MedStar Health DocTalk

Returning to play in sports medicine

June 21, 2023 Richard Hinton, MD and Mackenzie Bane, DPT Season 3 Episode 28
Returning to play in sports medicine
MedStar Health DocTalk
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MedStar Health DocTalk
Returning to play in sports medicine
Jun 21, 2023 Season 3 Episode 28
Richard Hinton, MD and Mackenzie Bane, DPT

Sports medicine orthopedic surgeon Dr. Richard Hinton, and athletic trainer and DPT McKenzie Bane talk about the wrap-around care necessary for not only a successful return to play, but to return to performance. It's never soon enough for an athlete.

Topics covered include commotio cordis, preparation for catastrophic events on the athletic field and the evolution of sports medicine.

For more episodes of MedStar Health DocTalk, go to

Show Notes Transcript

Sports medicine orthopedic surgeon Dr. Richard Hinton, and athletic trainer and DPT McKenzie Bane talk about the wrap-around care necessary for not only a successful return to play, but to return to performance. It's never soon enough for an athlete.

Topics covered include commotio cordis, preparation for catastrophic events on the athletic field and the evolution of sports medicine.

For more episodes of MedStar Health DocTalk, go to

Debra (Host) (00:00:01):

Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health Doc talk. The process of getting an athlete back to practice or competition after illness or injury is referred to as returned to play or R rtp. Multiple factors are considered to make sure the individual's return to sport is done safely with minimal risks of re-injury. Rarely is it soon enough for the athlete, but to get them there. Physicians and physical therapists use collaborative process with well-established protocols and a managed treatment plan. I wouldn't know two better experts to share insights on that plan in process than our guests. Today. We are joined by sports Medicine orthopedic surgeon, Dr. Richard Hinton, and physical therapist slash athletic trainer, McKenzie Bane, who has kindly invited me to call him Mack, both with MedStar Health. I'm your host, Debra Schindler. Thank you both for being here.

Richard Hinton, MD (00:01:00):

Thanks, Debra.

McKenzie Bane, DPT, ATC (00:01:00):

Yeah, it's a pleasure.

Debra (Host) (00:01:01):

As we get started, I'd like to make sure our listeners get a clear understanding of what expertise you bring to the subject. Give us a little bit of your background of working with teams and athletes.

Richard Hinton, MD (00:01:11):

Sure, Debra. I'm currently the medical director for MedStar Sports Medicine. So we're the largest provider of comprehensive sports medicine services in the Mid-Atlantic, uh, covering the Ravens, Orioles Capitals, wizards, and about 15 colleges and universities in the area. Clinically, currently, I am a sports orthopedic surgeon. Uh, primarily due surgery about the knee and shoulder arthroscopic procedures, but like Mac, I started out my life as a athletic trainer and a physical therapist. So that was a great background. And then the other background that has really been the very helpful in this area is I took a year out and did a master's in public health over at Johns Hopkins and focused primarily on injury prevention, injury epidemiology. So overeducated, underpaid. My mother used to tell me, now my wife tells me the same <laugh>.

Debra (Host) (00:02:04):

Well, and you are, you're also fellowship trained in pediatric

Richard Hinton, MD (00:02:07):

Pediatrics, uh, orthopedics, and in orthopedic sports medicine, which is, so, peds is a lot like sports in that you have to look at the child from the floor to the top, the whole body. Uh, and it's not just about isolated joints, but looking at the whole individual and Mac and I will talk about that as we go on.

Debra (Host) (00:02:26):

Alright. Right. Mac, you are both an athletic trainer. Any physical therapist ex, explain how they differ and how each fits into the process of returning athletes safely to play.

McKenzie Bane, DPT, ATC (00:02:36):

For sure. So when it comes to physical therapist and athletic trainer in the sports medicine setting, they actually look pretty similar. Um, they differ a little bit in, let's say the athletic trainer's ability and their acute care management with emergency response on the field. But when it comes to clinical treatment, they're pretty similar and overlap quite a bit. And they actually can work quite symbiotically and help the athlete that they're treating a lot. And physical therapist has a little different scope and some things they can do, like manipulate joints and stuff like that. But overall manual therapy, neuromuscular reeducation, therapeutic exercise and activity, they all actually cover, uh, pretty similar scope when you're in the sports medicine setting. And they can be really helpful for these return to play processes.

Richard Hinton, MD (00:03:16):

So Debra, a big thing there though is, is not so much the difference between PTs and ATCs now, but PTs and ATCs today compared to when I was a PT and an ATC 20 years ago. The, the world of opportunities and places that physical therapists and athletic trainers has grown exponentially over the past 20 years. When I was a trainer, you could either work in a college, high school or professional training room, that was it. Uh, athletic trainers now work in industry. They work in corporate America, they work in with corporate partners in sales. Um, athletic trainers are working, running data collection systems for professional teams. And the same with therapy. So mm-hmm. <affirmative>, and in our system, it's not always the physicians that are taking the lead and working groups or other areas, but it can be a physical therapist or athletic trainer, uh, that's very motivated and, and knows that area of expertise as well as physicians do

Debra (Host) (00:04:16):

Taking the lead. Where do you mean on the field?

Richard Hinton, MD (00:04:19):

So, uh, well, both with emergency action planning and here at MedStar, we have a lot of subspecialty, uh, sports groups, uh, lacrosse, medicine, uh, basketball medicine, baseball, medicine, golf, uh, running medicine, golf, a lot of sports, golf, medicine, a lot of sports specific areas. And we have, uh, physician leaders in those groups, but sometimes the leaders administratively of those groups, uh, physical therapists or athletic trainers. And, and in today's world, uh, with a shortage of both physical therapists and athletic trainers, uh, we see that with emergency action planning, we can get people out on the field. And oftentimes with the emergency planning from physicians in the healthcare systems, PTs and ATCs may be the primary care provider at a lot of athletic events, uh, because physician hours just don't allow them to be out there quite as much as we used to be.

Debra (Host) (00:05:20):

What are some of these emergency events that you're talking about?

Richard Hinton, MD (00:05:24):

Yeah, so when we look at emergency action planning, we're trying to plan ahead for catastrophic things that could happen on the athletic field. So cervical spine injury, heat illness, uh, cardiac events, uh, things that happen infrequently, but when they happen can be catastrophic. And also things that unless you are pre-planning for those, you even with the best of intention cannot take care of when it happens unless you've had the pre-planning of policy and procedure. So for all of our partnerships at the high school collegiate and professional level, we have a multidisciplinary team of people, primary care physicians, emergency care physicians, orthopedists, athletic trainers, strength and conditioning, physical therapy that are all on the same page about what has to happen from an equipment standpoint, an emergency care standpoint, uh, engaging the EMS system for catastrophic events like heat illness, cervical spine injury, cardiac events. So AED utilization, where the AEDs are, how are they appropriately used, what's the handoff between the field care and the EMS transport. So we, you know, we've had issues here in time where catastrophic life-threatening events have been avoided because every, everyone had practiced those on a regular basis, and all of the equipment and policy is in place.

Debra (Host) (00:06:56):

How do you account for that kind of evolution in sports medicine? Because you've been here a long time, but Union Memorial started out with, at the original sports medicine program for MedStar Health, right. First sports medicine program in a hospital in the nation.

Richard Hinton, MD (00:07:11):

Yeah. I think it's pretty simple. I mean, uh, athletes died on our athletic fields. Athletes have been unnecessarily hurt on our athletic fields, and people have gotten smarter about the concepts of injury and even death, not just being part of the game that is accepted, but something that can be studied and prevented. So it's this whole concept of looking at sport injury and the infrequent sport related catastrophic deaths in the same model that we look at disease, that we look at auto injuries, that we look at infectious disease, that we look at the whole situation and put together preventive plans and not just treating injuries after they happen.

Debra (Host) (00:07:57):

Sounds to me like there you have a whole lot more responsibility on the field. They're putting more trust is being put into your hands, whereas maybe it used to be the doctor's responsibilities.

McKenzie Bane, DPT, ATC (00:08:07):

Yeah. So that's just speaks to the level of education and just the growth of sports medicine and all the research and progressions we've made in the medical field, particularly in sports medicine where, you know, physical therapy started out as a bachelor's, moved to a master's, and now we've transitioned to a doctorate in physical therapy and athletic training is just grad is now just graduating their last bachelor's and moving to an entry level master's program. So I think it's just a natural progression of medicine in general where they have the skillset and they need to, and they have a scope of practice that encompasses all these things that can be utilized on the field in conjunction with the sports medicine team. And it's something that's grown to where it's, um, something that is now a critical piece of the, you know, athlete care puzzle. And

Debra (Host) (00:08:55):

Speaking of, you have a doctorate in physical therapy? Yeah, that's correct. Yeah. Could you have put the same amount of time in to become a surgeon?

McKenzie Bane, DPT, ATC (00:09:01):

They're starting to look kind of like the medical physician model where you can do post-graduate residency into that, but it's still not the same amount of time and the same experiences that would get you to, let's say a physician surgeon level where you go through medical school. And I'm sure Dr. Hen can explain this a little better, but for the physical therapist, it's a clinical doctorate and not, we're not medical doctors. And so our scope doesn't quite overlap the same there. I see. But it doesn't have quite the same amount of training and length of time to get to that same level.

Richard Hinton, MD (00:09:33):

Yeah. Debra? I think the biggest thing that has changed, look, uh, as we mentioned it early, I mean, over the course of my career, I literally tried to put together the pieces on my resume that are a modern sports medicine team. I was a PT and athletic trainer, healthcare administrator, uh, public health and surgeon. Um, the thing that has changed the most, the physicians are still the key, often leading the charge here. Um, but it is not about singular physicians. Mm-hmm. <affirmative> providing care. Now. It is a team of care that wraps around the athletes, both in the emergency situation, in the elective care situation, in the prevention situation. It is a team of people. And that team has to include everything from a surgeon to a primary care, to a therapist, the trainer, strength and conditioning, mental health, nutrition. Uh, so, and the athletes now, interestingly, some they don't really care that much about what letters are behind your name.


They want to know whether you are value added to what they're trying to accomplish. Mm-hmm. <affirmative> as an individual athlete, as a team, are you helping them move forward? So again, that's the, the interesting world of PT and athletic training now, and it's always been this way a little bit in, as a physician, you can be as smart about something in today's world as you want to be, and you can be as value added as you want to be. And because you happen to be a PT or an attc or a primary care and not a surgeon, that doesn't mean you won't excel or don't, or that you won't be viewed as an expert by the app that you're working with.

Debra (Host) (00:11:20):

One title that you did not use in identifying yourself was athlete. Right. And both of you have an athletic background. Do you think that inspired you to do what you do now? Go

Richard Hinton, MD (00:11:30):


McKenzie Bane, DPT, ATC (00:11:30):

Certainly gave me a good perspective what it's like to be an athlete in medical care, uh, going through different injuries, having my own surgery, going through rehab, which didn't go so well. It certainly gives you a good perspective and an appreciation for a medical, uh, team that actually is having your best interest in mind and actually at the top of their game and what they're providing. So it was funny where I went into sports medicine a little later. I actually did a victory lap at Maryland, did a fifth year to get all my prerequisites in before going into physical therapy and athletic training school. But it was something where my love for science kept steering me towards sports medicine that ended up ultimately pursuing this career. But having the background, I thought it was intriguing. I I really appreciate how sports medicine is never stagnant.


Like what we're doing now is gonna be different in five or 10 years. And I haven't been in the sports medicine field as long as Dr. Hinton here, but I'm sure he can speak to how he wouldn't do half the things he did when he first started out his, uh, his career as an athletic trainer, physical therapist, or even a sports med surgeon. So it was definitely just, uh, something that I think inspires me to continue to give the best level of care and to constantly keep up with changing practices. And, uh, you know, I think athletes recognize that when you have a surgeon or a physical therapist or athletic trainer that has been on both sides of the ball quite

Richard Hinton, MD (00:12:51):

Literally. Yeah. Debra, I would say, look, playing sports and being interested in the sciences related to medicine was a big reason that I got into sports medicine. Uh, probably the reason I've stayed interested in sports medicine and active in sports medicine though, has to do with this sense that sports is just so omnipresent in our American society, that sports is really a mirror on the bigger culture. And, uh, I'm most fascinated and interested in, in those areas where sport and culture meet, uh, in America, uh, who's spectating, who's playing, what sports do people play. Um, you know, it's, it's fascinating again, that sports has moved off the sports page to the front page, right? So, uh, becau I mean, you don't have that in other subspecialties. I mean, look, if your back hurts, you got great surgeons and people can relate to back pain, but that's not on the front page, right? I mean, sports medicine is always at the forefront because sports in America resides in the same place that our politics and religion does, right? So by being in sports, you can always find those interesting sort of places and interfaces that

Debra (Host) (00:14:11):

You worked in. But that is, that is pretty fascinating that you make that point. When you were playing rugby Yep. Did you get hurt? And what was the return to play for you like back then? Yeah,

Richard Hinton, MD (00:14:21):

I was pretty lucky I didn't have many musculoskeletal injuries. But an interesting thing that comes up is the difference in concussion care, which can be a surrogate for many of the things in sports. I mean, it used to be, look, if you weren't knocked out and you could come to the sideline and say, I'm okay, you could go back in and play. Right? But now there's a very objective, well substantiated best practices protocol for returning athletes to play based on a better understanding of the pathology and recovery ACL injuries. Another great, um, you know, example, when I first started practice, we'd fix your acl, you'd come back to see us post-op, and if in six months you didn't have an infection and your graft felt like it was stable, we'd say, go back out and play without even knowing. We were basically committing a lot of people to re-injury because although their ligament felt okay, not only was the muscle around their knee, not completely rehab, but we were not paying attention to the whole athlete.


You know, because if you tear your a c l, we fix it and I send you back to the same environment that you tore it in, but you're not a better spring if you're not stronger, faster able to absorb more en energy. Why would you expect anything different to happen right when you went back to the same environment? So we've gotten a lot smarter. The harder we look, the more we realize how long it takes for athletes to be ready, both physically, mentally, and skill-wise to go back to play after big injuries. And to be honest, at the upper level of play, regardless of how hard we're working, it's hard to return people to the absolute same level

Debra (Host) (00:16:10):

In all sports, or

Richard Hinton, MD (00:16:11):

Not all sports, but you know, if you look at the professional league in the highest level of play where you have to be clicking on all cylinders, people get back to play with great rehab and great medical care and mental health services. But going back to that nth level of play, performing at exactly the same level, it's hard. I mean, like Tommy John comes up a lot, you know, ki parents bring their kids in because they want their kids to have a Tommy John surgery. Well, Tommy John was a power pitcher before he hurt his elbow. He was never a power pitcher. Once he went back, he was a finesse player. Uh, many professional athletes find a way to accommodate, but it's hard getting all the way back, even with the best care, and it's hard getting even closer, safe back without a multidisciplinary team wrapped around you.

Debra (Host) (00:17:03):

Can we talk about the return to play and what the steps are broadly? Or does that have to really be applied to each individual sport? Because I imagine they're all different.

Richard Hinton, MD (00:17:12):

Uh, there's some really broad concepts that apply to all sports and Mac will run to, and it could apply to even a active person in a physically demanding job. There are these concepts of steps you have to go through and, and I do think conceptually you have to tweak 'em for individual sports, but they're very much the same. So Matt, yeah,

McKenzie Bane, DPT, ATC (00:17:34):

They're certainly, certainly overarching principles that are gonna guide rehab, uh, in a return to play, um, aspect. And so, um, smooth overarching principles is obviously going in, let, let's say, let's use an ACL for an example, right? We see a lot of those. And like Dr. Hinton said, it's one of those things where it's a little humbling when you look at return to play numbers, return to sport numbers and re-injury numbers. And as we learn more about it, the more you know, you kind of realize you don't know. And with, let's say an A C L injury, you gotta make sure you have a quiet knee. And as you get back into activity, you're looking at their sport, but trying to establish aerobic capacity and aerobic capacity. And there's also a degree of how the brain actually gets back into sport. So for an example, with an acl, a lot of the newer research has actually been talking about how this is a brain injury, not just an isolated ligamentous injury, and that there's actually a functional reorganization in the central nervous system that happens after you have a ligamentous injury.


And I think that's part of why we see some re-injury rates and some changes in performance and, and return to play after certain injuries is because we're just learning about more factors that are actually going into this. And that's why it's even more important to have a full holistic kind of multidisciplinary team with the return to play athlete. And so I think what happens is, is typically you get some physical qualities back where it might be strength. Like obviously we use Dr. Hen and I use hop testing, Biodex numbers, things that measure strength, reactive power, et cetera. And that's all fine and dandy. But this knee doesn't just live in isolation. It's attached to a human being with a central nervous system that has to control this knee in sport, which is a inherently chaotic environment. And so what we're starting to learn is, is that we really cannot rush the return to play process when it comes from a controlled environment in the clinic setting.


Wow. Your knee is so stable and solid and strong to a very chaotic environment where you're dodging multiple people trying to tackle you running after a ball and kicking it. And there is a, a phenomenal article by Matt to Burner and all in, uh, the be digital sports medicine that looked at the control to chaos continuum. And I think that's what we have to try to emphasize on the, uh, the multidisciplinary side of things where on our sports medicine team, people think that there's like these really defined stages and you're kind of going upstairs. It's a continuum and it's a dimmer switch where we're slowly turning the dial up. We're slowly transitioning from one phase to the next. There are certainly guidelines for healing and return to play, but I don't let an athlete get too married to a chronological timeline, sets up a lot of anxiety if they feel behind.


But we're looking at functional measurements that they have to meet to get to certain levels of return to play. So let's say, you know, a person with an ACL injury is nine months out and they're like, all right, I'm ready to play. That's what the literature says. What's what we know is we're starting to get into some return to play metrics here. Uh, well, if you don't meet your certain quad, you know, uh, symmetry index and other reactive or, you know, strength measures, we're not gonna be necessarily ready for that next step. And then there's a degree of going from that controlled environment to a chaotic environment where the brain has to adapt from small sided drills, pre-planned stuff into more unpredictable, large scale things that kind of simulates, uh, let's say an actual sport. So I think it's something that it gets real tricky when you do actually pass, let's say your ACL testing.


And I think that's where it really comes into play, where you need to have like, let's say the strength coach and the head coach in addition to just, it's a round table discussion, right? Obviously we have our sports med physician, physical therapy and athletic trainer, uh, all at the same table, but we're talking about how we're gonna transition into the sport because that's kind of like the nuance and I think where sometimes it gets rushed. And of course when you're in elite sport, there are some timelines and some certain things where you look at risk reward, but it's the more difficult part of rehab after you get them back to a certain level.

Richard Hinton, MD (00:21:38):

It's interesting, we had Greg Rose with us, uh, from Titleist Performance Institute two weeks ago, probably the best voice in golf medicine and physical training for golf in the country. And it's an example. Your people listening will understand. Uh, a lot of people hit the ball great on the range, but when they take the game to the course, it doesn't hold up because they're going from a very predictable, comfortable, safe environment to one that is filled with both perceived, uh, demons and real ones. Okay? So everybody can understand. It plays golf in your audience, hitting the ball great on the range, but not hitting it great on the course. Interestingly, the same thing applies to rehabilitation and returning athletes to play. Many athletes will get to the point that their joint looks great, and even their performance of exercises within a controlled physical therapy and athletic training environment look great.


And they are performing on test grade. But when they take that and they move it into, as max said, this unsafe, chaotic, uncontrolled sporting environment, they fail. Now, that's a whole new concept in returning athletes to play in the past few years. Cause in the first part of my career it was, did the knee look great? The second part of my career is it, did we, uh, rehab the entire athlete? Could they incorporate the knee and power activities in jumping the next set of where we're going is, can the athlete move their rehabilitated joint, their rehabilitated body and take the performance from a controlled environment in the gym to the athletic field physically? And then the final part of that will be what are the mental cues and the mental side and the reorganizing of the central nervous system to get them back to where both they're comfortable and performing in that sport environment.


So that's a real transition. And then for bigger points is this concept. You go from an athlete to a, an acutely injured person that's, that's devastating. An acute injury that's got a lot of worries, a lot of stress around it. Then you go from being acutely injured to being a patient that's either head surgery or a head rehab. Then you go back to being a gym-based athlete, then you are a field or environment based athlete, and then you have to go back to being a sport specific athlete and then a position specific athlete within your sport. So they're sort of the transitions that we're thinking about. They're overlapping, but this concept of controlled rehabilitation, some somehow positively progressing to performing in uncontrolled chaotic sport environments. That's the fascinating part of rehabilitation and return to play these days.

Debra (Host) (00:24:52):

So you mentioned the transition from athlete to injured athlete and back to athlete. Mm-hmm. <affirmative>. And those stages, it doesn't happen easily, obviously. What can go wrong without respect for the treatment plan or proper care? What can go

Richard Hinton, MD (00:25:03):

Wrong? Early catastrophic things can go wrong. You don't, uh, you don't follow the, the instructions about maybe your weight bearing status. If you've had to had a big meniscus repair along with your ACL reconstruction, and if you get back to jump cut, twist, turn too soon, you can retear your graft or retear the meniscus. That's a catastrophic failure of a, of a very straightforward manner. The other things that we see are athletes trying to take their chassis back into an uncontrolled environment before they're ready, either before the isolated joint has had time to heal, or they're able to incorporate the joint in full body activities. Typically, that is due to, again, this cultural side of things. And return to play is a great example. Lots of pressure, lots of secondary gain issues in young athletes now about having to get back out on the athletic field because it not only defines their worth and their social circles, but it essentially in many times defines the worth of their entire family and parenting about their sports participation.


I don't know if you know this, but you know, Maryland, we're talking to Maryland doesn't demand athletic trainers in every public high school in Maryland, but we have seen fit to approve name, image and likeness for high school athletes in Maryland. So another whole layer of uncontrolled unad secondary pressures on young athletes when they can literally potentially be the breadwinner in the family through their athletic activities and advertising options. Now, if you're that young athlete and you've got a bad knee, there's pressure on you to get back to play maybe before you're ready from a lot of different places. Right.

Debra (Host) (00:26:56):

I was, I was gonna ask how much pressure then comes back on you guys? You said it was a round table discussion with multiple people.

McKenzie Bane, DPT, ATC (00:27:04):

It's an important thing. And I, I realize we've left out one important piece of this end, end of this team is, is the athlete and talking to them, right? And like Dr. Hinton said, I mean, you have to see what else is going on in the world. Cause that's gonna change what you're implementing, what you're doing, how you're getting back. And it's something that can, you can have the perfect rehabilitation plan in place, and that's your X factor. And so I think it's something that you really have to highlight and

Richard Hinton, MD (00:27:30):

Right. And it's, I I, you have to bring everybody in. And again, if you are viewed as value added by the athletes, by the athletes parents, by the coaching staff, again, there's this transition from medical to sports strength and conditioning, very important part of this, and a very important player. So you have to, again, this is return to play. Who are we most successful in returning to play? It's many of the athletes that we have relationships before they're hurt, right? So they're in our strength and conditioning programs. They know and trust the people that are getting them bigger, faster, stronger, more mentally capable to play their sport. They trust the people who are setting up their emergency action plans and trying to keep them safe. If in today's medicine you are waiting to engage with patients after they are hurt or have a disease, you have started way too late in this ongoing sort of relationship you should have with patients.


So through the relationships we have with teams, both colleges and clubs and communities, uh, a big part of getting people back is that them trusting you before they were injured, okay? And giving them education and giving them services, uh, that they need. Because you have to be trusted because again, more and more secondary gain at younger and younger ages in sport, everybody's aware, well, when the professional hurts their knee. Recently, you know, was this case that, uh, in the NFL of, of, of a doctor being sued for tens of millions of dollars for a sort of a professional decision that was made at time of surgery. But as younger kids, more college monies involved, more n i l money involved, those sorts of things start creeping down in age. So you got to be a trusted partner. The athletes can sniff that out. They know who's caring about 'em, who understands their space. They know the therapists that know what they're doing. They know the strength and conditioning people that can make 'em better, uh, faster, bigger, stronger, more capable. Uh, I think it's long-term relationships. What

Debra (Host) (00:29:38):

Kind of effort do they make to try to get you to sign off on their return to play? Do they ever take you aside and say, look, I'm, I'm good. I'm ready.

McKenzie Bane, DPT, ATC (00:29:46):

Oh, man, go ahead. Uh, I think I've heard it all. <laugh>. Yeah. There's like negotiations and, and, uh, well, I don't know if it was that or, you know, I, I look at it this way. It's like, you know, I think that's where we have to rely on objective data and not having an emotional, too much of an emotion, uh, emotional investment in the, uh, decision to return. Obviously there's nuance to all of that, but, you know, athletes can say and do just about anything to try to get. But if, if you have a real honest conversation and you know the athlete really well, especially, uh, the higher level athletes, they know when they're ready and they know when they don't feel the same. They know when they're not performing the same. And it's about having that relationship already established. That trust that Dr. Hinton was saying that I think is imperative because it makes those hard conversations much easier and it's a lot more honest and open. Yeah.

Richard Hinton, MD (00:30:38):

And again, that conversation is much easier after an injury if you've had it before the injury, right? Yeah. So part of prepping people to understand what the return to play protocols will be and what metrics they have to meet, is that the first time they're hearing them is not eight months after the injury? Yeah. They're hearing them the first time they're in physical therapy. Mm-hmm. <affirmative>, here are the metrics. Yep. Also, here's the literature on your risk of re-injury. And that risk is even higher if you're going back before. So if you're in high school, uh, if you've had one big injury, an ACL injury, plenty of college athletes playing college sports after an ACL in high school, not many playing after an acl and the retail of an acl. Mm-hmm. <affirmative>, I think it's sharing early. You got to be talking to the athletes and their families and their coaching staff and their strength and conditioning people early, uh, and often about what the expectations for return and the metrics are.


And at some points, look, you have to say, I'm here to tell you what you need to hear, not what you want to hear. But also at the end of the day, uh, some risk acceptance. Uh, this is a world of patient-centric care. Now part of that is patient understanding and taking responsibility for their care in a very partnership way with their providers. So if you're a college senior, if you're a professional athlete, uh, I will sit down and talk with you about the pluses and minuses and the relative risk of return. And there will be people that make more aggressive decisions than others. So I have to give 'em the information and we as a team have to put it together, but them as the patient, ultimately a lot is their decision. Now, we cannot let people go back that are obviously at medical legal risk for high re-injury rate if they're on teams that we are responsible for. But individual athletes can make those decisions, but we just have to be open and honest with

Debra (Host) (00:32:37):

'em. Have you ever been the singular at that round table discussion where Sure. And then what happens? Sure. I'll

Richard Hinton, MD (00:32:42):

Give you a great example. It used to be, again, this, I'm an orthopedic surgeon, but I'm a team physician, right? Right. I mean, so we used to get sued or threatened to be sued. A great example is because if a kid say had a two organ issue, you know, two eyes or two ovaries, or two testicles or two ears, um, if you had significant decrease function in one, uh, there were medical legal cases about letting kids return to play with single organ function. Cause if they had a catastrophic injury, then they would lose that sensory ability. Now we get sued because we're not letting kids go back with single organ function. Mm-hmm. Okay. Because this concept legally has become, you have to inform the athlete of the risk. They have to understand the risk, and they have to be a partner here. Even things like return to play after major heat illness is a question in the literature. It used to be you just can't go back. There's a life-threatening issue here and you are at higher risk. Well now athletes are very aggressively turning to their medical providers and saying, I want to play part of me, part of my identity if I can't play there other problems elsewhere as mental health and which side of that pendulum I've been on in my career, <laugh>, you know, it changes, but where much

Debra (Host) (00:34:07):

It changes because of the case,

Richard Hinton, MD (00:34:10):

It changes because of the sport. It changes because, uh, athletes now are more involved and should be in their decision making on risk acceptance. Take for an example. If you had a 12 year old, uh, young lacrosse player, rugby player, football, anything tore their aco, uh, 10 years ago, people would've said, don't get your aco. You're too young. Just stop playing sport. Okay? Now everyone wants to keep playing sport, but I have to give them the literature that says you're 12, you go back to same environment, you got a one in five chance of tearing your a c o. But if we rehab 'em completely, and the family and the athlete understand that, then we go back into that environment the best we can. Not avoiding it like maybe 10 years ago and just saying, stop playing because there are a lot of positives for play, but there are risks. Big difference has been getting the athlete more engaged in the decision making process, providing best information and looking at it as a team between this multidisciplinary health team and the athlete being at the center of it

Debra (Host) (00:35:22):

With metrics being a big part of Absolutely. The information. What, what kind of metrics are there? Because I wanted to get back to that because you've mentioned it a couple times, but yeah. What are some of the metrics that are used?

Richard Hinton, MD (00:35:31):

I'll let Matt get on that. Yeah,

McKenzie Bane, DPT, ATC (00:35:32):

So we're looking at quad strength relative to their contralateral side strength as well to their contralateral side, as well as proportional to their body weight. Um, so we always look at both bilaterally, but also within the individual because we want to make sure that we're not clearing an athlete comparing the involved side to just underperformed and detrained uninvolved side, but also relative to their body weight. They have some metrics that look at different age groups as people, uh, go from high school to college to pro to make sure they have enough quad strength relative to their body weight. Um, we look at reactive strength index, um, and we look at, we actually have four splits now at US Lacrosse where Dr. Hinton and I work. So we can look at different rates of concentric, eccentric loading, ground contact times. Everything that allows us to look at is this athlete, do they have the physical qualities in in their lower extremity or whatever their body part may be to return to their sports safely.


And again, we're looking at how can we mitigate risk, uh, by making sure they're the most prepared. But again, this knee is not functioning, let's say in isolation, but we do look at those physical parameters to make sure that we're not letting our eyes fool us. Because you can have an ath athlete squat, a lot of weight, and the brain can pick and choose different movement patterns and muscles and joints to bias. And it'll look cer completely symmetrical. But they could be stress shielding their quad because they're using more hip extensors and back extensors. And then when you isolate their leg, you can actually go, okay, you're, I actually look at my professional athletes as professional compensators. Typically, the better they are at their, let's say sport, the better they can get around having a weak, they involve body part. And I'll often, let's say a knee, it's quite impressed to see how much they can do. But then when you isolate their, their knee, you go, wow, this is setting you up for failure because you can't compensate around a 60% quad index. That's, you're gonna get into a position in the chaotic nature of sport where you just can't, you're not gonna be able to hide that, and you could be at risk for re-injury. So, so that's where the

Debra (Host) (00:37:37):

Rehab comes in for sure.

Richard Hinton, MD (00:37:39):

Pt. And then another big thing again, is this concept of extending medicine back out to the field. Because even when they're look aerobic capacity, power, complex physical movements, we videotape, uh, most of our athletes with lower extremity injuries. We do a complete lower extremity strength and endurance profile. But then the question is, we can connect to strength and conditioning. Say J Dyer works with us out at USA Lacrosse, how are they performing in complex power lifting activities in the gym? But then even more important than that, our job isn't done when the athlete leaves the facility because the coach in interestingly, is going to be able to see things that the kid is not performing skill-wise at the level that they were. Or look, the tight end just can't get off the DB now like he used to. There's something wrong. He's missing a half step of speed.


So that's why, again, when people leave, you need to stay connected to them, be available to them, because it's not until they get back into their sporting environment that upper level functional deficits can be noticed. Cause kids can sometimes test that great, but then you talk to the coach and they go, Hmm, not performing. So then we get back together and see if we can help be value added by tweaks in their strengthening conditioning tweaks, in their mental approach, tweaks in other things that can help them perform. Sometimes they look good in the office and they don't look good on the field, and we have to still own that.

Debra (Host) (00:39:15):

How do you separate your responsibilities? Generally speaking, what is the focus of a PT versus the focus of a physician or a sports medicine primary care doctor? Can you gimme a scenario like maybe a real case that you guys work together on? And

Richard Hinton, MD (00:39:28):

Yeah, I would tell you that hopefully we leave the audience with the fact that that's blending. Every subspecialty has their basic sciences and their clinical knowledge. But when it comes to bringing MedStar Sports medicine out to Tyson University, to USA lacrosse to Morgan State, to the ravens, to capitals wizards, it is a team of people that need to share what we call a transdisciplinary body of knowledge that everybody taking care of those teams shares a common set of knowledge in injury prevention, sport performance research and design ethics. That if you're in that sports space, you need those shared bodies of knowledge. And then, yes, I will then put on my orthopedic surgeon hat, but I'll be honest, I expect Mac and Mac does know, or the other OBS senior therapist, they understand the basic steps of a lab repair in the shoulder. Because if they don't understand the basic steps of that, then they don't understand the rehab.


And on the flip side, I as a surgeon need to understand what Mac and the therapists are doing to keep the stress off the labrum when they're rehabbing. So I would say the new sports medicine team comes from a team that shares a base of knowledge at the pyramid and then goes off into their subspecialty areas, but staying connected as we do. So you don't wanna be an orthopedic consultant that sits in the office and never engages with the athlete until they're on your OR table, because then you don't know the difference between taking care of shoulder instability in a senior football player who has six weeks left to play versus a freshman recruit who has five years left to play, even though they have the same pathology and they may require the same surgery. But when you do that, how you do, that's completely different based on who the athlete is. But is

Debra (Host) (00:41:33):

That different what you just described from multidimensional care? No,

Richard Hinton, MD (00:41:37):

No. I think it's, I I think it's not the name that's all the same name. Okay. I mean, look, there's, there's wonderful literature right there that's growing. Look, healthcare, it's not just sports medicine, it's everything in healthcare is going to team oriented care. And there is a good basic science that is helping to define how multidisciplinary teams work better together. How you work best as a group is not always about having the smartest group is not always the group that has the smartest individual is the group that can work together best. Um, so that sense of multidisciplinary care is here to stay not just in sports medicine, but really in every facet of medicine. We'll come back and talk about that on another podcast.

Debra (Host) (00:42:24):

Yeah. I mean, there, there's so many other questions that I have. I mean, where does rehab fit into this? Does it actually fit into return to play though?

McKenzie Bane, DPT, ATC (00:42:31):

It, it surely does. Especially, uh, we know that going in with a, uh, a better knee helps after the surgery. It's always a conversation with the whole sports medicine team because sometimes, again, there's timelines and sport, but I mean, overall, certainly it helps. And you know, I even want to tie this back into what Dr. Hinton was saying earlier with the community and having an athlete to an injured athlete back to an athlete. And I really do feel like it's our duty as a sports medicine team to be involved in the community as we all, and it's the best thing to already know the athlete before they get injured. And what are we doing to prevent injury in our communities, especially the underserved population. But I mean, very simple things have massive impacts. I mean, something as simple as the FIFA 11 plus program reduces a c l injury risk by a substantial percent.


And the earlier you start, the better it is. And for those that don't know you can, it's easy to look up. It's just a neuromuscular type of program that takes 20 minutes or so to perform twice a week. And it has substantial impact. And when you have as many a c l injuries and other things that happen with our youth population and our athletic population, I think we need to do more before they actually get into the, the physician's office into the PT clinic. Because I think that's what our duty really is. Once they get, once we get there, we know what we need to do to get back. But I, I really do think, like Dr. Hinton said, we have to have that relationship before it starts. And I think we can do a lot more for prevention and injury risk reduction when it comes to these type of type of

Richard Hinton, MD (00:44:06):

Things. And the prehab is a great place to start, as we talked about patient education mm-hmm. <affirmative>, patient expectation, family involvement, resource assessment. You don't want the, the patient after a knee surgery to find out mm-hmm. <affirmative> six weeks into their rehab that they've only got 15 physical therapy visits approved by their insurance. You need to know that upfront. So if you know that upfront, then you can space the 15 visits over four months rather than over four weeks. Right. So prehab before surgery, uh, that interface serves not only a function of getting a joint in better shape for surgery. Yes. But it is setting yourself up for success through patient education, patient expectation, that's all part of it. And mentally preparing for here's what I have in front of me for the next 12 months. You need to talk about that before surgery, not after surgery

McKenzie Bane, DPT, ATC (00:45:01):

For sure. Yeah, exactly. It's setting those expectations, getting an aerial view of what rehab looks like, of what they should expect. Uh, typically that communication beforehand is what makes the rehab process and decision making process a heck of a lot easier for the athlete and the whole sports medicine team. So certainly, certainly a big time that makes the rest of everything you're doing way more effective.

Debra (Host) (00:45:24):

When are emergency action plans needed and how does that fit in with return to play?

Richard Hinton, MD (00:45:29):

Well, they're needed before injury happens, right? I mean, that's the whole thing about emergency action planning is bringing concepts, again from lots of different industries into healthcare, but by being a high reliability and, and not missing things and not, you know, a great example, uh, that people here in Baltimore will understand is lacrosse and this concept of kimmo courtes of a, a young adolescent male being struck in the chest with a lacrosse ball. It could be a baseball or, or a hockey puck, maybe another areas, but dying. And that would happen once or twice a year in this area, 15 to 20 times a year across America. And most American families whose kids were playing just wrote that off as part of the game that happens, we can't do anything. Well, the first thing you have to do, and MedStar's been very active in working with USA Lacrosse, both research, research-wise and financing research to look at and understanding how the ball striking the chest causes cardiac arrest.


You understand the basic science, then you understand how you try to prevent that energy exchange between the ball and the player. And that has a lot to do with protective gear. So lacrosse, shoulder pads now have a dropdown chest protector that is really very effective at absorbing that energy. Then you have to go through this, again, this social cultural side. How do you get the game of lacrosse to adopt those shoulder pads and for parents to go, I want my kids playing in those. Okay. And a lot of people initially said, no, you know, we don't want that. That's not manly enough for my son. And I would say, basketball, your kid can play basketball. Right? Uh, that's the same thing as playing lacrosse essentially. And then it used to be in lacrosse, in men's lacrosse, you could unload on an unprotected player from five yards away. And we found that most big injuries in lacrosse were coming in ground ball, unprotected situations where kids were being unloaded on. So now in lacrosse that's been decreased to three yards, not five. And it is illegal to hit an unprotected player in all situations in the men's game. So things that are catastrophic can be, if subjected to, you know, the appropriate science can be decreased back to the eap. The EAP is pre-planning, assuming that these catastrophic things will happen.

Debra (Host) (00:48:02):


Richard Hinton, MD (00:48:03):

Emergency emergency Action Planning. Thank you. And it is policy and procedure and practice. So three P's, policy, procedure, practice by everyone on the team anticipating 360 degree recreation of a commercial court situation. What happens, who's on the field? Who's doing the resuscitation? Who's calling ems? Who's putting on the a e d policy at a school level to support a e d application around the school, uh, policy to understand, uh, that all coaches, that all athletic trainers should be a D trained and CPR trained. And when you do those simple things, you're saving kids' lives. Right.

Debra (Host) (00:48:47):

And we just had a case like that, right, with MedStar Health a year ago. Yeah. Talk about that one.

Richard Hinton, MD (00:48:51):

Well, again, it's representative of what happens. Again, it, it gets, it got a lot of attention here, but the reality is, on average, it was happening 20 times a year across America that young, young athletes would die from cardiac arrest that was preventable in team sports.

Debra (Host) (00:49:10):

But in this situation, tell us the happy

Richard Hinton, MD (00:49:12):

Story in this situation. The happy story is a lacrosse player at a team, uh, at a school that we partnered with and had practiced all of the procedure about what to do in this situation that had the policy that demanded that there be an athletic trainer and a physician at game side. And that AEDs were available at games, uh, literally saved this young man's life. I mean, uh, uh, lacrosse player who goes down cardiac arrest, essentially did resuscitated and was back at school in three days.

Debra (Host) (00:49:46):

I just heard this morning that in Denmark, these AEDs are located everywhere. Mm-hmm. <affirmative> like in the community. In the community, yeah. In in restaurants. Does it feel like we're a little bit behind? And what's, what's the problem with getting more of those? Is, is it that they're so expensive? I mean, why don't, they're not

Richard Hinton, MD (00:50:02):

That ex. I mean they're omnipresent. Is it training that? A lot of that started in a study in O'Hara airport, so they know all the cardiac arrest and cardiac deaths. They put AEDs in O'Hara airport and had a significant number of saves, right? Mm-hmm. <affirmative>. So a ads are much more omnipresent in American society now. But a great example is schools initially didn't want to pay for 'em. They just didn't understand the importance. And it, it takes a combination of legislative change of community activism to apply the sciences in the real world. So we always lag behind, you know, um, people are reticent to change when it comes to sport. So it's hard sometimes, you know, people want to, you know, be all shook up after the fact. But when you're asking people to get involved, spend a little bit of money, take a little time.

Debra (Host) (00:50:58):

Is there one sport that is hard to return an athlete to play in than others? It seems like maybe football would be a more challenging return to play sport because of the risk, the higher risk, maybe of injury. Yeah,

McKenzie Bane, DPT, ATC (00:51:11):

I would certainly say sports with contact carry more risk involved. But when we're talking about return to sport and return to performance, every sport has their pinnacle of athletics that let's say their athlete needs to get back to. I would be very hard pressed to say that one sport is more difficult than the other when you're trying to get to a certain level.

Richard Hinton, MD (00:51:31):

And I think, yeah, I think, I think it's odd because it's probably the position within the sport rather than the sport itself, much harder to get the quarterback back with a bad labral tear than it is to get the offensive lineman back with a PCL tear. It has to do with the demands on their body, I think. So there's more variation within a sport than between sports,

McKenzie Bane, DPT, ATC (00:51:56):

Those saying. Yeah. And certainly like, like that you're saying, like definitely the injury itself and what their role is. And I think it, it's gonna be so independent on all those variables that it's, it's really hard to say and put one, one on top of all the others. I

Debra (Host) (00:52:11):

Liked how you distinguished return to play and return to performance. Do they have to reach that goal for returning to performance to be able to return to play?

McKenzie Bane, DPT, ATC (00:52:19):

No. So this is like part, that's a good question. It's a really good question, <laugh>. And that is the, uh, difficult thing. I think some of the literature says return to play, right? They could step on the field for one minute or one second, and they've checked that box from a literature standpoint, and then return to performance can be a little subjective in terms of how that athlete is playing. And so they are certainly different because I've been really learning, and we have to objectively reflect on what we're doing on the sports medicine side, is that athletes are returning to play, they are getting re-injured at a rate that I don't think anyone would care to admit and return performance and at, to their previous level is very difficult. And I think we have to delineate that because 95% isn't good enough. And that's a, that's an issue. Yeah.

Richard Hinton, MD (00:53:06):

So right now, I mean, if you're playing professional sports in America, you have some biometric device on you nearly the entire time you're on your campus. All practice sessions, all game sessions, uh, many just rest hours if you're on campus. So what we're finding out with game video, with biometrics is that, yes, say in the nba, uh, let's say 85 to 90% of players get back after a major lower extremity surgery, but less than 50% have the same height on their vertical jump on their 18 foot jump, they, their shooting percentage goes down from a certain distance on the court. Uh, the time that it takes them to get ball from inbounds to half court on a full dribble in speed never quite gets back. So that's that transition between medicine strength and conditioning, wellness and performance that we have that's part of that multidisciplinary team.


Because the reality is they're passing all of our tests, we return 'em to play, but very, you know, insightful question. Okay? Right. But the higher the level of play, the harder the return to performance, right? Mm-hmm. <affirmative> mm-hmm. <affirmative>. And the reality is when you go back at that level of play, D one in professional sport, everybody on the fields at that level. So you can be a high school player and maybe you're returning to play for your high school team and cause you're a better athlete than maybe some of your other kids on your team. You look like you're performing. But it's hard to hide if everybody on the field is at a really high level. So that return to play, return to performance question is even more. And that we see that in all of the professional sports, the return to performance lags woefully behind the return to play.

Debra (Host) (00:54:58):

What's the worst injury for returning a player back to performance? The, the most re

McKenzie Bane, DPT, ATC (00:55:04):

Inhibiting, I think it has to do again with like a good question, but definitely gonna have to do with their, their skill, their position. Like their, their what their actually, what their duties are gonna be on the field. Uh, and I think each injury presents its own unique difficulties with returning to their position specific skills and like actual physical abilities they need to perform.

Richard Hinton, MD (00:55:26):

So I mean, you look at that microscopically, you can look at that holistically, that question. So a microscopic answer there would be lateral meniscus tears in jump cut, twist turn, athletes bad injury. If you look at ncaa, I mean the NFL data, it is worse as far as return to play and career and game and practice time loss to have a bad lateral meniscus tear than it is to have an isolated ACL tear. That's an example of a small answer. Uh, I think the bigger answer is the worst athletes to return to performance are the athletes that do not have a supportive holistic package. And that could be everything from not having the money or parental time to get them to their rehab. Uh, it could be a kid who is mentally very stressed out about their athletic performance and cannot engage in the rehab who is scared to go back to play or is being pushed back to play, uh, by, by, by parents coaches, parents, peers themselves.


Mm-hmm. Um, it can be the athlete whose their position on their team was in question before they even got hurt. So if somebody trying to take my space, is there going to be a space for me when I go back? And interestingly now there's a lot of growing information that says both returning to injury and high level of performance can be predicted as well or better by some basic mental health screening than by the physical screening we do. So there's some wonderful information out of the professional soccer leagues in Europe that say, if you track the player's daily hassle factor, so that's a validated, reliable survey that follows how aggravated they are during the day. That, and you couple that with sleep, you have a better predictive model of injury rates than anything you can measure physically. Wow.

Debra (Host) (00:57:26):

Wow. That says a lot.

Richard Hinton, MD (00:57:27):

Right? You know, traditionally we've not been addressing those things. One, because a lot of player associations don't want to get into that. Right? But if we wanna recreate a 360 view of, of injury modeling, then you have to know where the player's head's at, right? Were they angry? Were they, were they mad coming to the field? Had they been embarrassed the last time they played against this team, uh, were they worried about something else and not focusing, because even some of these as ACL injuries, it probably has as much to do with your ability to perceive your surroundings as it does the contact or energy to your knee. So a lot of ACL injury prevention that Mac and the therapists do have to do with perception improvement, increasing your acuity, and that's why kids get injured. Kids kids don't incorporate peripheral vision into their athletic activities, so they're at higher risk. But working on peripheral vision and reaction time and understanding your environments better, uh, maybe

Debra (Host) (00:58:32):

Dynamics. What is your takeaway in summary? What would be your takeaway for listeners,

McKenzie Bane, DPT, ATC (00:58:36):

Meg? I mean, I definitely think that some of the points that Dr. Hinton touched on too is just realizing that the player fits within a interdisciplinary team, fits within a community f uh, has their own individual community. And then even beyond that, factors that are gonna play into what return to play actually means and how it fits into a bigger picture of culture and what it could be for their livelihood. And I think that, you know, just making sure that people are appreciating all of those factors. When you have one injury, it's attached to a human being and all that, it comes with it. And so you just can't have a cookie cutter approach when it comes to return to play. And because one thing worked prior doesn't mean it's gonna work again. So just having these principles in mind when doing return to play and return to performance, very, very mindful of all those variables that go into it.

Richard Hinton, MD (00:59:34):

I think for me, look, uh, it's a complicated question. You know, why do athletes get injured to begin with? If we're trying to return 'em, why did they get injured in the first place? And there's a simple answer for that. It's because they failed to effectively absorb the energy from their sporting environment. That's one sentence answer. So how you improve their ability to absorb energy from their sporting environment is multifaceted, though it can be better protective equipment, it can be better training, it can be better rules and officiating. It can be better mental health of the athlete. It can be children maybe not playing the same sport all year round, weakening their muscles. But then you have to step back and look at, well, what is the society and what is the club sporting environment that is demanding single sport play? Then you have to take another step back and say, well, in the bigger culture, why is it that we don't fund our rec leagues anymore?


We don't fund public school sports anymore. Venture capital comes in, fills the void, they got a different set of priorities, and then suddenly everybody's playing sport, single sport year round, significantly higher injury rates because they're spending more time in games and they're using this same muscle groups. So injury prevention, injury return is the, you got to take the big picture. Um, so that would be my, my sense o of things is that it's uh, it's complicated. It needs to be holistic, uh, and it's like a lot of other things in medicine. It's not as simple as everybody wants it to

McKenzie Bane, DPT, ATC (01:01:13):

Be. Yeah, I definitely agree with that. And one thing I want to add, I know you can edit this in, is certainly like he was saying, adding in objective data into your decision making process certainly will make you more effective. And, and not ignoring something that is objectively true in terms of physical qualities and things of that nature, even though you're appreciating the whole person, definitely need objective measures and data to help guide your return to play process.

Richard Hinton, MD (01:01:40):

Right. So, uh, again, I would say athlete centric and team oriented is kind of the, the how we approach things now. We used to be very physician or singular physician making all the decisions, you know, orthopedist in the nice suit, telling everybody what to do, not even talking to the athlete or the therapist or the trainers, but it's team oriented. But it has to be athlete centric. So,

Debra (Host) (01:02:05):

So the next podcast then is the epidemiology of sports Medicine injuries. Okay. Research, right. <laugh> can be. I thank you guys for your expertise.

Richard Hinton, MD (01:02:15):

Well, Mac and I are happy to come back anytime. Okay.

Debra (Host) (01:02:17):

Okay, good. Cause I, I love talking to you. Yep. Well good, good stuff. Thank you so much for having us. Thanks Debra. Appreciate it. We've been talking with sports Medicine orthopedic surgeon Dr. Richard Hinton and physical therapist, athletic trainer McKenzie Bane for MedStar Health in Baltimore. Thank you both for sharing your expertise with us here on DOC talk for an appointment with one of our sports medicine experts. Call 8 7 7 34 Ortho, that's 8 7 7 34 6 7 8 4 6 or visit MedStar sports