and we need to keep it below certain thresholds.

We clearly know what the patient's brain perfusion is in terms of what's the state of blood pressure to brain tissue. So we monitor a patient's systemic blood pressure, their body's blood pressure well, and have to get the brain perfusion pressure in a particular range.

That's a quick summation of the management principles of a patient with severe traumatic brain injury. Not every patient requires a big-time operation and removing part of the skull or sucking out blood, but when we do place brain monitors, we do have to drill a small hole in people's skull to place these monitors. We have to remember that brain injury comes in many different flavors, even severe traumatic brain injuries.

Interviewer: So you just keep an eye on all the things that are going on with your monitors and everything to see whether or not there's injury?

Dr. Gandhi: Absolutely. And we use CAT scans liberally to help us understand more about the evolution of the brain injury. Zoe did have blood in her head, no question about it, but we did not feel that this blood would require us to take her to the operating room for an emergent surgery to remove the blood.

Interviewer: It's my understanding that Zoe then was a part of a study dealing with neuromonitoring. So for someone who's listening right now, what exactly is neuromonitoring, and why is it so important that we do research with it?

Dr. Gandhi: Whenever someone is classified as having a severe traumatic brain injury, we know from years of research and guidelines and a lot of work from really experienced, savvy, thoughtful leaders in the field that patients should get particular things monitored.

As I had said, we want to get invasive arterial blood pressure monitoring so that we can get a good second-to-second, moment-to-moment gauge of what a person's blood pressure is not using one of those expandable blood pressure cuffs. So this is something that allows us to know on a moment-to-moment basis what a person's blood pressure is doing.

We also ensure that the patient has adequate ventilation using a breathing tube. We study their intracranial pressure via an intracranial pressure monitor.

Finally, one of the things that has been important recently in the care of patients with severe traumatic brain injuries is the concept of whether brain tissue oxygenation can help guide therapy for a patient with a severe traumatic brain injury.

So historically, many university centers across the world, many experienced Level 1trauma centers have been using brain tissue oxygenation monitoring, basically almost as though you had a pulse oximeter of brain tissue. Many folks around the world have used brain tissue oxygenation monitoring as another way to help manage their patients with severe traumatic brain injury.

Here at the University of Utah and also many sites throughout this country and across the world in a separate study have decided to do a randomized controlled trial on this and understanding whether it will bear out in a huge patient population of improving outcomes. And Zoe was enrolled in that trial, and the trial is called BOOST-3.

Interviewer: So what exactly is BOOST-3 looking to do?

Dr. Grandhi: What we're looking for in the BOOST-3 trial is to determine whether using brain tissue oxygenation monitoring in the care of patients with severe traumatic brain injury improves outcomes at six months.

This is over and above using traditional monitoring techniques such as intracranial pressure monitoring and cerebral perfusion pressure monitoring that are already used commonly as part of guidelines that have been established in taking care of patients like Zoe.

Interviewer: So, Zoe, we've been talking a lot about kind of the medical side of things. I want to go back to you. What was it like when you first had Dr. Grandhi or any of the other specialists kind of explain the condition to you and what was going to be expected moving forward?

Zoe: I think in all the research that I've done and the people around me have done and then my discussions with Dr. Grandhi initially and shortly thereafter, and from what I gather from all of that, is that it's largely unexpected. The results and the things that come of it are known and yet unknown, right? It's things that they know come from a severe traumatic brain injury and then there are things that you don't really know will come up until they come up and until you experience them.

So from what I've been able to dissect from this injury is kind of pick apart, or notice rather, the moments in my own life where the thought comes into my head saying, "No, this isn't really you. This isn't really the Zoe that has made it to this point." "This is the TBI speaking," I guess, for lack of a better term or phrase.

An example would be if I'm feeling really, really agitated one day or even one hour and then the next hour I'm back to feeling normal again. So it's really quite a rollercoaster, I would say.

Interviewer: But what did it feel like to kind of hear that? I mean, as an outsider, as someone who's never experienced this kind of thing, that sounds kind of scary to me.

Zoe: Well, I would say more jarring than frightening. As the patient or as the person with a severe TBI, you don't necessarily . . . or I didn't, at least, necessarily believe the things that were being told to me. Not that I would think, "Oh, Dr. Grandhi is a liar," but I didn't necessarily believe it until those things started to show up for me in my own life later on and as time went on.

So months later, it's coming up on a year, so a full year later, I notice things that they told me initially that I might feel or that may come up. And at the time, I was thinking, "Well, I feel fine now, so we're good. We're all good here. Have a nice day." So it wasn't until up to this point that I think, "Oh, okay. I see what they mean by this progression and regression of things that may come and go," and things that I might feel that I didn't think I would feel at the time.

So it was definitely helpful to hear that then, and thinking about it now, "Oh, okay. They were right all along. They know what they're talking about."

Dr. Grandhi: I think it's really important to understand that while we as physicians, particularly as neurosurgeons who take care of patients with severe traumatic brain injury, I look at Zoe, and we raise our hands and we run a victory lap saying that she is a success.

And first things first is just in the acute setting, there's more research coming out that shows that if you are able to get a patient through the acute brain injury setting and manage them correctly and take care of them, we should not be nihilistic about where they will be one year later.

There's new research using big data sets that show that patients such as Zoe who come in with severe traumatic brain injury can have favorable outcomes at one year. Part of this data set also shows that 20% of patients can perhaps have no disability at one year.

But that being said, Zoe's experience alludes to the fact that we cannot forget about our patients. They still sometimes experience some sequalae that are hard to just kind of put a finger on. Like Zoe talks about, just agitation, maybe irritability, maybe memory issues.

So this is a process, an evolution, and it's really important for us to be able to support our patients, get them the correct resources, and really kind of steer them and continue to shepherd them through the process, which may take many more years.

Again, the concept of neuromonitoring for patients with traumatic brain injury only pertains to patients with severe traumatic brain injury, patients who are in a coma, patients who come into a hospital in a comatose state.

And I think we're going to learn a lot through this study as well as over the next years of how to really target various treatment thresholds and really tailor a patient's care to perhaps the type of pathology that they're coming in with.

So this is really important to patients with severe traumatic brain injury, but for the audience out there who is interested in traumatic brain injury in general, because most of the patients who experience a traumatic brain injury don't come in like Zoe in a coma, we're learning a lot about traumatic brain injury in general.

We're learning that there are so many different components to living with a traumatic brain injury. We are understanding that there are perhaps new ways of diagnosing patients and understanding what's called biomarkers and their role and understanding whether they're different symptoms, sequalae, or phenotypes that people experience after a traumatic brain injury.

Finally, it's really, again, very important to support our patients because it's not just the acute recovery stage. One of the people who trained me told me the biggest misnomer in patients who come in with mild traumatic brain injury, which is sometimes called a concussion, is there's nothing mild about it if you experience headaches two months after the fact, or if you have problems with staring at your computer screen if you're a person who works on computers and have eye strain after that, or have problems with balance. There's nothing mild about it.

And now the question is, "How can we support our patients better and get them the needed resources they need to get back on their feet and get their life back in order?"

Interviewer: So, Zoe, you're 25 now. It's been a year since the initial incident. How have you felt along the process? And how do you mark your own success and, I guess, healing from this particular incident?

Zoe: It actually took quite a while for me to recognize my own success, my own progress. It's really been just recently, actually, that I've been able to think to myself, "Oh, okay. You can actually do that thing now that you weren't able to do three months ago, four months ago."

It's more so just the ability to recognize those things. And I wasn't able to recognize those things previously. So it's been really difficult to measure my own progress based on what that looks like or what that has looked like in the past year.

I mean, highs, overall, I would say the ability to remember. Honestly, my short-term memory was completely restarted, completely obliterated in the beginning, and I wasn't able to hold a memory for several minutes. I would forget the thing before. So my working memory and my short-term memory have improved significantly.

Luckily, nothing really ever happened to my long-term memory, so I was able to remember years past. I could tell you where exactly I was and who I was with, especially right in the early beginning.

One of the most difficult things, but probably does not top the list, that I've experienced from the fallout, if you will, is the changing of relationships in my life. Friendships and various other things that have been really difficult to not only maintain, but to offer my lived experience as it is and as I see it and as I experience it. It's extremely difficult to explain the mindset that I have and where my brain is at on any given day.

And luckily, some of them have had extreme understanding and extreme patience with me. And that's really all I ask of the people in my life now, is, "Please be patient with me and my progress and the things you likely don't see on a day-to-day basis." On hour-by-hour basis even.

I've told the people closest to me, "This could be a years-long journey process, if you will, for my mental state, so the patience is so appreciated."

And then the highs . . . To be quite frank, I think the highs for me personally, they've been recognized by the people in my life for a while now, for the last year, but I personally have not been able to see or really process or digest those highs.

So it's really just been very recent in the last few months that I've been able to look at myself and say, "Wow, you can do that now after being completely immobile for nearly two months," or, "Wow, you can move that way again," or, "You can stretch that way again."

I used to and would eventually like to get back to very, very involved in hot yoga. I used to do hot yoga frequently. And before that, I was a gymnast and a dancer. So in the beginning, it was very excruciating for me to, say, not even touch my toes. And that was a huge blow more so to my ego than anything else, but a huge blow nonetheless.

And so I think the highs now are being able to recognize that, "Hey, I am able to touch my toes," and I stretch, and I exercise, and I do all these things every single day to better myself.

Initially, it was very much like, "Wow, you aren't able to do this? What happened?" And then it was up to a few months ago that I started telling myself, "No, you have to be much more patient to yourself, much more kind to yourself," than the completely and constant berating myself for why I'm not able to do something, or accomplish something, or say something in the way that I want to say it, etc.

Dr. Gandhi: I think that was just incredible to hear. As I said before, we run laps when we look at Zoe, but to hear her personal experience and understand that this is not over for her and understand what she goes through and also understand what defines us is the little things that make us who we are. Zoe touching her toes, doing hot yoga, it's incredible. It makes us really take a step back and understand this as a human experience, understand this as a personal experience.

The privilege of being able to be involved in Zoe's care and the care of others is not lost when you hear these things. The story of Zoe and patients like Zoe is not done in December 2021. It's an experience that she's going to live through and get through for the rest of her life.

She's sitting 10 feet away from me right now and her mom is right here as well. She's going to get there, and we just have to do everything we can to support her. She's just incredible. And to just hear Zoe, hear her voice come through in this experience is just profound for us. As many times as I've seen Zoe, I've never known these little things about Zoe, and it's amazing to hear.

Interviewer: To find out more about traumatic brain injury as well as the services offered through the brain injury program at the Craig H. Neilsen Rehabilitation Hospital, visit the link in the episode description.

Interviewer: According to the Centers for Disease Control and Prevention, more than two million Americans experience a brain injury each year. While some of these injuries result in relatively short-term impact on a day-to-day function, others can lead to long-term challenges or even a permanent disability.

Today, we'll be speaking with Zoe, a young woman who experienced a traumatic brain injury after an accident and the long journey of her recovery and the daily experience of overcoming the long-term challenges of life after an accident like this.

And to help us better understand the medical side of a traumatic brain injury, joining us is associate professor of neurosurgery at University of Utah Health, Dr. Ramesh Grandhi, the doctor who helped stabilize Zoe after her accident.

Zoe, why don't we start with what kind of led to your traumatic brain injury in the first place? What exactly happened?

Zoe: Yeah. Well, interesting story. I had just moved to Salt Lake City in August of 2020, and this occurred . . . or rather, my accident occurred December 5, 2020. So I had just shy of five months in the state, really.

So I hadn't experienced a lot, but a friend and I really wanted to ski together. I bought a season pass at Alta, was really excited to get up there. And it was day one, in fact, of the ski season that this happened. So really did not get any other skiing in, obviously, but this was day one.

Yeah, I mean, I don't remember a whole lot about the day itself. I have spotty memories of the drive up to Alta, getting to Alta. I actually have some spotty memories of being on the lift up to the first run. After that, I don't remember anything. I remember a bit of skiing, and that's really about it in terms of the day.

And then subsequently, upon waking up, I have absolutely no memory of the remainder of December. My memory is really spotty from about Thanksgiving up to December 5th. So Thanksgiving, I would say, is the last clear memory that I have and everything else is kind of spotty. It appears in my head almost as if I made it all up.

I've had to ask a lot of people, especially family members, "Did this really happen? Can you describe this thing to me or remind me who was at Thanksgiving again?" I never would have guessed something like this when I first started skiing with my dad 10-plus years ago.

And I was maybe 500 yards behind several of my friends, so I was alone during the actual collision. I ran into this group of trees that sat right in the middle of the run that I was on at Alta.

In this tree well, it was icy. I slipped on the snow evidently and collided with some trees in the tree well. What I would assume happened at that point is I was knocked unconscious by the collision and then fell and was hidden by this tree well and this group of trees. And then because I wasn't found until about four hours later, I had become buried or covered by snow by people skiing by, obviously.

Interviewer: Sure. So you're spotty memory-wise from Thanksgiving to . . . When did you start to remember things again?

Zoe: Right. So really, my lucidity, I would say, started to come back right around January 6th, 7th, 8th, right in that area. This is purely what I was told, is that I woke up somewhere mid to end of December. The rest of December went by. I was then transferred to a long-term care facility outside of Salt Lake City. And right around that, again, 6th, 7th, 8th of January is when I have memories that I'm able to go back on and say, "Oh, yeah, that was right in the beginning of January." Before that, though, I have no memories.

Interviewer: Wow. So, Dr. Grandhi, I want to go to you at this point. When did Zoe come into the care of you, your team, the University of Utah Hospital?

Dr. Grandhi: As I recall it, I didn't find out about Zoe until Sunday morning first thing. I know that she presented as a transfer to our hospital, and clearly, she had traumatic injuries. And the first principle of what we do is just stabilize the patient. The trauma surgeons and a number of other services are super important and are our partners in making sure that a patient is appropriately stabilized.

And then my partner was actually on call and received the first call about her. He then got in touch with me. We do a really nice job within our department about communicating about patients with traumatic brain injuries, and specifically, patients with severe traumatic brain injuries.

So I remember that Sunday morning very well because she was downstairs in our surgical ICU. I went and saw her and just looked at her images, and then went out and talked to her dad who was sitting in the waiting room all by himself.

I remember the exact seat he was seated in early on that Sunday morning, probably around 8:00 a.m. or 9:00 a.m. And he was just by himself. I just walked up to him and told him what my assessment was of the situation based on looking at her head CT and things like that.

And at that point, it was just me trying to tell him that we're going to do our best to take care of her, that she presented with what we call a severe traumatic brain injury, and what the principles of managing patients with that are, and also, honestly, giving him hope.

Interviewer: When we talk about traumatic brain injury, is it a lot of skiing injuries, sports injuries? What is the most common type of traumatic brain injury?

Dr. Grandhi: Traumatic brain injury is a significant burden in the Western world. It's the number one cause of death amongst young folks in the Western world.

Traumatic brain injury falls into three buckets: severe traumatic brain injury, moderate traumatic brain injury, and mild traumatic brain injury. And oftentimes, patients with mild traumatic brain injuries don't even come into the hospital. We call it a concussion. And oftentimes, a patient may stay at home after hitting their head, or being involved in a sports injury, or a motor vehicle collision, or falling and hitting their head.

The burden of traumatic brain injury in the United States today is about 2.5 million patients per year. So many patients don't even come into the hospital. Many patients are discharged from the ER.

Interviewer: Zoe and her accident, of those three buckets, what did hers fall into, and why?

Dr. Grandhi: Zoe had a severe traumatic brain injury. And the way we diagnose severe traumatic brain injury is quite simple. We just gauge it in terms of what their neurologic exam is when they come in. So are they able to open their eyes? Are they able to speak? Are they able to follow commands?

Interviewer: And Zoe was unable to do those things?

Dr. Grandhi: Correct.

Interviewer: Wow. Zoe, do you remember any pieces or parts of the story? How did you feel when you were first, I guess, coming out of it?

Zoe: Yeah. Again, like I said before, the first memories I have are really in the long-term care facility that I was transferred to after leaving The U. I think it was sort of a slow realization.

And then since then, I would say I've noticed things that are sort of side effects or fallouts from having a severe traumatic brain injury: getting frustrated much more easily, being able to jump to anger much more easily, having very little patience, amongst many others. So it was very much a slow realization and slow rollout. And then still to this day, new things come up.

So it was much more slow. It wasn't similar to if you broke your arm and someone said, "Oh, you broke your arm," and then they casted it up right then and there. It was much more prolonged than that and slow realization.

My initial thought, honestly, was because I was awake and lucid and conscious, "Oh, my brain is fine. Well, everything is good. I can speak. I can see. I can hear. I can eat. I have my motor functions." And so, initially, I didn't think too much about the effects on my brain, and that did come up much later and still continues to this day.

Interviewer: Dr. Grandhi, when it comes to treatment of a case like Zoe, what was done to help Zoe get from the accident to where she was stabilized and in, I guess, a longer-term facility to kind of monitor her?

Dr. Grandhi: Well, I think we need to kind of dial it back a little bit to understand the management principles of patients with severe traumatic brain injury. And it starts, honestly, in the pre-hospital setting in which those who are on the first line understand how to manage a person, particularly with a pathology as significant as severe traumatic brain injury.

So first things first, getting the patient stabilized in the field, making sure that people are very cognizant of taking care of the patient, immobilizing their neck. Again, we don't know if a patient has had an injury to the cervical spine. Zoe clearly hit trees, so she could have very easily had damage to her neck, to the bones of her neck, spinal cord, etc. So getting a patient stabilized at the point of injury, then making a decision of where the patient goes.

There is data to show improved outcomes in patients who have a severe traumatic brain injury who are taken to Level 1 trauma centers. So understanding where to send the patient when the patient comes in.

Again, we have a huge bevy of services that are there in the ER, in the trauma bay awaiting a patient, because there's pre-hospital notification. And so if a person is coming in as a Level 1 trauma to a Level 1 trauma center, we do have orthopedics right there. Neurosurgery is right there in the trauma bay. Obviously, trauma surgery, the ER doctors, a number of different services and specialties are there awaiting the patient.

Airway management is important, worrying about circulation, blood pressure, ensuring that there's no intra-abdominal injuries. After that, there are a lot of scans that are ordered inclusive of CT scans that are literally performed head to toe to make sure that we're not missing significant injuries that need actionable treatment, such as rushing a patient up to the operating room for an intra-abdominal injury.

That being said, once that is done and there's nothing imminent that needs to be treated emergently, the patient is generally taken up to the ICU. And in Zoe's case and a patient with a severe traumatic brain injury, they're ventilated, and then there's a lot of management that occurs then predicated on blood pressure management, good oxygenation for the patient.

And for patients with severe traumatic brain injury, when we know a patient has a severe traumatic brain injury, we place particular monitors in the patient's brain because we're obligated to make sure that we have good control of intracranial pressure. So we want to make sure that we know what a patient's intracranial pressure is, and we need to keep it below certain thresholds.

We clearly know what the patient's brain perfusion is in terms of what's the state of blood pressure to brain tissue. So we monitor a patient's systemic blood pressure, their body's blood pressure well, and have to get the brain perfusion pressure in a particular range.

That's a quick summation of the management principles of a patient with severe traumatic brain injury. Not every patient requires a big-time operation and removing part of the skull or sucking out blood, but when we do place brain monitors, we do have to drill a small hole in people's skull to place these monitors. We have to remember that brain injury comes in many different flavors, even severe traumatic brain injuries.

Interviewer: So you just keep an eye on all the things that are going on with your monitors and everything to see whether or not there's injury?

Dr. Gandhi: Absolutely. And we use CAT scans liberally to help us understand more about the evolution of the brain injury. Zoe did have blood in her head, no question about it, but we did not feel that this blood would require us to take her to the operating room for an emergent surgery to remove the blood.

Interviewer: It's my understanding that Zoe then was a part of a study dealing with neuromonitoring. So for someone who's listening right now, what exactly is neuromonitoring, and why is it so important that we do research with it?

Dr. Gandhi: Whenever someone is classified as having a severe traumatic brain injury, we know from years of research and guidelines and a lot of work from really experienced, savvy, thoughtful leaders in the field that patients should get particular things monitored.

As I had said, we want to get invasive arterial blood pressure monitoring so that we can get a good second-to-second, moment-to-moment gauge of what a person's blood pressure is not using one of those expandable blood pressure cuffs. So this is something that allows us to know on a moment-to-moment basis what a person's blood pressure is doing.

We also ensure that the patient has adequate ventilation using a breathing tube. We study their intracranial pressure via an intracranial pressure monitor.

Finally, one of the things that has been important recently in the care of patients with severe traumatic brain injuries is the concept of whether brain tissue oxygenation can help guide therapy for a patient with a severe traumatic brain injury.

So historically, many university centers across the world, many experienced Level 1trauma centers have been using brain tissue oxygenation monitoring, basically almost as though you had a pulse oximeter of brain tissue. Many folks around the world have used brain tissue oxygenation monitoring as another way to help manage their patients with severe traumatic brain injury.

Here at the University of Utah and also many sites throughout this country and across the world in a separate study have decided to do a randomized controlled trial on this and understanding whether it will bear out in a huge patient population of improving outcomes. And Zoe was enrolled in that trial, and the trial is called BOOST-3.

Interviewer: So what exactly is BOOST-3 looking to do?

Dr. Grandhi: What we're looking for in the BOOST-3 trial is to determine whether using brain tissue oxygenation monitoring in the care of patients with severe traumatic brain injury improves outcomes at six months.

This is over and above using traditional monitoring techniques such as intracranial pressure monitoring and cerebral perfusion pressure monitoring that are already used commonly as part of guidelines that have been established in taking care of patients like Zoe.

Interviewer: So, Zoe, we've been talking a lot about kind of the medical side of things. I want to go back to you. What was it like when you first had Dr. Grandhi or any of the other specialists kind of explain the condition to you and what was going to be expected moving forward?

Zoe: I think in all the research that I've done and the people around me have done and then my discussions with Dr. Grandhi initially and shortly thereafter, and from what I gather from all of that, is that it's largely unexpected. The results and the things that come of it are known and yet unknown, right? It's things that they know come from a severe traumatic brain injury and then there are things that you don't really know will come up until they come up and until you experience them.

So from what I've been able to dissect from this injury is kind of pick apart, or notice rather, the moments in my own life where the thought comes into my head saying, "No, this isn't really you. This isn't really the Zoe that has made it to this point." "This is the TBI speaking," I guess, for lack of a better term or phrase.

An example would be if I'm feeling really, really agitated one day or even one hour and then the next hour I'm back to feeling normal again. So it's really quite a rollercoaster, I would say.

Interviewer: But what did it feel like to kind of hear that? I mean, as an outsider, as someone who's never experienced this kind of thing, that sounds kind of scary to me.

Zoe: Well, I would say more jarring than frightening. As the patient or as the person with a severe TBI, you don't necessarily . . . or I didn't, at least, necessarily believe the things that were being told to me. Not that I would think, "Oh, Dr. Grandhi is a liar," but I didn't necessarily believe it until those things started to show up for me in my own life later on and as time went on.

So months later, it's coming up on a year, so a full year later, I notice things that they told me initially that I might feel or that may come up. And at the time, I was thinking, "Well, I feel fine now, so we're good. We're all good here. Have a nice day." So it wasn't until up to this point that I think, "Oh, okay. I see what they mean by this progression and regression of things that may come and go," and things that I might feel that I didn't think I would feel at the time.

So it was definitely helpful to hear that then, and thinking about it now, "Oh, okay. They were right all along. They know what they're talking about."

Dr. Grandhi: I think it's really important to understand that while we as physicians, particularly as neurosurgeons who take care of patients with severe traumatic brain injury, I look at Zoe, and we raise our hands and we run a victory lap saying that she is a success.

And first things first is just in the acute setting, there's more research coming out that shows that if you are able to get a patient through the acute brain injury setting and manage them correctly and take care of them, we should not be nihilistic about where they will be one year later.

There's new research using big data sets that show that patients such as Zoe who come in with severe traumatic brain injury can have favorable outcomes at one year. Part of this data set also shows that 20% of patients can perhaps have no disability at one year.

But that being said, Zoe's experience alludes to the fact that we cannot forget about our patients. They still sometimes experience some sequalae that are hard to just kind of put a finger on. Like Zoe talks about, just agitation, maybe irritability, maybe memory issues.

So this is a process, an evolution, and it's really important for us to be able to support our patients, get them the correct resources, and really kind of steer them and continue to shepherd them through the process, which may take many more years.

Again, the concept of neuromonitoring for patients with traumatic brain injury only pertains to patients with severe traumatic brain injury, patients who are in a coma, patients who come into a hospital in a comatose state.

And I think we're going to learn a lot through this study as well as over the next years of how to really target various treatment thresholds and really tailor a patient's care to perhaps the type of pathology that they're coming in with.

So this is really important to patients with severe traumatic brain injury, but for the audience out there who is interested in traumatic brain injury in general, because most of the patients who experience a traumatic brain injury don't come in like Zoe in a coma, we're learning a lot about traumatic brain injury in general.

We're learning that there are so many different components to living with a traumatic brain injury. We are understanding that there are perhaps new ways of diagnosing patients and understanding what's called biomarkers and their role and understanding whether they're different symptoms, sequalae, or phenotypes that people experience after a traumatic brain injury.

Finally, it's really, again, very important to support our patients because it's not just the acute recovery stage. One of the people who trained me told me the biggest misnomer in patients who come in with mild traumatic brain injury, which is sometimes called a concussion, is there's nothing mild about it if you experience headaches two months after the fact, or if you have problems with staring at your computer screen if you're a person who works on computers and have eye strain after that, or have problems with balance. There's nothing mild about it.

And now the question is, "How can we support our patients better and get them the needed resources they need to get back on their feet and get their life back in order?"

Interviewer: So, Zoe, you're 25 now. It's been a year since the initial incident. How have you felt along the process? And how do you mark your own success and, I guess, healing from this particular incident?

Zoe: It actually took quite a while for me to recognize my own success, my own progress. It's really been just recently, actually, that I've been able to think to myself, "Oh, okay. You can actually do that thing now that you weren't able to do three months ago, four months ago."

It's more so just the ability to recognize those things. And I wasn't able to recognize those things previously. So it's been really difficult to measure my own progress based on what that looks like or what that has looked like in the past year.

I mean, highs, overall, I would say the ability to remember. Honestly, my short-term memory was completely restarted, completely obliterated in the beginning, and I wasn't able to hold a memory for several minutes. I would forget the thing before. So my working memory and my short-term memory have improved significantly.

Luckily, nothing really ever happened to my long-term memory, so I was able to remember years past. I could tell you where exactly I was and who I was with, especially right in the early beginning.

One of the most difficult things, but probably does not top the list, that I've experienced from the fallout, if you will, is the changing of relationships in my life. Friendships and various other things that have been really difficult to not only maintain, but to offer my lived experience as it is and as I see it and as I experience it. It's extremely difficult to explain the mindset that I have and where my brain is at on any given day.

And luckily, some of them have had extreme understanding and extreme patience with me. And that's really all I ask of the people in my life now, is, "Please be patient with me and my progress and the things you likely don't see on a day-to-day basis." On hour-by-hour basis even.

I've told the people closest to me, "This could be a years-long journey process, if you will, for my mental state, so the patience is so appreciated."

And then the highs . . . To be quite frank, I think the highs for me personally, they've been recognized by the people in my life for a while now, for the last year, but I personally have not been able to see or really process or digest those highs.

So it's really just been very recent in the last few months that I've been able to look at myself and say, "Wow, you can do that now after being completely immobile for nearly two months," or, "Wow, you can move that way again," or, "You can stretch that way again."

I used to and would eventually like to get back to very, very involved in hot yoga. I used to do hot yoga frequently. And before that, I was a gymnast and a dancer. So in the beginning, it was very excruciating for me to, say, not even touch my toes. And that was a huge blow more so to my ego than anything else, but a huge blow nonetheless.

And so I think the highs now are being able to recognize that, "Hey, I am able to touch my toes," and I stretch, and I exercise, and I do all these things every single day to better myself.

Initially, it was very much like, "Wow, you aren't able to do this? What happened?" And then it was up to a few months ago that I started telling myself, "No, you have to be much more patient to yourself, much more kind to yourself," than the completely and constant berating myself for why I'm not able to do something, or accomplish something, or say something in the way that I want to say it, etc.

Dr. Gandhi: I think that was just incredible to hear. As I said before, we run laps when we look at Zoe, but to hear her personal experience and understand that this is not over for her and understand what she goes through and also understand what defines us is the little things that make us who we are. Zoe touching her toes, doing hot yoga, it's incredible. It makes us really take a step back and understand this as a human experience, understand this as a personal experience.

The privilege of being able to be involved in Zoe's care and the care of others is not lost when you hear these things. The story of Zoe and patients like Zoe is not done in December 2021. It's an experience that she's going to live through and get through for the rest of her life.

She's sitting 10 feet away from me right now and her mom is right here as well. She's going to get there, and we just have to do everything we can to support her. She's just incredible. And to just hear Zoe, hear her voice come through in this experience is just profound for us. As many times as I've seen Zoe, I've never known these little things about Zoe, and it's amazing to hear.

Interviewer: To find out more about traumatic brain injury as well as the services offered through the brain injury program at the Craig H. Neilsen Rehabilitation Hospital, visit the link in the episode description.

Interviewer: For a patient who has experienced any sort of traumatic brain injury, recovery can be something that might seem a little scary. How long is it going to last? What can you expect, etc.?

So to answer some of these questions, we are here with Dr. John Speed. He is a professor in the division of Physical Medicine and Rehabilitation and practices at the University of Utah Health. Now, Dr. Speed, when we talk about a traumatic brain injury, that's a pretty big term. What kind of patients are we talking about here?

Dr. Speed: We're talking about a huge spectrum of people, from an individual that may have sustained a concussion heading a soccer ball all the way to someone that's been in a catastrophic car accident and sustained a brain injury that's left them in a coma for a prolonged period of time.

Interviewer: And what kind of patients do you see the most getting these types of injuries?

Dr. Speed: Well, the most common type of brain injury really is the concussion or mild brain injury that might be seen in the emergency room and sent home. But here at the Craig H. Neilsen Rehabilitation Hospital, we take care of patients in the hospital that have sustained more severe injuries that are perhaps comatose or have much more significant problems that last for a longer period of time.

Interviewer: So someone comes into say the hospital, the emergency room, this particular center with a brain injury, what's the first things that you guys are going to do to, you know, make sure that they're okay?

Dr. Speed: Well, that piece of it really falls to my neurosurgical and emergency room colleagues. They'll do any necessary surgical intervention to, say, remove a blood clot that may have formed. Possibly they'll do a procedure to remove a piece of skull to allow for brain swelling, which can be incredibly frightening for family members because obviously it looks very awful. But then once the person has recovered from a neurosurgical standpoint and they're ready for rehabilitation, they'll transfer over to the Craig H. Neilsen Rehabilitation Hospital and they'll have inpatient rehabilitation here working on all of the problems that they may have as a result of their brain injury.

Interviewer: And what are some of the problems that a patient like this might be experiencing?

Dr. Speed: Well, the brain is awfully complex and it does everything. So it could be emotional problems. It could be cognitive problems. It could be paralysis of one or both sides of the body, swallowing problems, speech problems, visual difficulties, you name it.

Interviewer: So when we talk about emotional or cognitive, what kind of things are we experiencing? Like a change in mood and behavior, lack of memory, what are some of those things?

Dr. Speed: Well, early on a person may still be in what we call post-traumatic amnesia. They have no idea where they are. They have no idea what's going on. They can't process information. They can't make sense of their environment. And I make the analogy that it's somewhat like living inside a kaleidoscope. They're just presented with all of the sensory input that they can't make any sense of. And so, of course, that's a very frightening experience, and oftentimes the reaction is one of thrashing around, being agitated, yelling, screaming, because it's a very frightening and disorienting experience. But as a person continues to recover, that orientation improves and the person can make sense of their environment again and that agitation will eventually settle down.

Interviewer: That sounds like a kind of situation that could cause some anxiety for both a patient and for, say, the loved ones that are looking on. What can, you know, doctors like you or someone at a center like the Craig H. Neilsen Center do to help relieve these kinds of symptoms and get the person, you know, closer to normal?

Dr. Speed: Well, the first thing we do is have the person in a low stimulation environment because the less sensory input coming in, the low light, low sound, the TV is off, blinds are down, etc., and minimize the stimulation. And then if necessary, we may use a person's music that they're familiar with, that they enjoy. That can be calming for lots of people. And interestingly, I had patient years ago, who was a young man who was into head banging heavy metal and that was something that was very calming for him. It was very disturbing for the staff, but it worked to help him feel more comfortable and relaxed.

Interviewer: So after a patient has gone through that post-traumatic amnesia, what are some of the steps that come next, and how long can a patient and their loved ones be expecting the recovery to take?

Dr. Speed: Well, of course, the recovery is incredibly variable, and it depends on the severity of the injury, it depends on the type of injury or injuries, and it also depends to some extent on what the person had in terms of life experience prior to the injury. But once the typical sort of sequence of events is the person will proceed out of post-traumatic amnesia. So they'll be oriented, they'll know where they are, they'll know what year it is, and so forth. They'll know that they're in the hospital and why they're in the hospital.

And our therapists are excellent at working with people to regain physical function, balance coordination, mobility. Our occupational therapists will work on what are called activities of daily living. How does a person get dressed? How do they bathe themselves? And those sound pretty basic, but, you know, if a person has had a brain injury, they may not be able to dress themselves. They may put their pants on and then put the underpants on outside because they just don't know the sequence of events that are necessary and they can't process that. So occupational therapists will work on those kinds of things. And then we also have speech therapists that will work on cognition, memory, and also address any language problems that might exist and also any swallowing difficulties that might result from the brain injury.

Interviewer: So what are the expected outcomes for the types of treatment regardless of what kind of brain injury this individual is having and comes to a center like the Craig H. Neilsen Rehab Center?

Dr. Speed: Well, outcomes, of course, are incredibly variable, but we're very proud of the outcomes that we do achieve here. And more than 80% of the people that we admit to the Craig H. Neilsen Rehab Hospital with brain injury are discharged to home. And that doesn't mean the rehab therapies are finished at that time, but people do go home and continue their therapies in some fashion after discharge to home.

Interviewer: And how long are they typically at a center like the Neilsen Center?

Dr. Speed: Well, our typical length of stay for someone with a brain injury that's admitted here is somewhere between two and three weeks.

Interviewer: Wow. So I guess one of the messages maybe that, you know, with the right help and the right medical assistance, there is hope for someone after a traumatic brain injury.

Dr. Speed: Oh, absolutely. For sure.

Interviewer: Now, if your child is complaining of leg pains, could it be growing pains, or is it something more serious?

Dr. Julia Rawlings is a nonoperative sports medicine physician here at University of Utah Health. And let's start with the type of leg pain I think just about every kid, at some point, experiences. One point or another, it seems pretty benign. What exactly is growing pain? What are growing pains, I guess?

Dr. Rawlings: Yeah. So growing pains, the name came kind of early in the 1930s and 1940s when people thought that growth was related to these pains that children get, usually later in the afternoon, evening, or maybe even wakes them up at night. But we know now that it's not related to growth, but it's more likely just related to children being very active during the day. So it's just these pains that come on later in the day or at night, mostly from kind of overuse of muscles.

Interviewer: But it's not like the bones are stretching or anything like that. It's just . . .

Dr. Rawlings: No, it doesn't have anything to do with growing. It does happen in children, but it doesn't affect their growth. It's not directly related to growing.

Interviewer: My understanding is it's pretty normal for kids to be having this and just as part of, like, I guess being active and running around.

Dr. Rawlings: It's very common. And the places where it's most common, usually it happens in the calf, the thigh, or the back of the knee. So those are some of the spots that we look at.

Interviewer: Okay. And it's like an aching or just like . . . I guess, how do we know that it's like that kind of pain?

Dr. Rawlings: Yeah, it's like an aching or a throbbing pain. Sometimes children will grab the back of their legs or grab their thighs or just be more cranky. It's usually at the end of the day. It can wake them up at night though.

Interviewer: And so your child's complaining of pain. I guess, as a parent, if you're worried, you know, what should you be on the lookout for to find out if it's something more than just typical growing pains?

Dr. Rawlings: Yeah. So growing pains usually happen intermittently. So it can happen every night, but that's a little less common. So growing pains typically are intermittent. They're usually in both legs, not necessarily at the same time. And the child usually wakes up in the morning completely fine and running around like there's nothing wrong. Those are all very typical for growing pains.

Interviewer: So say a kid is, you know, maybe continually complaining about leg pain or maybe they're getting it through the day. As a parent, what are some of the signs and symptoms that you should be on the lookout for to kind of let you know this isn't growing pains, it's something more serious?

Dr. Rawlings: Yeah, great question. So if your child is complaining of pain, particularly during the day, if they are complaining of pain in the same leg, if the pain stops them from participating in sports activities or from running with their friends, if they are limping with the pain during the day, or if you see anything else that seems abnormal, so swelling of the leg, redness of the leg, if they're getting fevers with it, all of that is something besides growing pains, and you should be seen for that.

Interviewer: And not to, say, worry parents, you know, prematurely, but what could be going on with their child?

Dr. Rawlings: So it could be something as simple as an overuse injury. Lots of times, in children that play sports, we see overuse injury at the growth plates actually. That's probably one of the more common things. If they're very active, say a teenager running, they could get a stress injury. They could just have tight muscles, and stretching could be helpful. All the way up to the more serious things that are very rare and uncommon, like childhood arthritis or bone cancer.

Interviewer: If your child is, say, showing some of these symptoms, what kind of doctor should you be going to, to, you know, treat the leg? Is it a primary care pediatrician? Is it a sports medicine specialist?

Dr. Rawlings: I think, initially, if your pain is kind of vague and you're not sure what's going on, starting with the pediatrician is a great place. If it's something more serious, like they're not limping, they can't get into the pediatrician, it is reasonable to go to an urgent care or the emergency department, particularly if they won't walk at all. We need to see what's happening. There are . . . sometimes toddlers will have a small fall and twist their leg, and they won't walk, and they'll have a little fracture that you won't even pick up on. And so that's one of the more common reasons we'll see toddlers stop walking, and that's something that can be taken care of either by a pediatrician, a nonoperative sports medicine provider, or in an urgent care emergency medicine setting.

Interviewer: And is there anything, maybe a home remedy, something they could try at home before they, say, take them into a doctor to maybe alleviate any of the pain that they're experiencing?

Dr. Rawlings: Yeah. So if they're experiencing more of these growing pains, kind of intermittent pains in the evening or at night, you can do things like massage the legs, massage the muscles. Warm packs, heating pads are helpful. If it's severe, you can try some acetaminophen, Tylenol, or ibuprofen. And sometimes if it's pretty frequent, you can have them do some stretching during the day and see if that helps as well.

Many kids, especially athletes, will complain that their feet hurt at some time. Heel pain is especially common and especially during growth spurts.

Heel pain in athletes who are growing actually has a name. It's called calcaneal apophysitis, otherwise known as Sever's disease. It is most common between the ages of 9 and 14 and is seen in athletes who do a lot of running and jumping. My teenage soccer player has this and actually so do several of his teammates, or the teammates of my younger son who will probably end up having this also. Basically, what it is, is inflammation of the growth plate of the heel bone. The bones, muscles, and tendons in that area all grow at different rates during puberty. And when they're out of sync, the muscles and tendons pull too hard on the growth plate and that causes the inflammation.

So what can your child do to help once the pain has started? Well, to be honest, the pain will improve most once your child is done with their growth spurt. Also, it's best to stop any activities that cause pain. But, of course, we know that's not going to happen, especially if your child is on a competitive or a school athletic team.

So other things that help include having an ice pack in a towel and icing the heel for 15 minutes every one to two hours during flare-ups. Have your child take an anti-inflammatory pain medicine, like ibuprofen or naproxen. But be sure to check with your child's pediatrician on dosing. Gel heel cups and shoes with good support are also helpful. They help put less pressure and less stress on the heel. Your child's pediatrician can also give you exercises that can help with stretching and which can help with the pain and help keep the condition from getting too bad.

If the pain continues, your child may be referred to a physical therapist. And if all else fails, then your child will be put into a walking boot and referred to an orthopedic specialist for management of severe cases. Eventually, Sever's disease gets better, but not really until your child has stopped growing and that growth plate closes. Until then, manage the pain and follow the advice your child's doctor gives them.

Interviewer: Yeah. So, if you have some elbow pain while you're pitching, there is something you can do about it and actually something you should do about it. And there's a new procedure that might be the thing that you need.

Dr. Peter Chalmers is an orthopedic surgeon. He's an elbow specialist. He's also the current team physician for University of Utah baseball and Salt Lake City Bees Triple-A baseball. So if somebody does have elbow pain while they're pitching, where do you start with that diagnosis, Dr. Chalmers?

Dr. Chalmers: Yeah. Absolutely. So elbow pain during pitching, it's not normal to have really, really a sore elbow with pitching. And there can be a couple of different causes, and some of them can be problematic for the future for a pitcher. So, definitely, I think it's worth, after a period of rest, if the pain doesn't go away, seeing someone to be fully evaluated with, you know, having someone take a look at the elbow, and then potentially getting an MRI to take a look at the cartilage and the ligaments within the elbow.

Interviewer: All right. And if the condition happens to be something called an ulnar collateral ligament injury, then there's a procedure that's been used for a long time called Tommy John surgery. Tell me a little bit about that, and then we're going to talk about the alternative, which could be better for some patients.

Dr. Chalmers: Yeah. Absolutely. So, for a long period of time, if you tore your ulnar collateral ligament, the ligament on the inside of the elbow that basically holds the upper arm and the lower bones together when you pitch a baseball, if you don't have that ligament, those bones try and fall apart, and it's basically not possible to pitch a baseball. If you tore that ligament, historically, then your career was just over.

And there was a pitcher named Tommy John, who had that injury, and he went to a surgeon who said, "Well, there's got to be something we can do," and they invented this procedure to reconstruct or rebuild the ligament using a tendon graft. And that actually works pretty well, but it has a very long recovery. It takes about a year to get back to play because the new tendon has to become a ligament over the top of the old ligament. And that process is very slow.

So that was the historic way that we would treat ulnar collateral ligament injuries, and the pitcher that first underwent it, his name was Tommy John. So they're commonly referred to as the Tommy John ligament or Tommy John surgery.

Interviewer: And now there's a new procedure. So I've heard that considered called reconstruction, and now there's a new procedure that actually just repairs the ligament and has some better outcomes. So tell me a little bit about that.

Dr. Chalmers: The good thing about many of these ligament tears is often the ligament is torn right off of either the upper arm bone or lower arm bone side. And the ligament itself is still good quality tissue. So, historically, we would replace that whole ligament with a new tendon graft.

The new procedure is to repair the patient's own ligament and allow their own ligament to serve as their ligament going forward. That has a much quicker recovery and can get pitchers back to play in six months. So that's been a huge advance in our treatment for this injury and has certainly, for a lot of our players, granted them ability to get back to another season or even sometimes to get two seasons in depending on the timing.

Interviewer: So, when you're working with a pitcher, how do you determine which one of these two that you're going to use?

Dr. Chalmers: So there's a number of factors that go into that. Certainly, the appearance of the ligament on the MRI and the location of the tear play a role, but often during surgery, we'll also assess the quality of the tissue. And if the tissue is robust enough, then we can use the patient's own tissue to do the repair.

Interviewer: If it is an option, then is it just as good as the Tommy John surgery? You said, definitely, you could get back to playing faster. Is it as a robust of a repair?

Dr. Chalmers: It may be better.

Interviewer: Oh.

Dr. Chalmers: Some of our early data suggests that the rates of return to play may be higher after repair than they are after reconstruction.

Interviewer: And I understand another advantage of the ligament repair is if you have a younger athlete, that this would be an option where Tommy John surgery would not be an option. Tell me about that.

Dr. Chalmers: Yeah. Definitely, younger athletes have the highest capacity for healing. And so, in a younger athlete, this surgery can work very, very well, and that's who it's been performed in mostly to date. But in someone who's really young, if they have open growth plates, you may be concerned about performing a surgery with a ligament graft, where we may have to drill tunnels in the bone that may disrupt the growth in the future. So this is a nice option for that patient population.

Interviewer: And what does the recovery look like then? You said that the recovery is faster. You know, Tommy John surgery could take up to a year. How fast is this recovery, and what's the rehabilitation process like?

Dr. Chalmers: So as early as two weeks out from surgery, the patient begins moving their elbow. About a month from surgery, they begin strengthening. And the whole goal here is that you have to start strengthening early because as early as three months out from surgery, the pitchers will start throwing again.

Interviewer: Wow.

Dr. Chalmers: And the goal then is to get back to full play with full velocity, pitching full games by six months.

Interviewer: That sounds pretty amazing. Is that pretty amazing from your perspective as an orthopedic surgeon?

Dr. Chalmers: It's a huge advance. It's a huge change over the year, sometimes 18-month recovery we saw historically with reconstruction surgery.

Interviewer: Are there downsides to this type of repair?

Dr. Chalmers: Well, it's a relatively new option, and so we don't have 5 or 10-year outcomes with it so far. But so far, it appears to have few downsides as compared to the reconstruction. There had been some concern that if you do this surgery, it may make another surgery in the future more difficult. And so far, those have not appeared to be true, but there have been very few of those performed because it works so well.

Interviewer: And it sounds like this is a very specialized procedure still at this point. What advice would you have for somebody choosing an orthopedic surgeon to do this type of procedure?

Dr. Chalmers: Well, I think that one of the most important things patients need to understand is that surgery itself is a technical skill, and it's important to find a surgeon that you feel like performs enough of those procedures to feel competent at it. So, as a result, I think when you look for a procedure that's less common like this, you need to find a surgeon that feels comfortable and performs enough of them, that they'll have already worked through the kinks and make sure that they're not going to have any problems performing this procedure for you.

That's one of the benefits of coming to a place like the University of Utah, where you have specialists in a large variety of areas. It allows each of us doctors to find a smaller niche and then, as a result, to be better at what we do.

Interviewer: I want to talk a little bit about this procedure. So what is, in your mind, the youngest patient that you would do this type of a procedure on?

Dr. Chalmers: One of the things that is unique about this area of the elbow is that right above the ligament is a growth plate. So for people who are skeletally immature, it's very rare to have the ligament be injured. And the vast majority of those that are skeletally immature, the growth plate itself sees most of the injury, if there is an injury. As a result, we very rarely perform this procedure for anyone under the age of 14 really.

Interviewer: Is there anything else about this procedure that you feel that a patient or a patient's parents would be interested in hearing that I missed?

Dr. Chalmers: One of the things that I think is really interesting about this procedure and really important for people to understand is that we've talked historically about the reconstruction and the tissue within the reconstruction as though we can make you a new ligament. But I will tell you that the tissue that we bring in from somewhere else is not the same as what you were born with. It doesn't have the same nerve fibers. It doesn't have the same pressure fibers.

And we demonstrated that actually pretty elegantly recently in a study we did with the Angels, where we looked at the changes in reconstructed ligaments as compared to non-reconstructed ligaments over the course of a single season or off-season on ultrasound, and found actually that the ligaments that had undergone a prior reconstruction respond differently to stress than native ligaments. And I think that's probably because they don't have all of their normal sensors within them.

So one of the big benefits of this procedure is that it preserves all that. It preserves all the normal pressure sensors and nerve fibers within your own ligament and allows it to respond normally to stress in the future. So that's a real benefit of this procedure over the reconstruction, and one reason why I think we're probably going to head more and more in this direction in probably a lot of areas of our field in the future.

Interviewer: Are you working out from home with exercise bands? Well, you might want to watch out for this injury.

Dr. Troy Madsen is an Emergency Room physician at University of Utah Health. And a lot of us are trying to get in some exercise at home, and we might reach for those exercise bands. But, Dr. Madsen, I understand that there could be some risk working out with those exercise bands. Tell me more about that.

Dr. Madsen: You know, Scot, I have used exercise bands, and this is a risk I've never really considered, but apparently there is an increase in risk and injury to the eye that has been something that's been noted since the pandemic started. So what we're seeing, I think, more and more people are not going to the gym, they're working out from home, and a great tool is a resistance band. If you've ever used this, it's like a giant elastic band. You know, these things are huge. You put it around your foot, and then maybe you're leaning back or doing something with your leg, all kinds of different things, stretching, strengthening.

Well, at the University of Miami, they actually published their experience with seeing multiple patients come to the Emergency Department with injuries to their eyes from these resistance bands. So the title of this article is "Ocular Trauma Secondary to Exercise Resistance Bands During the COVID-19 Pandemic," published in the "American Journal of Emergency Medicine."

And you can imagine how this can happen. I don't know if this has ever happened to you, but let's say you wrap it around your foot, and you're stretching your leg out, and that thing is really tight. And then, maybe you've got socks on or something, and it slips off your foot and flips back and hits you in the eye.

Interviewer: Oh. Ow. Oh.

Dr. Madsen: Yeah, sounds miserable. Sounds absolutely miserable.

So they reported their experience in the "American Journal of Emergency Medicine," and they talked about 11 patients they had seen, and these were not minor injuries to the eye. So they said 11 patients, 14 eyes, so that means several of these patients had both eyes injured. Eighty-two percent of these patients had a hyphema.

So a hyphema is a pretty big deal. That's where you get blood behind the cornea. And, you know, if you ever look in the mirror, you see the cornea, you see your iris, the colored part of your eye. The cornea is the clear part over the top of that. And if you ever see blood there, it just looks like just this red line that's filling up behind there, that's a pretty big deal. That's a serious injury.

And then, vitreous hemorrhage in 36% of these patients. That's blood back behind the iris, back in kind of the main part of the eye. That can really affect your vision. Potentially, if it causes enough damage, potentially have long-term effects. Same thing with a hyphema if it's not treated.

So these are not minor injuries, but they saw a number of these, and just given the number they've seen, they reported on it in the "American Journal of Emergency Medicine" to make people aware that things are happening with resistance bands.

Interviewer: All right. So not happening to, necessarily, a large number of people that we know of, but is in the realm of possibility of happening apparently.

Dr. Madsen: Exactly. And I think the reason they published this and their conclusion was, if you're using a resistance band, wear glasses or consider wearing goggles. I mean, it may seem like overkill. It is something that emergency departments are seeing. This is one emergency department's experience. I'm sure it's happening elsewhere. I have to be honest. I have not seen this in the ER yet, but if we talk to some of our ophthalmologists, my guess is that they probably have. So it's out there, it's happening. You know, takeaway, be aware of it and consider wearing some glasses or goggles if you're using a resistance band.

Interviewer: Yeah, or consider just making sure that you're looking at how you're using it, and "If it was to slip right now, would it slip back and snap me in the eye?" And is there an adjustment you can do in your form that would, you know, prevent that from happening?

Dr. Madsen: Yeah, exactly.

Interviewer: Travis Nolan is an athletic trainer that works for the University of Utah Health Orthopedic Center and also works with high school athletes here in the valley. And the question today is if an athlete gets a fracture, should you always go get that x-rayed? Now, I threw on a trick word there, Travis. I said "always," right?

Travis: Yes, yeah, yeah.

Interviewer: So maybe not always. But first of all, you were saying that you've got stories of people who got a fracture, didn't get it x-rayed, didn't get it taken care of, and then it really impacted them later in their life. Give me an example of how that might happen.

Travis: I ended up coming in over this summer just to do some check-up on the school I work at and things like that, and this athlete pops in my room. And he wasn't really thinking about it much. He was doing some lifting and just experiencing some slight pain in his wrist. And he's like, "Hey, man. Is this normal? I took a little follow-on a couple of weeks ago." He actually did ended up going to see somebody. He was instructed to come back in if it wasn't getting better, and the athlete didn't do that. And so after evaluating it, I was pretty concerned for a fracture still present in his wrist.

And so we sent him back in. And I guess, long story short, since that second referral, getting him back into a doctor again, he has actually had four different surgeries on his wrist trying to restore normal function and trying to properly heal the bone that broke. And so he ended up breaking his scaphoid bone. And for those that have broken it or know about that bone, I'm sure they know the complications that can come from breaking that bone, and then it not healing properly because that bone can lose blood supply. And when that happens, it's called necrosis. And so part of that bone can sort of die off. He, to this day, still has trouble playing athletics. It has affected him in class, in school, writing, typing, so many aspects of his life, carrying things, lifting a backpack. And so he is definitely one of my big advocates when I have to tell other athletes to go get an x-ray, and he'll back me on that a lot of the time, so yeah.

Interviewer: So, for young high school athletes, are there some fractures that tend to occur more often that if it does occur, that is definitely a reason you want to go see somebody, ask for an x-ray? What are those kind of common fractures that could really give you problems down the road if you don't take care of them almost immediately?

Travis: Yeah, the ankle. So whether or not it's from twisting your ankle, getting it caught up in a pile, or if you're a basketball athlete, very common to come down on top of somebody's foot after you jump up into the air, and then any kind of fracture around the ankle bone. So whether it's a small chip off your tibia or fibula, those are sort of common when it comes to spraining your ankle. And most of the time, why doctors recommend x-rays for ankle sprain is because you can get . . . whether it's a small piece of your ligament sort of pulls off a little piece of bone, that's a common area to fracture as well.

The other area of the body that is another big one to go get checked out is called the base of your fifth metatarsal. So that's on the outside of your foot there. And that's a special bone because it's sort of just like the one on our wrist where if we don't catch it in time, it can also go through that sort of necrosis. And it's called a dancer's fracture, actually, because it happens in dance quite frequently. And so that's one of those areas where if you do have pain on the outside of your foot sort of near the . . . we call it the base of our fifth metatarsal. If you have pain in that location, that's a very important one to go get evaluated and x-rayed because it can go through that necrosis process.

And then also, they actually are seen quite often in the military. They're called marcher's fracture. So it's at second or third metatarsal in your foot, and that's the same thing. It's going to be those repetitive stress motions. So whether it's marching, running, jumping, that's another very common area in athletics or the sports world to see a fracture in.

Interviewer: So I noticed that these common fractures in athletics that you believe should be x-rayed seem to be around the wrists, ankles, and the feet, the smaller bone.

Travis: Yeah.

Interviewer: Yeah. So those are the ones that if you don't get them looked at, x-rayed, follow your doctor's instructions can really kind of mess things up in the future for you not only in athletics, but in regular life as well. And I'd imagine a lot of those you don't even know that there's a fracture. You probably . . . just pain. You thought maybe just strained something or sprained something. Is that accurate?

Travis: When athletes have a bigger emotional response, it's pretty easy to convince someone, like, "Hey, we should go get an x-ray on this," like, "You're in a lot of pain right now." It's more time those athletes that they're able to tolerate it. They're sort of pushing through it, they're playing with it still, or they come in and they're, like, "Dude, this is something I can deal with." And you have to have that conversation and you have to educate them on, "Hey, look. It's not about you missing a couple of games." This is about your long-term health, especially for those important areas, whether it's the scaphoid, the base of the fifth. There are some areas in your body where if you don't get them checked out and treated properly, they will cause long-term complications. You will have to get multiple surgeries on them in order to try restore normal function in your body.

Interviewer: And if the athlete is experiencing that, how much time do they have to go get the x-ray? Now, I know at University of Utah Health, we have a walk-in orthopedic center, which is great because you could just walk in, tell somebody what's going on, and they could do an x-ray right there. If they need to have a couple of days in order to arrange that, did you have a couple of days to do that or you really want to get it checked sooner than later?

Travis: Yeah. So can you wait overnight? Sure. Should you wait the entire weekend and then maybe go get it checked out on Monday? Those are some things that I probably wouldn't recommend unless you've been advised and it's already been evaluated by somebody, but make sure you're getting evaluated by a professional that can give you recommendations on, "Hey, this is one of those high-risk areas and this is why I would go get an x-ray tonight instead of waiting over the weekend."

updated: December 8, 2022
originally published: March 3, 2021

Interviewer: How to handle a knee injury. Dr. Julia Rawlings practices primary care sports medicine and also pediatric emergency medicine, and she is one of the physicians that you would find at the walk-in orthopedic clinic at University of Utah Health. I wanted to talk about knee injuries and young athletes actually. What are some common ways that young athletes can injure their knees? What specific sports or activities do you see?

Dr. Rawlings: Yeah. So it's really common to have a knee injury when you're playing sports, particularly contact sports. But severe injuries, including the ACL, don't always have to be from contact. So we typically see knee injuries that are acute, meaning they happen from a trauma, when you're doing an activity where there's either contact or you change directions quickly, so you're pivoting, you're shifting, you're changing your weight, and the knee can kind of buckle on you and get injured. In people that do more endurance-type sports, like cross country runners, we tend to see more chronic knee pain just from overuse.

Interviewer: Got you. So you kind of covered some of the common injuries to the knee. What could be handled at home without a clinic visit? And then we'll get to when you should perhaps consider coming in.

Dr. Rawlings: Yeah. So starting with an acute injury, meaning that's something you were out doing your sport, you were doing something, and all of a sudden you felt the knee pop, or you twisted it, or something happened. A couple of clues that I would give to go ahead and come in to be seen is, one, if you're having a hard time walking on your leg, then we would really like you to be seen sooner rather than later. We'd like to get X-rays and make sure there's nothing that's broken and then do a good examine and check out the ligaments and the meniscus of the knee.

Another clue is if your knee gets pretty swollen, then that means that there's something significant going on in your knee that should be seen sooner rather than later. Two more other clues, things that I like to ask people about and look for. If your knee feels like it's buckling under you, it's giving out when you walk, then there's the potential that every time it buckles, that we're doing more damage. And in that case, we'd like to get you on crutches and get you into a knee brace. Or if the knee is getting stuck or locked, meaning you can't bend it or you can't straighten it very well without kind of forcing it, those are all things that we'd want to see you sooner rather than later for.

Interviewer: And then when somebody comes into the clinic with some of those more serious symptoms, as you said, what does the clinic do?

Dr. Rawlings: Yeah. So if you have, say, a big swollen knee and we're worried about bigger injuries to the ACL or to the meniscus, something like that, what we would generally do is start off with X-rays, make sure there's nothing that's broken, and then we would do our exam, get a feel for what we think is going on, and then generally get you set up in a knee brace that's appropriate for the injury you have, plus or minus crutches. And then often, patients with significant injuries we'll get set up for an MRI to check out the soft tissue structures, which we can't see on X-ray, and get a definitive diagnosis. And then depending on what we see on our exam, we'll either get you set up with one of the non-operative sports medicine providers for follow-up or our sports medicine surgeons. My practice myself is I typically just let people know what their MRI shows, and then depending on what they need done, I'll then schedule the appointment with the appropriate follow-up person.

Interviewer: And when people come in, how often would you say that they could just come into the clinic and that's kind of it? It's just going to take a little bit of rest, and they're going to recover from their injury.

Dr. Rawlings: You know, it depends a little bit, I think, on the age demographic. So we do see a fair amount of people that come in with an acute knee injury that have just flared arthritis, and they don't actually have an injury to the ligament or something that we would need to do an MRI or surgery for. And those patients we really treat with physical therapy, maybe a steroid injection, and kind of getting them back to functioning, hopefully, so that we can prolong the longevity of their knee. In those cases, then, yeah, all they need really is just that visit in the orthopedic injury clinic and then a follow-up appointment down the road with a primary care sports medicine person or a sports medicine surgeon.

Interviewer: Are there any final thoughts you would want a listener to know about the clinic, or knee injuries, and how to handle that or take care of it?

Dr. Rawlings: I think definitely when in doubt, especially when it's an injury that's happened within the last day or two, come on in. We'll be happy to take a look at it. And if you're getting a chronic injury from training for a marathon, or in kids, they can often get growth plate injuries, again, if they've happened in the last three months, we're happy to see you in injury clinic for more of a chronic developing problem as well.

Interviewer: When should you consider University of Utah Health's Orthopaedic Injury Clinic over perhaps a visit to the ER or urgent care, or is it something you can handle on your own? That's what we want to find out today.

Dr. Julia Rawlings is a primary care sports medicine and also practices pediatric emergency medicine, but it's that sports medicine doctor that we really want to talk to today. So the first thing I want to find out is what are some of the common orthopedic injuries a person should consider using the Orthopaedic Clinic versus an ER or urgent care?

Dr. Rawlings: The Orthopaedic Injury Clinic is a great place to go if you have an acute injury, meaning that you have had an injury that you've sustained recently. We're actually willing to see people that have had an injury anytime in the last three months, but preferably not something that's chronic and going on. We'd rather you go ahead and make an appointment with a regular physician during regular hours, although it can be at the Orthopaedic Center.

Specifically, things that are good for the Injury Clinic. So we see a lot of injuries from the ski slopes. We see people that have been playing different sports, or running, biking. We see some football injuries. Anything that's kind of acute. Anything that could go to an urgent care can go to the Orthopaedic Injury Clinic if it's a musculoskeletal injury.

A couple of things we don't see at the Injury Clinic. We don't do stitches there. So if you're bleeding and you think you need stitches, an urgent care or the emergency department would be more appropriate. Also, if your bone is pretty crooked, it's probably a better idea to go to the emergency room. We can do some local numbing medicine to set some easy broken bones, fingers, and things like that, but larger fractures would need to be seen in the Emergency Department for sedation.

Interviewer: And what kind of diagnostic tools do you have there that kind of makes you the choice for some of these as opposed to perhaps an emergency room or an urgent care?

Dr. Rawlings: Yeah. So the Injury Clinic is fantastic because we have access to x-ray on-site, and we can see those images back as soon as they are done. And depending on the time of the day, we actually can often get the reads back from a musculoskeletal radiologist within a few hours. Sometimes those reads don't come back until the next day. We don't have the capability to do CT scans at the Injury Clinic. We do have access to scheduling MRIs in the building, but that's not done the same time as the visit.

So one great thing about the Injury Clinic is you get kind of a full package. So you get your x-rays. You could get an MRI set up. We have all of the braces and everything that you would need, crutches, things like that. And then, we can get you set up with a specialist, whether that's a sports medicine surgeon, foot and ankle surgeon, or one of our non-operative primary care sports medicine physicians. We will actually make that appointment for you while you're there for follow-up.

Interviewer: So the clinic, it sounds like a better option than perhaps making an appointment. It can be difficult to get in sometimes with an orthopedic doctor at times. So this clinic, it's primarily walk-in, is that how it works, or do you have to make an appointment?

Dr. Rawlings: It is walk-in. It's a little bit tricky right now with coronavirus going on, but, typically, it is walk-in. They are switching to appointments during this period of time, but that's going to be very temporary. Generally, it is walk-in, first come, first served.

Interviewer: How can a person decide if an injury is something that they can treat at home or they can just try to see if it's going to get better versus coming into the clinic or seeing a professional?

Dr. Rawlings: Yeah. So we're always happy to check anything out if you're not sure. A couple of tips that just come to my mind. One is if you have an injury that's bad enough you can't really walk on it or bear weight on it, that's something that should be seen, probably get an x-ray, make sure you haven't broken a bone. Or if you really can't move your shoulder or can't move your arm in some way. If you twist your ankle, and you're walking on it okay, and it gets a little bit swollen, that's something that you could probably wait on at home and see how you do. But, yeah, if you have a hard time moving a body part, that's a good time to go in.

Interviewer: All right. Are there some injuries that really you do want to have looked at, otherwise it could affect you and your mobility in the future?

Dr. Rawlings: Yeah. So there are definitely, particularly injuries that involve the joints. We often like to get a sooner look at what's going on rather than a later look, just because things can happen down the road that can lead to arthritis if they're not treated early. That being said, a lot of musculoskeletal injuries aren't emergencies. Meaning, even if you get something like a torn ACL, which is considered a pretty big injury in the sports world, if you're diagnosed several days after that happens, in general, that's okay. It's not something that absolutely needs to go to the emergency department or into the Injury Clinic even the same day you have it. You'd really be okay to get yourself a pair of crutches from the garage and come in a couple of days later.

Interviewer: For the particularly injury-prone that might have some crutches?

Dr. Rawlings: Exactly. There are a lot of people with crutches in their garage from siblings, so.

Interviewer: Any final thoughts that you have when it comes to the walk-in Orthopaedic Clinic? It's such a great resource. I was able to utilize it. I had a shoulder injury. I'm not even going to go into how that happened because it was not cool, it was not athletic. But it was great because I could go in, they were able to look at it, make sure that I didn't, you know, do any permanent damage, which I didn't, and then, you know, gave me a reference to go to a physical therapist to do some exercises to rehabilitate it, so.

Dr. Rawlings: I think it's a fantastic clinic. I mean, it's staffed by people that are trained in musculoskeletal medicine, so we have a little bit of an advantage over lots of the urgent cares that are more kind of general medicine, that we treat a lot of musculoskeletal injuries. We can get you set up with physical therapy pretty easily. And one or two days of the week, we actually have a physical therapist with us in-clinic. So if your injury is appropriate for that, we can even get you started on physical therapy the night that you come in. So I think it's a fantastic resource.

Interviewer: What should you do if you get a burn injury? Annette Matherly from the Burn Center at University of Utah Health, what should I do?

Annette: We go to our four C's and those are cool it, clean it, cover it, and call for help. Cool it. Place it under cool, not cold, water for about 10 minutes to take the heat out of the tissues. Clean it with soap and water. Get the debris out of the tissues. Cover it because we want to stop the pain from those nerve endings. And then, we want to call for help.

Now, this could mean a couple of different things. If it's a large burn, then 911 may need to be alerted. If it's a smaller burn, that doesn't not necessarily mean that you don't need to call for assistance. It may be that you need to call a local burn center, because even a small burn injury can result in a lifetime of impairment if it's not treated correctly.

updated: April 12, 2021
originally published: July 25, 2017

Dr. Miller: Rest, ice, and stretching are not the only ways to repair tendon injuries. We're going to talk about some of the new treatments next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Nick Monson. He's a physician here at the University of Utah in the Department of Orthopedics. He's a non-operative physician and he specializes in sports medicine. Nick, what's the story? I understand there are some new treatments out there to help with folks who have tendon injuries that have become chronic.

Dr. Monson: Well, one of the things that we've been really looking at over the last decade or two is the usage of ultrasound and the ability to find issues within tendons or joints or different areas of the body by an in-office imaging modality which is ultrasound, kind of like looking at babies. But now, rather than just looking at babies, you can actually look in and see a tendon. Then, what you can do is you find that area of pathology or the area of irritation within a tendon. You can actually see it with the ultrasound, which makes it much easier for us to actually find approaches to attack that area of issue in patients.

The areas develop typically from overuse. It also happens because tendons just notoriously don't have a great blood supply to them, and blood is what brings the healing factors to our body. So when you don't have that healing component coming to the tendon, it has a hard time healing. That's the way that we've addressed it.

Dr. Miller: So how do you use the ultrasound to guide treatment? And what are these treatments that you're using now?

Dr. Monson: Yeah. So one option is something called PRP, platelet-rich plasma. There's also another treatment option which is in the same family, which is called stem-cell therapy. These are both areas of a lot of excitement. The research on them is still forthcoming. In the orthopedic usage of it, or in the tendon issues, we've seen that it does seem to provide benefit for patients. It's a discussion I have with them. It's not always the perfect option. But for a lot of patients, it's something that we can offer where, ultimately, it involves a blood draw.

We take the blood off of a patient. We spin that blood down. We take the healing components of that blood and actually reinject that into the tendon under visualization of ultrasound so we can find that area that looks like it's irritated or has the issue. We directly inject into that area using that PRP injecdate that we've harvested from the patient by a blood draw. Then we can stimulate regrowth of the tendon as the theoretical purpose of it. But often, what it seems to do is cause the inflammatory reaction in the area, or it just kind of stimulates the healing in the area, and has provided a lot of relief for our patients.

Dr. Miller: Which tendons do you usually look at when you consider this therapy, or which tendons do you most frequently treat?

Dr. Monson: It can be done on any tendon that there is noted pathology in. So if you see an area of issue, it can be done in just about any tendon. Tendons that we typically think of, of having frequent issues are the shoulder, so the rotator cuff. We think about tennis elbow, so that's on the outside of the elbow. Golfer's elbows, on the inside of the elbow. We'll do it there. We see it in knees, particularly for people that have something called jumper's knee which is at the tendon of the knee. Achilles' tendon. Even in like the plantar fascia, this can be done.

Dr. Miller: These tendon injuries, they're not short-term injuries. Would these be folks that have chronic problems with the tendons that would be over weeks or months, perhaps?

Dr. Monson: Certainly. Yeah. Yeah. So that's usually, somebody will come to see me. They have a new injury, we'll work them through the things that we have the best evidence for, what we know works. Things like rest, avoiding aggravating activities, pain modification, medications. Then also, eccentric exercises are very important. We have good research showing that those are helpful.

Dr. Miller: What are eccentric exercises?

Dr. Monson: Yeah, so those are the exercises where the muscle is fired but it's actually lengthening at the same time. So we're lengthening a tendon and muscle unit while there is force.

Dr. Miller: Well, for stretching.

Dr. Monson: Yes, correct.

Dr. Miller: Okay. So how do you use the ultrasound to guide your therapy?

Dr. Monson: So the ultrasound, first of all, identifies the lesion. So then I know exactly where I need to go. The second thing you can do is the ultrasound will actually, if I place a needle into a patient, I can follow the course of the needle the entire time. I can see the surrounding nerves. I can see the surrounding blood vessels and I know exactly where I'm at. First of all, it's very effective for safety or avoiding those structures that we don't want to hit. But second of all, it helps us target very directly where we want to be within a tendon and make sure that we're in the correct spot.

Dr. Miller: Now, I'm assuming before you enter, you have a patient undergo this type of treatment, you have gone through the standard therapy. So they've gone through a physical therapy. They've done the stretching. They've done the icing, and they're just not getting results.

Dr. Monson: Correct. There's one other procedure that we've added to this as well. It's a needle procedure as well. So that means that it's not done in an operating room, but it is done in a procedure room where we, again, identify that area of concern. We're able to use a specialized needle tip that it pulsates at the very tip of it very quickly, about 17,000 times per second.

Dr. Miller: That's fast.

Dr. Monson: We're talking about a millimeter of movement. Yeah, it's fast. It's not a lot of movement. It's enough that it actually, you think of it as kind of pulverizing the tissue in there. It's emulsifying the tissue is the term that we use. It's the same technology that cataract doctors, or eye doctors, use to remove cataracts out of patients. It breaks up the tissue, removes it from the body, and then leaves the healthy tissue around it. This is a newer treatment, probably in about the last five years that this one's been out. For the same tendon issues that we just talked about, this is another treatment option for patients that's been very promising so far.

Announcer: Thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Dr. Miller: Diagnostic ultrasound. We're going to talk about that next on Scope radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Daniel Cushman. He's a sports medicine physician in the Department of Orthopedics at the Orthopedic Center here at the University of Utah. Daniel, welcome. Tell me a little bit about ultrasound-guided diagnosis of musculoskeletal disorders. I know this is a new technique, relatively new. It's been around for a long time but it's finding more applications these days.

Dr. Cushman: Definitely. Ultrasound is kind of a non-invasive way of looking at structures underneath the skin. It doesn't do a great job for things like bones which we have X-rays for, but if you're talking about something above the bone like a tendon or a muscle or those kinds of things, we can see those very well with ultrasound.

Dr. Miller: Does it assist you in your clinical diagnosis?

Dr. Cushman: All the time. For example, somebody hurts their shoulder, we can get a good look at those tendons, the rotator cuff tendons with ultrasound or if somebody's wrist is hurting we can look at the tendons there. Sometimes we can look at nerves particularly to see if they're being pinched somewhere.

Dr. Miller: It would help you, let's say, looking at a shoulder with an ultrasound, that might help you determine whether there was a full thickness tear or partial tear or even no tear.

Dr. Cushman: Exactly, and that's something that on exam when we're examining patients it's not something that's as obvious as it seems it should be. A lot of the time we can have patients who have completely torn their rotator cuff and they don't really have too many problems and then the opposite is true where somebody has done almost no damage to rotator cuff but they're in severe pain.

Dr. Miller: This would also help you decide on the guidance of treatment, right? Whether they go to physical therapy or whether you rest the shoulder for time.

Dr. Cushman: Exactly.

Dr. Miller: It just gives you a better sense of your diagnosis I suppose.

Dr. Cushman: All the time.

Dr. Miller: The other thing that's interesting is you're doing this right at the clinic visit, so this sort of obviates the need for having an MRI.

Dr. Cushman: Yeah. Definitely. A lot of the time I'll just simply grab the ultrasound machine with my patient in the room and it just takes a little bit of gel and that's pretty much it.

Dr. Miller: So this also maybe has a lower cost than the standard sort of other imaging techniques that we have.

Dr. Cushman: It's significantly lower and I don't know the exact numbers but probably somewhere in the range of a tenth the price of an MRI if you're looking at a shoulder for example.

Dr. Miller: Is it as good as good as an MRI for looking at, let's say again, a shoulder?

Dr. Cushman: Yes. That's really dependent more on the person doing the exam. If somebody has had a lot of experience with ultrasound, studies show they're about as good as an MRI. If somebody is not as experienced, then it's really only as good as the person who's doing the exam.

Dr. Miller: What other areas of the musculoskeletal system do you use this on? How about Achilles tendons or . . .?

Dr. Cushman: A lot of the time we can tell without having to use the ultrasound machine what the problem is but other times it's very helpful and so Achilles tendons, we do use it on occasion. There are there are some times where we think we know the diagnosis and this really either confirms it or shows us that something else is causing the problem and so it's helpful in that regard.

Dr. Miller: How about in the hip?

Dr. Cushman: In the hip joint there's a couple of uses for that pretty commonly. People who have had hip replacements where they can't really do an MRI afterwards and they still have some pain, a lot of times some of the hip replacement surgeons will have us take a look at the tendons that are going over the the prosthesis.

Dr. Miller: Sometimes patients will come in with pain and you've told me previously that you can use the ultrasound to sort of find out where that pain arises from or is there a structure along the nerve that is actually causing the pain. So for instance you might think it's . . . the patient may tell you that they have pain at the wrist or the end of the arm but actually the generation of that pain is higher up and you've learned that from the ultrasound.

Dr. Cushman: Yes, exactly. One of the one of the disadvantages of something like an MRI is you can really only do one segment at a time so you can only look at the neck or you can only look at the shoulder. You can't really do both at the same time. With an ultrasound, if you're thinking maybe a nerve is causing this, you can trace it all the way from the finger, all the way up the arm to the shoulder, to the neck and get a pretty full view of the entire nerve or whatever structure you're really looking for.

Dr. Miller: How many specialists like yourself are versed in using ultrasound as a diagnostic tool nowadays?

Dr. Cushman: Here at the U, there's probably about four or five of us at least in our department and it's getting more and more popular because it's such an easy test for patients. Patients generally love it by comparison to having to do an MRI or going back and additionally it's so much cheaper for the patient.

Dr. Miller: It also gives you real time feedback so that you don't have to wait for test results coming back from radiology.

Dr. Cushman: Definitely. A lot of the time, one other thing I was going to mention was that when patients say, "It hurts when I do this," and they move their arm or they move their leg, we can actually look at it while it's moving as opposed to an MRI or an X-ray, which only shows a static picture.

Dr. Miller: Do you think in the future that more orthopedic surgeons and sports specialists will be trained in this technique so that it's pretty common throughout the specialty?

Dr. Cushman: I think so. I think it's becoming kind of a second set of eyes for people to look under the skin.

Announcer: Thescoperadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at Thescoperadio.com.