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Return to Sport
23 Plays22 minutes ago
In this episode, Miranda and Josh talk about a particular case involving return to sport, including how they approached progression, readiness, and the key factors that guide safe decision-making
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Transcript
Introduction to Hand Therapy Academy
00:00:06
josh MacDonald
Hi, I'm Josh McDonald.
00:00:07
Miranda Materi
And I'm Miranda Matieri and we are Hand Therapy Academy.
Determining Return to Sports for Pediatric Patients
00:00:11
josh MacDonald
So let's talk a little bit about when we should send our patients back to sports. I had a situation actually today in the clinic where we had two kids in the in at the same time and when to send especially our pediatric patients back to the the playing field can be a little little tricky.
Importance of Sports to Kids and Parents
00:00:30
Miranda Materi
Yeah, and what do you do, especially if they're not professional athletes, right? You're like, well, Do you jeopardize them having another injury or something that could be more long-term? And so I guess I'd be curious as to what you did and what those cases look like.
00:00:44
josh MacDonald
So, yeah, it's it's tough because sometimes the kids take it more seriously than adult pros, right? Like these kids, like it is their entire world and sometimes their parents' world too. Yeah.
Case Studies: Two 15-Year-Old Boys with Fractures
00:00:54
Miranda Materi
Unfortunately, yes.
00:00:54
josh MacDonald
Right, right. So we had two 15-year-old boys in the clinic at the same time, one with a fifth metacarpal fracture for punching a block wall um after missing a lift in the gym. And he is two weeks out for what at the time was a pretty unstable 40-ish degree angle metacarpal distal neck fracture, excuse me, distal shaft fracture. um And he's in an ulnar gutter splint.
00:01:20
josh MacDonald
The other patient is 15-year-old who fell during basketball practice and had a small finger P1 fracture that was pinned. It was pinned for two weeks. Pins were removed. And then two weeks later, sent to therapy and said, at four weeks post-operative, you can go back to basketball. Just be careful. Don't fall while you're running.
00:01:40
josh MacDonald
And so the The metacarpal fracture, the doctor said like nothing, nothing, don't plan on doing it. He had just made the basketball team when this happened. And he was told, um you're not going to play basketball this season.
00:01:52
josh MacDonald
Like don't
Dilemma: Doctor's Orders vs. Risk Assessment
00:01:53
Miranda Materi
Thank
00:01:53
josh MacDonald
plan on it.
00:01:53
josh MacDonald
You're not you're making mountma basketball season. Where that fracture could heal and he might have the capacity to play towards the tail end. But doctor just said, write it off. It's gone. Move on. The other kid, this doctor is sending him back four weeks with two of those in pinning.
00:02:08
josh MacDonald
on a P1 fracture saying, don't fall. Like, I don't know if this doctor knows how basketball practices and games work, but he's going to get a shooting hand whacked. He's likely going to fall down the kid.
00:02:18
josh MacDonald
these I mean, these' fifteen is he's 15. He's a baby giraffe and he's falling all the time during wind sprints. He's going to fall. So it's just this, like, how do doctors decide when they send kids back? And then we've got to like back up those decisions. It's tough.
00:02:34
Miranda Materi
that's very tough. And then like, does the kid have pain at his fracture? So I don't know. Does he have pain at the fracture site? Is there like good heal? You know,
00:02:41
josh MacDonald
Yeah. Yeah. Neither of these kids have really any perceivable pain. They talk about the worst is like two out of 10. If they bump it on something in their splint or something like that, they both feel fine. They're both highly motivated to get back.
00:02:54
josh MacDonald
And so we're telling this one kid that's going back to play back to practice basketball. We're telling him, you got to be careful. Like if you fall again, this is catastrophic, but I'm asking a 15 year old without a prefrontal cortex development to make good choices about when his buddies are all sprinting hard and he's got to tell the coach, I can't run hard.
00:03:15
josh MacDonald
Well, then you're not going to play in the game, right? Like what's the point
Trusting and Verifying Medical Orders
00:03:18
josh MacDonald
of all this? He's just going to keep his mouth shut and do what he's going to do.
00:03:21
Miranda Materi
Right, exactly. And I think the the thing is, is that they're 15. So I think, you know, as as a parent and as a parent of an athlete too, I think I would still be like, we're going to wait longer, right?
00:03:26
josh MacDonald
Yeah.
00:03:36
josh MacDonald
Yeah. Yeah.
00:03:36
Miranda Materi
And, but then, I mean, what do you say when the doctors that, you know, I guess we know, cause we have our background in orthopedics, but if the doctor's saying it it's okay, I mean, what are you going to say?
00:03:44
josh MacDonald
Yeah. And the doctor that gave the approval after four weeks with only two weeks of pinning, I've asked follow-up questions of in the past, and it was not well received.
00:03:57
josh MacDonald
It was the the the physician's assistant when I said, hey, are we sure we should be moving this patient already? They're only two weeks out after a fracture and pin's out. Like, are you sure you want the aggressive range of motion listed in the script? Yeah. Yeah. That's what we said.
00:04:09
Miranda Materi
Yeah.
00:04:10
josh MacDonald
Okey-doke. All right.
00:04:11
Miranda Materi
Well, yeah, I think it's interesting too, because I think we know physicians like that. We know physicians that will send a distal radius, no splint after surgery, get them moving, move on their way, be aggressive. And then we know people
Risks of Early Return to High School Sports
00:04:21
Miranda Materi
that will wait six weeks to take them out of their splint.
00:04:23
Miranda Materi
It's, it's such a huge variance.
00:04:25
josh MacDonald
Yeah. Yeah. And the the forces and loads in a sport, in in high school sports for 15-year-olds, even if it's not a contact sport, you know baseball whatever, it's still like you get tagged with a ball on that hand.
00:04:41
josh MacDonald
Yeah. And ah you know a rough slide into second. There are a lot of forces at play. And I just think the risk-reward is just not there.
00:04:50
Miranda Materi
Yeah, as opposed to waiting a couple even just a couple more weeks, right.
00:04:53
josh MacDonald
Yeah. Yeah.
00:04:53
Miranda Materi
Then, okay, so then let me ask you this. Do you, so what I always say to my team is we have to ah trust the captain of our ship, right? And so in that case, it's the physician, that's, it's the surgeon that did the pinning.
00:05:06
Miranda Materi
Are you trusting the captain of your ship or like, what are you telling the parents?
00:05:10
josh MacDonald
So yeah, yeah, I try in those situations.
00:05:11
Miranda Materi
Are you like going for it or what?
00:05:16
josh MacDonald
i I will never say, i will never recommend that they be more aggressive than the surgeon. I might, Hint, suggest and talk around, you know, maybe it's not a bad idea to wait a little bit because there's some risks involved with this. The doctor gave you permission. So it's, you know, if he thinks it's OK, but I might have my kid wait a little longer. I might I might talk around being more conservative, but I'd never talk around like, oh, you're totally fine to play. I don't know what he's
Handling Discrepancies in Medical Advice
00:05:44
josh MacDonald
thinking.
00:05:44
Miranda Materi
Yeah.
00:05:45
josh MacDonald
Yeah.
00:05:45
Miranda Materi
Yeah.
00:05:45
josh MacDonald
The risk to our liability is too high.
00:05:45
Miranda Materi
Or I mean, yeah, I think but too, like if the parent has concerns, I'd say, Oh, why don't you, you know, I, I think those are valid concerns. Why don't you bring them up with the doctor?
00:05:56
Miranda Materi
You know, which I think like you, you said though, like most of the time when someone's advancing them that quickly, when I've done that too, I've been done it with um a patient that had nerve transfers, it was a baby for a brachial plexus. And remember calling the doctor with some concerns that we were doing, you know, shoulder abduction too early, but they were like, nope, that's what we want. You do it, you know, and you're like, okay.
00:06:18
josh MacDonald
Yeah. Yeah. I've also had like a senior who hurt his hand like very beginning of the season. Didn't get to play any any games, wanted to be, wanted to dress and play his final season, you know, last game of his high school career, desperately wanted to play. And I said, all right, we've got to get these markers down before you can return. And then your doctor has to give you official permission. So you schedule a visit to see that doctor before your last game and get the x-ray as late as possible. And so we work with patients and try to make sure. But yeah, it's tough when you've got providers giving vastly different timelines on things.
00:06:55
Miranda Materi
Yeah. And I always think, you know what, like, yes, I want to trust this provider, but I'm going to verify, like, did you mean to say this? You know, I may ask the parents to verify because sometimes the parents tell us something different too, right?
00:07:07
Miranda Materi
Like the parents could be like, yep, they said two weeks. But when we go back and read the chart, we talked to the doctor, like, no, that we said two months. Right. So it's always like like verifying the order.
00:07:14
josh MacDonald
Yeah. Yeah.
00:07:17
Miranda Materi
And sometimes it's not even the doctor writing the order. It's an MA putting in the computer.
00:07:21
josh MacDonald
Yeah. yeah There can be typos on there. There can be errors. There can be, yeah. So it's not bad to verify, but you've got to know your, your referring provider and their receptiveness to that. And,
00:07:32
josh MacDonald
I don't want to make it about liability and just washing your hands and saying like, well, it's on the doctor because I want to, you know, be a good person and say like, Hey, maybe this kid shouldn't be going back in the football field with a scapho loonate injury six weeks later with no protection.
00:07:45
Miranda Materi
Right. Yeah.
00:07:46
josh MacDonald
Yeah.
00:07:46
Miranda Materi
And what can we do to get that kid safe, you know, to play? I think are all good questions.
00:07:50
josh MacDonald
Yeah.
00:07:51
Miranda Materi
I think good to
Communication with Doctors and Conclusion
00:07:52
Miranda Materi
verify. Trust, but verify. That's what one Hansard and i work with. He's like, I trust you, but I'm going to verify with you as well.
00:07:58
josh MacDonald
Yeah, yeah. I think that's good. and And trying to approach that conversation with the surgeon or the PA in that sense of like, hey, just wanted to clarify, make sure this is we're all on the same page and this is this is what you're looking for. Yeah.
00:08:11
Miranda Materi
Yeah, I think even saying something like the facts came through is a little blurry. i wanted to make sure, we're you know, like, it doesn't always have to because I think sometimes people think we're like confronting, especially surgeons, they don't want to be like confronted or told what they're thinking is or being questioned, right?
00:08:16
josh MacDonald
Yeah. Yeah.
00:08:27
Miranda Materi
It's just more like I'm there. And like some surgeons don't care. We know that. But some are like, no, that's what I said. And that's what I want. Don't you dare ask me questions about it.
00:08:27
josh MacDonald
yeah
00:08:35
josh MacDonald
Right. Which I definitely don't get that vibe from PAs very often, but we've definitely got one here that she doesn't, that yeah, it's it's usually the fact is blurry. Can't tell. Can you tell, can you tell, can you confirm for me, please?
00:08:45
Miranda Materi
He let me know.
00:08:48
josh MacDonald
Yeah. Yeah.
00:08:49
Miranda Materi
Yeah.
00:08:50
josh MacDonald
Well, it's not always super clear, but hopefully you can get some sense of clarity with talking with the patients and find a way to balance that return to sport in a safe way for your patients. So If you have any questions, reach out to us via email info at handtherapyacademy.com or on our social media platforms, Hand Therapy Academy.