When Pain Isn't Normal: Sports & Injury Truths with Dr. Max Kammerman

Everyone thinks they know sports injuries...

Most of us are wrong.

In this episode we sat down with Dr. Max Kammerman of UHS...a sports medicine physician who's been on the sidelines of high school, college, and semi-pro sports. We dug into the stuff most athletes, parents, and coaches misunderstand.

We talked about:

• The biggest myths about concussions
• Whether concussion "prevention" gear actually works
• The truth about stretching, sprains, and recovery
• Why some athletes come back stronger...and others never fully do
• What every parent should know when their kid says, "I'm fine."

If you've ever played sports...coached...or watched your kid take a hard hit, this one matters.

Sometimes injuries are something we can just play through, and sometimes the most dangerous injuries are the ones people try to tough out.

Transcript

SPEAKER_00 0:00

Hi everybody, welcome back to the Pressure Proof Podcast. This episode is sponsored by Curly Wealth Management out of Oneana, New York. It's a special guest here today, somebody I've never had on before. And his name is Dr. Max Camerman. You've been on the sidelines for college, high school, semi-pro, starting off hot. What's the wildest injury moment you've had to manage in real time? Alright, so first of all, thank you for having me, by the way.

SPEAKER_01 0:25

I appreciate it. So the wildest injury that I've ever had to manage in real time was at the local tennis center in Binghamton, actually. Really? Yeah, which you wouldn't expect, right? Like I'm always, you know, my my antennae are up for sure at a football game or you know, at a hockey game to see something crazy. One of the guys on the court got lobbed, so the opponent hit the ball up above the guy's head, and the guy tried to track it by kind of jogging backwards, and he caught his heel as he was going back. He whipped back and uh hit his head into the ground. And so I so I saw it happen. Um you know, immediately I'm thinking like the guy has a concussion, and and I'm aware that I'm gonna have to kind of jump into action. And and as he fell back, he hit himself in the nose with his racket. So he so he gave himself a bloody nose, and he's you know, he's covered in blood. Yeah, and we just kind of got him to the side and he was hanging for a bit, and things seemed all right, like he didn't lose consciousness, he was he was lucid, he was making sense. But I guess what what made it seem odd in the moment was that he was he kept kind of like fiddling with his ear, which is just that is weird, you know, and wasn't thinking of any anything of it. I thought he had some like blood in his ear, but over the course of like like 20 minutes or so of checking him out, uh we realized there was fluid coming out of his ear, and it was it was like a clear fluid. And so that's almost always if you have a head trauma, that's gonna be cerebrospinal fluid. So he had he'd given himself like a skull fracture from hitting his head and he was leaking brain fluid out of his ear, which doesn't sound good, which is bad for those of us who know who aren't in medicine. Yeah, so up until then, I'd said like, all right, you know, it looks like you have a concussion. We're gonna you're gonna go home, you're gonna rest, you're gonna we're gonna talk about this. No longer going home. No, no, I was like, all right, so you know, new plan, bud. We're gonna we're gonna call it the ER. You're gonna take a ride there. And yeah, so he spent nine days in the hospital.

SPEAKER_00 2:06

Was this a kid or like a college kid? Adult, like middle-aged guy. Wow, yeah. That's crazy. And he didn't say anything about his ear, nothing. Just kind of out that's nuts. Yeah, and fine, no. Like he's back in playing tennis, full recovery. That's crazy. So for the people who don't know you, how did you end up first? Well, first of all, where are you now? And how did you end up there? Tell us about who you are. For my uh Binghamton, New York.

SPEAKER_01 2:29

A sports medicine doctor from the non-operative side, and the associate program director of the fellowship out of United Health Services, and I'm an associate clinical instructor for SUNY Upstate. So I helped take medical students. Yeah. So I I grew up in the Northeast, I grew up in Binghamton, New York, and I did my undergraduate at Stony Brook University. I majored in biology. I went to medical school in Israel to Tel Aviv University.

SPEAKER_00 2:52

Oh crazy.

SPEAKER_01 2:53

So I did four years four years in Tel Aviv, and then I came back and did a residency in primary care at UHS in Binghamton, and then I did a one-year fellowship sports medicine and orthopedics at the university at Buffalo. Kind of been all over. So yeah, traveled a bit for the education. And then what's the your favorite part of what you do? I mean, it it's gotta be just being around athletes all the time. For me growing up doing sports, I think it's it's it's it's there's there's a through line from childhood to to now where it's it's the thing that I think about probably the most. Yeah. And so having the opportunity to, I guess, combine that with your job just feels really easy. I think I think I feel like I'm I'm I'm being a version of myself when I talk to my patients.

SPEAKER_00 3:34

Yeah, I mean that's kind of the the saying, right? You find something you do and you love and you never work a day in your life.

SPEAKER_01 3:41

Yeah.

SPEAKER_00 3:41

I mean it's not to say that it doesn't work, you know what I mean? Well, absolutely. By all accounts, you love what you do. So if you were a Division I diver and you played semi-pro Ultimate Frisbee. Was there ever a moment when you got injured and you thought, man, I wish somebody really handled this differently? Yeah, yeah, definitely.

SPEAKER_01 3:58

So I think that the biggest moment for me like that was my senior year on the diving team at Stonybrook. I was trying to do a uh front one and a half with a full twist, which is not like I don't even know what that is, but it sounds intense. It's you know, it's it's it's it's hard for like the lay person, and but it's pretty routine for someone at like the division one. Like you should everyone should do it. Like a good high school diver can certainly do it. Okay. And I just came in a little like it was, you know, I had to move, I was, I was like, maybe wasn't warmed up quite enough. I I kind of came in flat to the water. So normally you should go in head first. Yeah. Yeah. So I came in like sideways and I ruptured my eardrum really. I did that too. That was the worst pain of my entire life. It's pretty annoying to rupture your eardrum. Yep. What do they do for that? It's it's it's a kind of an odd injury. You can you can get surgery on it and have the hole in your eardrum patched, or you can try to like let it heal and just you kind of are vaguely on some timeline of like letting it get better. From my vantage point now as a sports medicine doctor, I have a lot of advice that I would give to somebody if they were going through the same injury. Yeah. But as a 22-year-old or 21-year-old, I think I was like, What do I do? Yeah, like what do you you know, what do you guys what do you guys want me to do? And I I got treated more of the injury by a physician who didn't specialize in sports at all, just from like an ENT. Yeah. And the advice they gave was don't don't dive anymore. You know, you'd really you're really making a mistake to to dive. You could damage your job. Like my parents were at least more peripherally involved in medicine. My mom was a nurse, my dad was a doctor. And so they were pretty involved in the process. Yeah, they were like, What are you doing? Like, don't like I was like, I was like, you know, maybe we see other people, yeah. Maybe I like push some like wax into my ear and I wear a diving hat, and maybe I can still dive. Yeah. And my parents were like, nah, you're gonna fool. Like, you know, so is that why you switched then to ultimate frisbee? Or no, the ultimate frisbee was kind of always there in the background. Okay. I just, you know, there's no there's no division one ultimate frisbee. Yeah, no, no. So it was the I mean, it was the end of diving for me. It was my senior year, and they were just like, you know, you're gonna wait this out, and then it took probably a year for it to get in in moments, yeah. You know, it's there's nothing, I mean, for me, the the thrill of it is is being in the air. It's like feeling your body like twist and flip and knowing where you are. There's like there's this uh incredible media to it where you really can't be distracted by anything, and and it forces you into this into this state where you're you're singularly involved with this. It's quite a it's quite a powerful and pleasant feeling flow state. Totally, yes. At least briefly. You know what I mean for like you know a second and a half until you're that's an awesome feeling to be in. What I don't miss is like learning a new dive and like belly flopping like 10 or 15 times in a row at like 6 a.m. Failing over and over and over again to get it right. It's painful, and it's like I mean, I mean, everyone has belly flopped just like I maybe maybe people haven't thought about what it's like to be like a collegiate diver who's I wasn't a great collegiate diver, but still if you if you go off the three-meter board, right? You're 10 feet up, right? If you get a good bounce, you should be an extra five feet up. Yeah. So even just belly flopping from 15 feet, let's say, would be unpleasant, right? Oh yeah. But imagine five feet. Sure, sure, right? Imagine like spinning into the belly flop.

SPEAKER_00 7:05

Yeah, no, thank you. That was roughly I that was a lifeguard at one point in my life, but that's no thank you. So you guys you would have done some of these things. You've tried to, you've never tried to say that. If I had to save a life, I could probably do a belly flop or two. Uh so when did you realize that you wanted to be, or maybe you always did with parents in the medical field, be on the medical side of sports?

SPEAKER_01 7:28

No, it was it was later. You know, it doesn't exist as a specialty in Israel, actually. And so really, yeah, there aren't there aren't really sports doctors. There were there were orthopedists. Why is that? My sense is that this as a specialty grew out of a an involvement that Americans have with sports. Because we tether our sports to like scholastics, right? Like most people get involved in their sports through their school. So you have a totally different, like totally different population of people in the United States that are doing sports, and there are more injuries as a result of that. And it's there's a need then for people who specialize specifically in sports. There, there's a role that I can play specifically for someone's health, or that any you know, sports doctor could in the United States. Probably, I I bet it will evolve such that there it will exist in Israel at some point, but they're maybe socialized air systems. And so you don't have this sort of like concierge service that you get in the United States.

SPEAKER_00 8:23

So let's let's talk about that here. You're you cover high school Friday night football games, college games, semi-pro hockey game. Why does it matter that you're on the sideline? Why not just wait for injuries to show up at your clinic?

SPEAKER_01 8:35

So there's so there's I mean, there's the the obvious reason, I guess, is that there are injuries that need immediate care. And having a physician there or somebody who's trained to make a hard decision in a moment can can really can save somebody's life. Yeah, right. Like the like when Damar Hamlin got commodiocortis on the bills um a few years ago, he was saved because there were experts in treating like cardiac arrhythmias on the field, right?

SPEAKER_00 9:07

That was even 60 seconds after it happened.

SPEAKER_01 9:10

Right, right. So so I had trained at that program. I recognized the doctors who were going out to to save him, right? I didn't I didn't tell, you know. So if if Mark, if you're listening to this, nice job, by the way. But shout out, Mark. Yeah. Um, but it's a I mean, but but that's you want physicians there for that reason. And and the truth is there are probably like the half dozen things that are catastrophes that you want your physician to be there for. Those are rare, you know what I mean? Many doctors can go through their whole career without needing to ever implement a life-saving technique. Yeah. More commonly, doctors who aren't trained in sports medicine issues, I think, inappropriately sideline athletes for injuries that don't that they don't need to be sidelined for. Yep. And so I think the real advantage to me being there is that I can appropriately triage an injury. Yeah. You know, like it not only can I diagnose an ankle sprain, but I can say, like, look, bro, this is a sprain.

SPEAKER_02 9:58

Yeah.

SPEAKER_01 9:58

It may hurt. But you can you can still play, you know, and get out there and and play in your sectional game right now. And I'm not gonna unnecessarily restrict you and send you to the ER or something.

SPEAKER_00 10:08

I didn't even think about that. But as a PE teacher, I see it all the time. Kids get hurt with a sprained ankle, come back with a note saying they can do nothing for four, six weeks, whatever it is. And I always encourage them to get a note that says you can do upper body stuff or you can do lower body as tolerated. Like you can at least do some things, but more often than not, it's just a blanket do nothing until it feels better, basically. Which it's tough.

SPEAKER_01 10:32

I mean, the the the there's no incentive to clear these kids early, right? Like the the physician or or provider who sees them, they're not gonna get in trouble for being too conservative. Correct. But it's it's meaningful for people, you know, like even in you know, in a gym class or something like that, who wants to spend a month and a half like on the sideline and doing you know doing paperwork or whatever. Especially when you think you're quote unquote fine. Um, as an aside out there for the listeners, there is very strong evidence, by the way, that a sprained ankle is best treated by early use and mobility. So day after you sprain the ankle, I recommend that people are up and walking on it. No kidding. No very low risk. Um why would it be better? I don't have a great answer as to why it's better. I mean, it's borne out in in the research that the amount of time that somebody is in pain or has dysfunction is uh diminished by early use. If I had to speculate, I would say that it's probably that they get to avoid some of the negative downstream effects of unnecessary immobilization. Yeah. Stiffness, swelling, weakness, loss of proprioceptive feedback. Whereas you know, I mean, imagining that we as human beings are you know evolved to live in a more pastoral world, a world of forests and gotta survive. You gotta survive. Most injuries are injuries could, in theory, work through. That blows my mind. Can I just give another example actually? So commonly in the United States, at least, right, when you if you tear your ACL, which is one of the main stabilizing ligaments of the knee, it's surgery in the United States. And the reason is because the ACL, if you if you lose it, if you tear it, it doesn't heal. And it will lead in many people to instability in the knee. And instability over the course of like a decade or two is going to be arthritis and then a knee replacement, it's a catastrophe. So but it's not that not everybody has instability, actually. Only about half of people have frank instability following an ACL tear. And so in Europe, for example, ACL reconstruction is much rarer than it is in the United States.

SPEAKER_00 12:35

Really? So they just have slightly more unstable knee than somebody who did. Maybe.

SPEAKER_01 12:40

You know, people can are pretty good actually at even subjectively relating about this. So like if you if you tore your ACL, did you ever tear your ACL? No, I didn't. So if you ever if you ever tore your ACL, yeah. Same same, by the way. Yeah, I haven't turned mine yet. It's waiting for me, I'm sure. If you tear your ACL, you can often feel if your knee is sliding around. And in that case, you'd probably be a good candidate to have it reconstructed. Yeah. But if you don't feel it sliding around and you're not looking to play high-level athletics, like if you if you said, like, look, I want to be able to walk around, I want to take a job, I want to hang out with my kids, be good.

SPEAKER_00 13:11

You can probably do it. It's crazy. I guess that's why you see some people tear an ACL and they don't even realize that they tore it until the game's over or practice is over or whatever, and then other people can't even put weight on it. Yeah, yeah, yeah. Interesting. So let's talk about high school athletes. What's something that you think, aside from the two things that you just blew my mind with, they don't understand about what goes on behind the scenes medically. They just hear doctor told me I can't play, that's it, period. That's a good question. It's interesting.

SPEAKER_01 13:40

I think that often on uh in a conversation with an athlete where I'm trying to inst them on some level, that I am really trying to look out for their for their best interest, and that I recognize that there's an urgency or a need for them to continue to be able to be athletic right now, in this moment. That it's not that it's not just about thinking about what they're gonna be like as an adult in 25 years or something. What's happening right now, and that if like if I if I have to make a decision or that involves sidelining a kid, right, for their health, that I better be I better be one really confident that I'm making a decision that that makes sense, that's reasonable. And I mean I I work very hard to make sure that the athlete knows why I'm doing that. I think that's huge. I think often they don't realize it. I think I think they don't know that.

SPEAKER_00 14:30

Why do you think that is? Just the the stigma of doctors always taking people out, or where where does that come from?

SPEAKER_01 14:37

I mean, I bet that's part of it, I guess. But two, I think that they, you know, a risk-benefit analysis for them, they they risk a lot more by being honest, I think, and potentially having a practitioner or provider pull them out than lying about their symptoms.

SPEAKER_00 14:53

So do you think in general athletes tend to under-report their injuries, kind of play it off like I'm okay, I can battle through it, or what do you think?

SPEAKER_01 15:02

I think that as a as a as a group, athletes probably under-report, but I think that it's I notice that there are patterns within sports. Sports that are maybe that one would perceive as being more aggressive, a little rougher, a little bit more contact-oriented. I find that they tend to under-report uh especially so. And sports that are non-contact, a little bit more individualistic, I find that I have people inappropriately sometimes reporting. And so one of my first steps when I come into the room is to try to do a little bit of like a psychoanalysis of the person to try to determine are you a bit of a hypochondriac? Are you somebody who's nervous about your your injury? Sometimes I try to I even try to have them like game it out, right? I'll say, like, look, like let's just say I told you you're gonna be fine. Your injury's not not not gonna prevent you from playing. Right. Do you do you still want to have this visit? Do we still need to do something? I'm surprised how often they're like, no, actually, if you said that I'm that I'm good, then I'm then I think I'm good. Okay. Which is great for me. Perfect.

SPEAKER_00 16:00

You know, in that case, you're good, no, call me if you're not good. So we talked about this a little bit in the last episode, coaching boys versus girls. Do you think there's any difference in injuries as it relates to how they report them for boys versus girls? Or is it just more sports-specific, like you said?

SPEAKER_01 16:16

No, actually, I don't have a great answer for this. I think that there's probably medical literature that would discuss rates of injuries between men's and women's teams, but it's it's hard maybe to parse out also whether the difference in reporting between men's and women's sports is related to different injury profiles. Yeah. Right? Like, for example, I don't know if this has been brought up on the podcast before, but like women tear their ACLs at higher rates than men.

SPEAKER_00 16:39

I did hear that, yeah. And so, yeah. Is that just like a body composition thing?

SPEAKER_01 16:42

Or there are probably multiple factors that are involved with it. For example, it's actually slightly more common to tear your ACL when you're really like changes in your hormone levels will change the elasticity of injury. It makes sense. I would never think about that, but so yeah, so I mean, so there have been some very some very clever researchers out there who's asked questions, questions about this. Um I don't know. So I would be yeah, I'd be totally speculating if I said that I thought that there was some difference. My my intuition is that it's slightly more common for women to report score uh to report injuries than it is for men. Um that's just your experience.

SPEAKER_00 17:14

It's my experience, and so I hesitate to like too strongly emphasize that. So, what are the most common injuries that you see in high school athletes?

SPEAKER_01 17:21

Generally, I see ligament sprains, probably of the knee or of the ankle most commonly, and then center that I work for in Binghamton also is the concussion center for our institution, and so I see a ton of concussions as well down there.

SPEAKER_00 17:35

So if I'm a parent listening and my kid comes home from practice every day and says, my knee hurts or my ankle hurts, how do I know if that's just normal or when it becomes a problem? So, first of all, I totally understand why this could be a difficult question to answer for a parent.

SPEAKER_01 17:52

Um there are certain features of a of an injury that I would say are worrisome or that you should be alerted to. You generally don't want to see what's called an effusion in a joint, in an injury that you can ignore. And so to say that more simply, right, if you injure your knee, you don't want to see that there's swelling within the joint. If there's swelling within the joint, it means there's a problem happening inside the knee itself. It's probably worth getting evaluated. But that can also be hard to evaluate for. I could totally respect, I don't, I don't, I don't know if there's a there's a joint swelling. Absolutely. If an injury is not inhibiting top-end play, and if an injury is something that a person can warm up through, it's something that hurts at the beginning, but then seems to get better as they continue, yeah, these are probably injuries that you could ignore. I can't give a you know blanket green light. But if that's good advice, as as somebody who's you know newly, newly apparent himself with a with a two-month-old at home, we're not we're not talking about these things yet, but this is this is the advice that I'm going to give for my daughter when she's old.

SPEAKER_00 18:51

Cool. So do you think that early sport specialization, I see it all the time now, kids say, I'm only gonna play basketball or I'm focusing on football or soccer or whatever it is, leads to more injuries for them. Would you recommend kids are more sport specific or play as many sports as you can? Is there any relationship between injuries and sport specialization or not?

SPEAKER_01 19:12

Yeah. Yeah, so so there's a few questions maybe there to parse through, but maybe just to take the first big one. There's good evidence, which is to say that this has been studied by physicians and scientists, that early sport specialization for most sports is worse than playing a variety of sports or having a variety of activities early on as it pertains to top-end achievement and as it may pertain to injuries. Why do you think that is? I think that our bodies are, you know, to maybe make an understatement, are complex. I think that there's a body didn't go to medical school, obviously. Yeah. We heard it here first. Um because of our intelligence range, various resources. Like our own learning and our own ability to understand things is a little bit of a black box. I think that we, the same way that like AI has a black box as to how it understands what to do. Yeah, the same is true for us. We don't we don't know how we learn how to do the skills that we have. We don't know why Steph Curry has one of the best three-point shots that's ever been seen. Is it only because he was concentrating in basketball, or is it because of the range of other experiences that he had, right? Like, you know, maybe just to stick on him that I arbitrarily chose as an example, like why has he been able to remain so dominant as an athlete in his role, despite other people knowing that we should be shooting three pointers more, right? Right? Like the whole game has changed largely as a result of his influence. He stayed the best. And he stayed the best. He's managed to maintain his dominance, right? How how does a how does a the number one guy in the world at any sport maintain their dominance when the the secret is out, right? You know what I mean? Like like when when Roger Federer became you know the king of tennis, right? And he has a he has a one-handed backhand, right? Yeah, everyone could see him, you know. And and despite that, he managed to remain, you know, the number one spot for like seven years.

SPEAKER_00 21:03

So we kind of talked about it a little bit. What what do you think the difference is between soreness and injury, right? So I'm sore after I'm sore when I wake up in the morning. I'm sore after practice, I'm sore after a game. How do you know? How does a kid know? How does a parent know? How does a coach know you're sore versus your injured?

SPEAKER_01 21:21

So I would expect that soreness would happen without a specific incident. You might be able to point to a to like a range of things that you've done, but it sh you shouldn't get sore in it in the way that I think that we that we mean sort of like muscle soreness from a particular moment, a particular pull or fall or incident. Okay. And so I'm much more wary. If somebody if somebody can point to a moment in their game or practice where they felt something happen, that to me is much more indicative of likely being an injury and not soreness, versus if somebody says, like, yeah, I don't know, it's been like a while. Yeah, exactly. Like if If they seem vague about it, it generally lowers the and so if somebody is just sore, what's the recommendation for that? I think first of all, just recognizing what a typical soreness pattern is, right? So soreness generally results from local inflammation in the muscles. The medical term for it is DOMS or delayed onset muscle soreness. And it's something that we would expect to peak in terms of intensity of pain within about three days, like 72 hours. And you expect that the symptoms to not last more than five days to seven days. And so if it starts to break that pattern, then we start to think about other things.

SPEAKER_00 22:35

Okay. So what I've also heard too from kids that that lift weights is it's a different kind of sore than when I lift weights and my arms are sore when I go home. It feels different, but still sore. Is that a reason for concern? Or are there different kinds of sore, I guess? Sure.

SPEAKER_01 22:51

I mean, I think that the question almost that you're asking, I'm gonna try to rephrase it just to make sure they understand. But as an athlete or as a you know, a younger person articulate well enough that something is happening, that something is unusual about your injury, and and can one parse through that, it's it can be it can be tricky. You know, the older that somebody gets, the more sense they tend to make. Yeah. You know, most 18-year-olds can like talk like pretty coherently. Yeah. When I have a five-year-old in the clinic, it's a it's it's totally a it's a crazy I had a so just as an example, I had a three-year-old in the clinic the other day. Really? For a concussion? No, for a for a leg injury. So she somebody had pulled the blanket out from underneath where she was standing and she fell and she she hit her leg. The parents kind of saw it, but it wasn't like a yeah, it wasn't really clear what had happened. The kid now for like three days won't walk on their leg. And so and so you know, they get an x-ray, and the x-ray is inconclusive. It doesn't show anything. Right. And so the so the question is, do I want to have the kid for can the can the kid articulate anything? Can the kid articulate where it hurts? It'd be difficult for a five-year-old to do alone a three-year-old. They weren't doing it, right? And so so then I am faced with this decision: do I do I get them an MRI and sedate them and have them go travel an hour to have this done? Or do I put them in a waterproof cast for three weeks and see how things go? It's it's what'd you do? I don't know. I think, I mean, I don't know how you would feel as a parent, but like if given the choice, but I don't want to sedate my kid.

SPEAKER_00 24:15

No. And then send them off to an MRI, I would go water. I think you made the right choice.

SPEAKER_02 24:20

I don't know who I am, but no, I mean, I think you're heard it here.

SPEAKER_00 24:25

Uh so we kind of talked earlier about the ACLs not always needing surgery. I think a lot of people assume that surgery is the fix. How often do you think surgery is actually necessary as it relates to sports injuries?

SPEAKER_01 24:39

I think that surgery is most commonly indicated for acute injuries, meaning injuries that have recently happened. Generally, a fresh injury, fresh tear, or destabilization of some joint can be corrected, and maybe surgically can be corrected. Yeah. Um for chronic injuries, surgery tends to be less helpful because the area is often already sort of extensively damaged. Right. I can tie this in with an example, actually. So when baseball players tear their UCL, the ligament that helps to hold the elbow in place. Tennis elbow? It's it's near tennis elbow, actually. So tennis elbow is on the outside of the elbow, and the UCL is on the inside of the elbow. This is the ligament that pitchers tear when they're throwing that they get Tommy John surgery for. So this ligament here on the inside of the elbow, if you're a base, if you're a pitcher and you tear that, you may end up needing to get Tommy John surgery, right? That's probably the only way that you're gonna be able to pitch hard again. Yeah, but when we look at the UCL actually of the athlete, of a baseball player, they're trash. Even before you spend 15 years developing a UCL that can tolerate the amount of force that needs to be put through it. Right. It's am I can I actually continue on this paper for a second? So there was an interesting uh what's called cataveric study that was done looking at the UCL. This is looking at at dead people, actually, and we we stress I'm saying we as if I was involved in this, I wasn't involved, and other people did it before I was a doctor. They stressed the UCL of people who were already dead and found that the UCL tears at around the amount of force that would take to throw an 80 mile an hour fastball for an average person. So, in order for a person to develop a fastball that goes over 80 without tearing their UCL, it means that the UCL has to adapt and scar and get thicker and bigger. Hundreds and thousands of reps. Yeah. Interesting. So yeah, by the time a baseball player, by the time a pitcher tears their UCL, it's already shot anyway. It's shot anyways. And so it's not that it can't be reconstructed, it's not that it can't be repaired. Right. But it generally isn't as of the same quality that you would see in somebody who just has a freak accident. Yeah. We're we're working recently with a with a semi-pro hockey player who tore his UCL of his elbow, and he's having a very different course, a much better course than what most baseball players have.

SPEAKER_00 27:04

Because he just has no scarring and it's inflamed and all that stuff. Yeah. Interesting. So let's talk about the big one concussions. Everybody's talking about it now. A 15-year-old takes a hit to the head, pops up, says, I'm fine. What is actually happening inside their brain at that moment?

SPEAKER_01 27:20

So, assuming that this 15-year-old is developing a concussion, what's happened is that when they hit their head, a small number of what are called axons in their brain tore. Axons are the connections between neurons, between brain cells, and are involved in sending information and electrical signals between cells. It's how you, it's how you think, it's how you understand and process the world. When these axons tear, they can no longer maintain the stuff that's supposed to be inside the axon as being separate from the stuff that's supposed to be outside the axon. So like these tubes, these axons, right, have materials that flow through them. And it's different than the material that's outside of them, presumably, right? And so when your axons tear, it's sort of like how you might imagine like a ship that has a hole in it that might react. So you'll see for the we can stick with the ship analogy for a second, you'll see seawater flow in, and there are pumps on the on the boat, right, that help to pump seawater out. The same is true in your brain. You have pumps actually that sit on the axon and will pump material so that it will try to maintain a gradient or uh maintain the difference from the inside to the outside. This, the use of these pumps requires energy, and over the course of up to a couple of days, the energy will get exhausted. You'll exhaust your energy supply, and what you'll see is this cascading effect where initially somebody might pop right up like this 15-year-old did and feel fine. And they legitimately do feel fine. Yeah. But as the energy in their brain is used up, it's exhausted, they're gonna find that they feel worse and worse. And this is the development of the concussion. It's this cascading effect out with, it's a physiologic injury to the brain. And that it's it's it's one of the hardest things about concussions is that you really can legitimately just stand up and feel like, yeah, I'm I'm good. And then hours later, how long does that whole process take you?

SPEAKER_00 29:17

Up to three days. Wow. It's crazy. So you could get a concussion on, say, a Thursday night, Thursday night, feel okay, playing the game Friday, yep, and then Saturday realize I'm not good. Wake up, you wake up on Sunday and be like, whoa, I feel a little, I feel off.

SPEAKER_01 29:30

I feel dizzy, I have a headache, I feel yeah. Interesting. I never knew that. Um it's a huge challenge, it's a challenge for everybody. It's a challenge for for coaches, for parents, for physicians.

SPEAKER_00 29:41

Do you err on the side of caution there or leave it to the parent or the kid? Or or what's the approach?

SPEAKER_01 29:47

You know, generally the party line right now in medicine is to be pretty conservative with this. You gotta cover yourself. Yeah, yeah, yeah, yeah, exactly. Yeah, yeah. Exactly. That's yeah, the adage that we teach our like resident physicians or fellows is when in doubt, sit them out. And this is only true really for concussions. If you think it's something else, like or rather, if it's a different injury, like you can kind of use your discretion. Yeah for concussion, we're we're aware that it's that it's a big deal. There have been I mean, I could I mean I could give so there's a there's a 2014 pediatrics article written by Elbin et al. I believe, which suggested that continuing to play in a situation in which you've developed a concussion will double your recovery time. Double. Double. So we're talking like an injury that in some, you know, it takes between two and four weeks on average for people to improve from. Now you're looking at two months. Right. That's insane. So it's it's it's a big deal to catch it. I mean, and rather it's in the athlete's interest, right? As much as it would suck to sit out the rest of this, let's say, third quarter and and fourth quarter, rather, if you want a chance in playing in next week's game, at all the rest of the season, even.

SPEAKER_00 30:53

It's it's total totally happening. So any other in, well, I don't want to say any other injury, but most other injuries, you know, you tear an ACL, you sprain an ankle, whatever it is, there's there's a medical fix for that, right? And then you're back to how you were. Sometimes you're stronger than you were before. Is there anything like that for a concussion, or do we just kind of let it naturally heal itself?

SPEAKER_01 31:14

So so I think there are maybe two questions in there. So one is is there anything that we can do to expedite recovery from a concussion? Yeah. And then two is maybe just long-term, can you emerge from a concussion in better shape somehow than where you entered into it? Right. So there's new research that's mostly come out of the University of Buffalo, actually, which by that I happen to do my fellowship there, but it also independently is like a really uh important uh place for concussion research. Okay. But there's this suggestion that doing what's called aerobic exercise, and I don't have to describe define aerobic for you, but maybe for the listeners. But so aerobic exercise will predictably shorten the length of time that somebody has to deal with a concussion. So just from the blood flow to the brain, or it's a good question. It's I'm gonna give maybe two answers as to why this would happen. Um maybe I'll just say what aerobic exercise is first. Is that okay? So aerobic exercise is exercise in which we see an elevation in heart rate without spiking one's heart rate. Think about activities like walking, jogging, running, biking, swimming, not hit workouts, not weightlifting, not sprinting.

SPEAKER_00 32:20

Is that why the return to play protocol is so, I guess, conservative? You start by just walking and then you go to light jogging and then you do some light training activities, and then you're full go.

SPEAKER_01 32:31

Yeah, I mean, it's it's the basis for, yeah, is it is is basically because aerobic exercise can be pretty controlled or prescriptive, how you would do it. But yeah, I mean, so are your your listeners are familiar with with the return to play protocol?

SPEAKER_00 32:43

Is that worth defining for a second? I I would probably say so, but we can define it for sure.

SPEAKER_01 32:48

Yeah, so so just briefly then the return to play protocol is a five or six-day program that demonstrates when an athlete or any individual has subjectively recovered from their concussion that we can prove by way of having them do intense physical activity that they are truly recovered.

SPEAKER_00 33:03

Um and any sort of setback takes them back to the beginning. Right? So if I say I have a headache after day five, I go back to step one?

SPEAKER_01 33:12

No, you actually stay at stage five. So it's it's it's only if you have several days where you're lingering at a stage that we might have you reassessed or try to determine it, but it's not but it's not it's not a blanket rule. Well, once somebody feels okay and they're like going through the protocol, if they are getting stuck at some point in it, it might be worth like a reanalysis. Like are we did we miss something? Is there some other problem happening here? Interesting. Maybe going back to what you were asking about why exercise seems to help. There are two theories, I guess, that I would say that are that are off-sited. One is that it's possible that just doing some exercise, which can trigger some symptoms of the concussion, yeah, just helps you become more tolerant to the symptoms and might make you feel better faster as a result of that. That's the it's the less rosy picture, but it might just be toleration of symptoms. The other idea is that not to get too into the physiology, I enjoy this stuff a lot, but you're fine. So concussion damages your ability for your brain to perform its normal function, right? And I think people are like aware that their brain like helps them think and do stuff, right? But some of what your brain does is regulate, for example, your autonomic nervous system. And so your autonomic nervous system is part of your body, you don't have control over the mushroom. You can't write anything dilate, or you can't make your, I don't know, you can't make yourself sweat by thinking. These are correlated by your autonomic nervous system. But your autonomic nervous system is disrupted by a concussion. And so we'll see derangements in how your autonomic nervous system works when you have a concussion.

SPEAKER_00 34:46

Is that like why some pupils are dilated and some don't react? And that's a little different.

SPEAKER_01 34:50

That might be a bleed. That's bad if that happens. Yeah, so just yeah, just a PSA. If anybody sees like a blown pupil after a concussion, you should just bring them to the hospital. That's it. Don't wait on that one. Um we see people with like blood pressure issues after a concussion. Really? Yeah. And it's like their blood pressure gets a little deregulated after a concussion.

SPEAKER_00 35:08

I never would have thought that. Well, interesting, yeah.

SPEAKER_01 35:10

So some some clinics will test blood pressure actually as a smart, as a as a part of their intake for this.

SPEAKER_00 35:17

So let's let's talk about some equipment. You see it all the time with NFL, they come out with new helmets, and even high school now has like I don't know what they're called, the helmet guards. The guardians. The guardian caps put over their helmets. Does that help reduce concussion risk at all from what you've seen?

SPEAKER_01 35:34

So there's pretty good evidence on this that has come out. So the guardian caps might a little, which is maybe the best the best that I can do with this. So maybe. So it's it has to do, unfortunately, with sometimes the complexity of the helmet itself. So really advanced helmets nowadays have certain flex points or depression points that it's meant to the same way that your car has a crumple zone. Yeah, your helmet, if it's an expensive one, has an area where it's meant to bend in from impact.

SPEAKER_00 36:02

And so protect your head, protect your brain.

SPEAKER_01 36:05

And so the guardian caps or these other covers that go over the helmet can disrupt sometimes where that point actually is. And so for cheaper helmets, it seems like it probably is helpful because these cheap helmets don't have it. Right. Expensive helmets are kind of counterproductive, right? It might be an expensive helmet. Yeah. Additionally, if I can add one more fun to that, when you have a glancing blow in a football game, let's say, right? You have guys who are going head to head, but they're off-centered a little bit from each other. Yeah. If you're wearing just the helmet, you can often clip each other and just slide right by. The helmets are smooth. When you use a guardian cap or another type of head cover, you might catch and end up with a twisting injury. I never even thought about that, but you are 100% correct. So you can injure the neck, and additionally, you could you could end up having a concussion. You can have what's called a rotational acceleration of the skull where your whole skull twists. Oh my god. And the brain will want to remain still. If you can imagine, let's see now, if you have a glass with some ice floating in it, if you twist the glass quickly, the ice will effectively stay in place. The same thing happens with your brain in your skull. If you twist this quickly, the brain will kind of bash into the side of the skull as the skull twists into it.

SPEAKER_00 37:18

So a high school football coach comes up to you and says, I'm thinking about getting guardian caps for football devices.

SPEAKER_01 37:29

I think that it's mostly an illusion. I think that you know you as an athletic director or coach would be better off spending that money doing something different with the case.

SPEAKER_00 37:38

Interesting. Because they're designing all of these helmets for this reason specifically, and then you throw something on top of it that was never supposed to be there.

SPEAKER_01 37:48

Yeah. Yeah, right. Like they're right, they're they're not making their helmets thinking that we want to make them compatible with some other product. Yeah. The same is true, by the way. Have you ever heard of the Q collar? Is that something that you guys that you see your guys wear at all?

SPEAKER_02 37:59

Yeah.

SPEAKER_00 37:59

Oh, on the back of the neck? On the back of the neck. I've seen them. We don't have them though.

SPEAKER_01 38:03

So so these are also, these are, these are, these are really just a sham, I have to say. There's the the science is kind of bad. Somebody's making money somewhere. A lot of money. Crazy. What is the thought process behind those? So the Q collar is like a U-shaped device that goes around the back of the neck and it's supposed to block some of the blood flow out of the jugular veins. So when you're you say your carotid arteries pump blood up into your brain, right? The jugular veins are what allows the blood to clear from your brain. So far so good? So far so good. So the idea is that if you partially block the flow of blood out of your brain, you will increase the pressure and the like you'll fill the space more with the with blood and prevent your brain from sloshing around, which isn't really what happens anyways in a concussion. Your brain doesn't actually move forward or backwards. I think a lot of people think it does, though. I did. Yeah, yeah, yeah. I think it's a really common misunderstanding about it because I think most people aren't thinking in terms of like neutral buoyancy often when they're imagining their brain. Your brain has the same density effectively as the fluid in which it sits. And so you're, it's not like a it's not sitting on top, it's not floating in the brain, and there's no extra space around it. It really is just snugly held in the skull. And so if you if you had like a hard, what's called linear acceleration, right? You like whip back and you hit your head into the ground. If you if you whip your head back, your brain doesn't in turn smash into the back of your skull. It's the energy that is transmitted upward through the skull and into the brain that actually damages it. It's like an energy that makes so much more sense.

SPEAKER_00 39:48

It's it's tough. So why why is there this conception or misconception that it's it's the shift in the brain? I hit the side of my skull, and that's what a concussion is.

SPEAKER_01 39:59

I think that it's it's a simpler explanation, and it and it goes along with what our understanding is just intuitively about how the world works, that if two objects moving together and one stops, the other one's just gonna hit into the back of it.

SPEAKER_00 40:10

Yeah, it makes sense.

SPEAKER_01 40:11

Um the oh, so if I I'll just finish up that point that I was making about the the cue collar. So this is based on how so actually, by the way. Yeah, straight up. They have a they have a long tongue that wraps around their head in their brain, rather they hit they could they were dropped. Yeah, so when they're pecking, they actually are stabilizing their brain with their tongues. No kidding. Yeah, yeah, yeah. But we're crazy. Yeah. Who knew that? Yeah, no, no, no. I mean, I didn't know it until I started researching this stuff about the about the cue collar, but it's uh but it's tough. Yeah, my my one line of advice is be just save your money.

SPEAKER_00 40:44

So you think cue collars have a negative effect on athletes if we're keeping that extra blood in our brain, or has no effect whatsoever?

SPEAKER_01 40:53

I bet no effect. I think that if it had a negative effect, it would probably get detected and it would get some bad bad publicity. You know, I can't I I can't say for sure, but I don't I don't hear about it as something that's negative either.

SPEAKER_00 41:06

I think it just doesn't understand. Let's let's talk about high school athletes a little bit more, um, or even high a college or younger. Doesn't matter. Have you ever had an athlete that really pushed you back on your decision to hold them out? And how how do you handle that as the the trainer on the sideline or the doctor in the clinic?

SPEAKER_01 41:27

So I think this maybe goes back to something that I was talking about a little bit before, which is that like I'm trying to do a little psychoanalysis when I am interviewing the athlete. And I think the first question that I ask myself when I detect that somebody is pushing back against my recommendation is to is why? Like, they do they not trust me? Is there some other motivator that I'm not aware of for the athlete? Is it is it a is it a personal motivation? Do they have overbearing parents? Is there a coach that wants them to do this? Is there like a financial or you know, some other incentive that I'm not privy to? So often if I find that I'm getting pushback, rather than try to convince the person immediately that I'm correct, I I really try to just pause and say, like, okay, look, man, like where are you coming from? Yeah, I'm detecting some some lack of trust. You're like, what's going on? Like everything good, you know? Like, do you do you want to play in this game? Do you not want to play in it? Like, you know, are you getting pressure from somebody? How's your coach gonna feel if you don't do this? Yeah, sometimes it's it's effective, but no, not always. It's it's tough. You know, you can only I think I can only I can only make myself so open of a character. But if you I don't know if you've been burned before, if you feel like, yeah, you know, I've tried to be honest before and I have got burned. Yeah, I can't blame them for that, you know.

SPEAKER_00 42:38

We talked about coaches a little bit. What's one thing that you wish every coach knew or understood about injury management? Because you we can't you can't be there for every practice or every game or whatever it is. What's one thing that you wish they understood?

SPEAKER_01 42:52

I guess I would first start by just saying that I've had a lot of a lot of respect for for coach. No, it's a I think it's a it's a pretty tough job and it's at a really important point our lives, and we don't get, I think, compensated quite well enough to do some of the some of the parenting that they're doing. I'm gonna quietly agree with you on that one. Um I you know, I I guess I wish that we answer this in a slightly different way. I guess I guess yeah, particularly. I think I I wish that coaches were a little bit better at recognizing sometimes if an athlete's whole identity is wrapped up in the sport in which they're playing. Um I think the hardest conversations that I have with athletes are the several conversations per year that I tell an athlete that they are not gonna be able to play this sport again the rest of their life, or that I would recommend against it.

SPEAKER_00 43:36

Yeah.

SPEAKER_01 43:37

And you see that athletes for whom this is their whole reason to be, their whole identity is tied in with this, they do terribly. Yeah. You know, they they don't hear my recommendation as a as a way of trying to save their health so much as they hear it as somebody attacking who they are taking away something they love. And taking it away. Right, right, right, right, tear tearing them apart in some way. And I think that it's I think it's tempting for a coach to encourage an athlete to be dedicated to their sport. And yet I think that when it's the only sport that a kid does, or when they're really dedicated to trying to make it to the D1 level, and they aren't going to make it for some reason or another, or they have injury. This is one of the this is these are some of the hardest conversations that we have. And I think coaches recognize that, and maybe I wouldn't want to tell them to say that to not play the sport, but to recognize that it would be helpful if they had other things in their life that they were focused on.

SPEAKER_00 44:28

Absolutely. Well, let's kind of touch on that mindset part of the injury or the rehab process. What does an athlete who heals well do differently than an athlete who maybe doesn't? And how much of it, if any of it, is mental?

SPEAKER_01 44:44

I think that athletes who heal well tend to be people who tend to be people, first of all, who have maybe like an intrinsic ability to face adversity with maybe better than some of their counterparts. I tend to see athletes who heal better having good support systems, parents that care about them, coaches that understand where they're coming from. I think that it's largely mental in the sense that given two identical people with identical injuries, the person who emerges relatively unscathed from the injuries sees this in the context of their of their life maybe as a whole and not an end to their identity. People who are simultaneously dealing with the physical discomfort of the injury as well as the loss of identity. It's a lot, especially for a kid to deal with all at once. I think. I mean it's often, I think, the first time that they're probably being faced with something that is this hard.

SPEAKER_00 45:39

Absolutely. Let's let's look at the long-term health of joints of athletes specifically. Um, at the highest level, isn't sport inherently risky? Like if someone wants to chase greatness, should they also be prepared to give up the long-term health of their joints?

SPEAKER_01 45:57

Yeah, I mean, I think bottom line, yes. I think no one can really emerge unscathed from the pursuit of high-level athletics. I think you could look at almost any pro-athlete who hasn't had a career in your sport, they have a list of injuries that I think an average person is like catastrophic. Yeah. If maybe as an aside, maybe is it okay if I bring up the concussion stuff again? Yeah. Were you gonna bring that up anyways in a minute? Or is that yeah, you know, you can jump into it. Yeah, yeah. So CTE, which stands for chronic traumatic encephalopathy, is a uh neurodegenerative process that occurs from repetitive head injuries. It's been seen a lot and been in the media a ton for the last 20 years now as a result of football. There was uh there was a pretty interesting study that was published in JAMA in 2017 by Anne out of out of Boston. Yeah. She had 202 brains that were donated to her from football players, 111 of which were from ex-NFL players. And in those 111 ex-NFL players, 110 of them were found to have CTE. No way. And wow, this is a lot. Yeah, I would say so. So, which is not to say that you're if you play in the NFL that you have a 99% chance of developing CTE. Your brains that were in this study were donated to the center because the family or people close to the person thought that this might be useful. Even if the people in the NFL who developed CTE were 100% represented by that 110 people, meaning that, like, let's say these these guys were active from I don't remember which years, but let's say from 1975 to 1995, let's just say those those 20 years, it would still represent nine percent of the total number of players in the NFL over the over that course. So at a minimum, we're seeing that as a rate NFL. Wow. At a minimum, it could it could not be lower than that based on just that number alone there. So how do we fix that?

SPEAKER_00 47:50

Yeah, it's it's true, it's a good question. So it's a it's a just get rid of football and contact sports altogether, or do you do you see CTE? Probably not at at such a staggering percentage, but in other sports, or you do, but it's lower. Yeah.

SPEAKER_01 48:05

Yeah. The issue is that it's it doesn't seem like it's even concussions necessarily that cause it. It's like what we call subacute head injuries, which is to say head hits, but that are below the level of rising to where even the person themselves detects it. Um I can quote one more study. Of course. Looked at high school football players in the season. Yeah. And what they would do is they would take their high school football players who were in protocol who had gotten a concussion that was diagnosed, and they would run them through an MRI and put them through like a whole battery of tests. They'd look at their brain, they'd look at how they're performing various like thinking tasks, cognitive tasks. Additionally, though, each week they would take players from the team who were not diagnosed with a concussion, asymptomatic players. Guys who were like, Yeah, I feel good, I'm fine. And about half of those asymptomatic players would do worse on their testing and C is easy in the beginning of the season. Wow, wow. Just a random, it's it's they weren't testing the whole team each week, but it was just a random assortment of like other guys who were. Holy cow. So I think maybe getting back to your to your bigger question, I I I love football. Yeah, you know what I mean? I I like watching it a lot. Um I I enjoy the bills, I've had I've had great experiences watching it, and yet I'm not sure that there's a way that we can change the pattern of injuries that we see without fundamentally changing the game. And I think that we as a society basically need to reconcile with that in some way, or sorry, not reconcile, reckon with that in some way, or sort of accept that we are a society that is going to produce, you know, elite-level football players with a cost. With a, with a with a cost, right? There's there's evidence that was done in the out of a study that was done in Sweden. Sorry to keep bringing up studies, but there's there was a there was a big study in Sweden for the like the Swedish Institute of Health that found that a single concussion, one concussion, can predictably at a societal level change the chance that somebody will have some sort of violent crime. No kidding. That's unbelievable. Just one. Just one. Wow. As somebody who said three, I don't feel great about this, but I gotta move my seat away a little bit. I know I'm getting a little bit more.

SPEAKER_00 50:18

All right, so you just had you just had your first daughter, yeah, a first kid. And ten years down the road, she decides she wants to try to play football. Your advice to her is No way. No way. I hate it.

SPEAKER_01 50:32

You know, I I hate I hate to to be that person.

SPEAKER_02 50:35

Yeah.

SPEAKER_01 50:35

But I think that I would be remiss as a parent in not attempting to dissuade them from doing an activity that has such an inherent risk.

SPEAKER_00 50:45

So, what about like say soccer, where they had the ball and there's still collisions? Even basketball, I guess.

SPEAKER_01 50:51

I'm mixed. I don't I don't have yeah, I I would be I feel I feel troubled by it, I guess.

SPEAKER_00 50:56

I I it's definitely a tough, tough situation to be in.

SPEAKER_01 50:59

What do I what do I say to my daughter? You're like, you can play, you can run cross-country.

SPEAKER_00 51:03

You can do tennis, golf. No, not even tennis. You can golf and run. You can do tennis and you have to stay in one place. Right.

SPEAKER_01 51:12

You can play table top. Um I I I don't think that I would I I don't think that I would encourage my daughter to dive, despite you doing it. Despite me doing it. I would I would finish practices sometimes and feel dizzy and feel like I had a headache. And it was never, you know, I don't think I had a concussion, but I think I was getting these just accumulated subconcussive injuries. How do you explain that to her?

SPEAKER_00 51:32

Well, if you did it, why can't I? Yeah, I it's weren't as knowledgeable. I mean, hopefully she would she would hear that.

SPEAKER_01 51:39

I guess it depends on what age we're having this conversation. You know, I I guess you you hope that your kids can learn from your own failures or or the hope anyways misses. I I'm not sure that you can. If she dived instead of participating in in, let's say, flag football, I think it's probably a win. Because her dad is like does research on concussions that she's gonna grow up in a house that's like steeped in conversations around head injuries. You know, she's gonna be educating all her friends on you shouldn't do this. I hope until you know, until I you know lose my job for for saying such such uh condemnable things about about our American past times.

SPEAKER_00 52:20

Well, I mean that went back to they knew what the risks were and they signed up for it anyways at some point. I mean, sport is inherently risky, right? Right. So I don't know, I everybody's different, everybody weighs out risks differently.

SPEAKER_01 52:33

Yeah. I mean, I guess uh the the tough thing with the kid, right, is that you you sort of have to do that though for them, right? I I do actually feel quite a bit more sanguine about a 23-year-old NFL player taking a risk with their brain than I do for a like like a father like me telling his you know fast forwarding a few years his now 10-year-old that they can do something that has risk involved with it. Yeah, you know, like like look at look at look at Tua, for example, right? Uh quarterback for the Dolphins has had four at least concussions in the NFL, maybe more in college. Yeah. I think there's a very low chance of him emerging as an older adult feeling fine. I think very low chance. I think that he's he's he's in trouble, right? And yet he's making what did he sign his contract for a few years ago, like 156 million dollars? Something stupid, yeah. But a lot, a lot of money, right?

SPEAKER_00 53:24

Justifies the inherent brain damage, I guess.

SPEAKER_01 53:27

He could save a lot of lives with 150 million dollars.

SPEAKER_00 53:29

His family's set for life, right?

SPEAKER_01 53:32

His his grandchildren will be benefiting from the career that he had.

SPEAKER_00 53:36

Yeah, it's noble if you think about it that way.

SPEAKER_01 53:38

Sure, right? A coal miner sacrifices their their health on the altar of improving their family's uh law.

SPEAKER_00 53:44

I think at some level, almost all professions sacrifice something for the good of their family, whether it's just time or you know, whatever it is, their own health. And you look at it that way, I guess it's really not that much different. Just it's a very it's a very visible way of watching permanent, serious, yeah, yeah. It's crazy. You want to switch gears for a minute?

SPEAKER_02 54:04

Yeah, totally.

SPEAKER_00 54:05

All right, so you you acted and directed at local theaters. How do you think that performance relates to athletics in terms of like the pressure or performing in front of people or having to work with a team or whatever? Do you do you see any similarities or yeah, yeah, hugely.

SPEAKER_01 54:25

Um so I think of I think of an acting, I think of a cast as being with a team. And everybody in the cast has their role to play the same way that you would in a in a team. And similarly, the cast is trying to convince the audience that something matters. A lot of what happens in acting, right? Is that it's it's only in everybody taking it seriously and being committed to some unified project that you end up with a show or an act that's that's worth watching. And the only reason it matters to the audience is because one, they believe that the actors care about it.

SPEAKER_00 55:02

Yeah.

SPEAKER_01 55:03

And two, it's because they're able to suspend their disbelief that it that it doesn't matter.

SPEAKER_00 55:08

Yeah.

SPEAKER_01 55:08

And the same is true, I think, in any sport, right? If you if you're watching, you know, the the Super Bowl, right, the only reason it matters for an average person, right, is because you can make yourself believe that these these you know you know, these these two teams of guys in costumes, you know, hitting each other and trying to do, you know, produce this show for you, yeah, matters. The only the the drama, and we we use the same word to describe word, the drama of sports is because they believe it matters, and you can borrow from their intensity of and and the belief that it matters.

SPEAKER_00 55:43

That's such an interesting concept. I hear kids all the time, like if they lose a game or have a losing season or whatever it is, it's okay. I just I didn't care anyways. The worst thing you can hear from somebody, right? I mean, like especially as like a coach or a teammate, like you don't want to hear that from your teammate. What if you don't care, what am I doing? Mm-hmm. It's crazy.

SPEAKER_01 56:02

It's I mean, I mean, maybe you can hear that as like a defense mechanism on the part of a kid to try to absolutely um shed some of the disappointment or shame that they might feel for like a poor performance, but it's I think I think the same thing happens in in in acting, right? Like there's like a there's a refrain that you might hear in in theaters, which is like, go for it. You know, if you have a desire to make to make a move to have your character do something bigger is better, go for it. Yeah, go for it because that's that's where the excitement is, it's where the drama is, it's where your audience wants to see it. And the same is true in in sports. I want to, you know, I want to I want to see Aaron Rodgers try to do that Hail Mary passing. Yeah, yeah. That's what I'm there for. Yep.

SPEAKER_00 56:43

That's why we're watching. Yes. So you enjoy conversations about sports, astronomy, and philosophy. I'm gonna try to blend them all together here. Easy. Do you think athletes are more like machines or artists? And why? I think they're more like artists. Okay.

SPEAKER_01 56:59

So why are they more like artists? Well, I think that it's now that I'm thinking about it more. I guess I could go either way on it. No, but I I like the idea that what is interesting often about what an athlete does is sort of how they do it.

SPEAKER_02 57:12

Yeah.

SPEAKER_01 57:13

The I think the sports that are the most interesting to watch are the ones that have components of it that are random or unexpected. Uh, most people, for example, don't really like watching like these like track races. Not to say that you don't want to watch like the 100-meter dash, but as soon as somebody's running the 5,000, yeah, no one's tuning in for 12 and a half minutes to watch like the Boston Marathon or something. I mean you watch for a minute, you know, check out school, they're out in front.

SPEAKER_00 57:37

Even even golf, same thing. Watch them hit the club at the ball over and over and over.

SPEAKER_01 57:42

And I think that these sports are sports where people are the closest TV. Yes, yes. Closest to where they don't where they don't allow for any artistry or any creativity. Yeah. What sport do you think allows for the most creativity? Sure, whatever answer I think of, I'm gonna be, you know, an hour from I'm gonna like a much better answer for that. I have to think it would be individual sports, something where it's not overly prescriptive. I think it might be something like maybe like like MMX.

SPEAKER_00 58:11

I was the first thing that came to my mind, real jujitsu came to my mind almost immediately. My son does it and he goes twice a week. And just watching like what they do, like they get very specific directions. Your head goes here, you do this, you turn this way, you do this. But then if they don't do exactly what they're expected to do, you gotta kind of figure it out on your own and get creative and figure out on the fly how to do what you want to do. Sure, right.

SPEAKER_01 58:34

It's there's there's like it feels like an endless amount of variation as to how you have to do it. It reminds me a little bit about like learning jazz, where like in order to be, I think, a good jazz musician, you have to be an expert on the blues scales, right? You have to know them all up and down perfectly, and yet when you're actually soloing, right, when you're actually when it's your turn at the at the microphone, yeah, you've got to be ready to be creatively moving through these scales. It can't feel like you're otherwise you lost them. You lost them.

SPEAKER_00 59:01

Yeah. Yeah. So what do you think sport is more sports are a science, or sports are more artists or a combination of both, I guess. Or maybe it depends on the sport.

SPEAKER_01 59:13

I mean, maybe it depends like or whom one is asking. Like for the for the athlete, I think that maybe it's more often maybe it's maybe it's both, you know. Like, I think there are there are there are athletes who are artists, and there are athletes who are technicians. There are athletes who absolutely who come in to feel the freedom of movement. And there are there are guys who come in to like, I know my numbers, I know my reps, I know what I'm gonna be doing, and I've like, I've boiled this down, you know. For researchers, I think you're often looking for ways to measure it. You're trying to turn it into a science, and yet it's always a sort of crude approximation of what's actually happening in front of you. It's too complex of a system to really isolate interesting, purely mechanical terms.

SPEAKER_00 59:54

Yeah, so what what do you think makes sports so appealing for so many people? Watching it, playing it, is it as simple as or is it something bigger?

SPEAKER_01 1:00:04

I think that it's I think that it's it must be harnessing something truly like primordial about us, something truly ancient in our brains, wherein play and competition was an evolutionarily valuable trait to have. And I think that we're playing out in some ways the desires or the impulses of our genetics. Yeah. I would suspect that at some point evolutionarily, it was beneficial, it was it was helpful in terms of passing on your genes to be not just athletic, but to have a joy or a desire to experience your environment through these activities through play. Yeah, I think that's why it feels fun, is that it's it's it's the reward system our body gives to us to make sure that we keep doing the the the thing, right?

SPEAKER_00 1:00:56

The same way that like procreation is is been around forever. Been around for a long time. And the more I think about it too, like you you go back and you see all of the all of the ancient artifacts, and and there's always drawings and pictures. And I think as far back as sports go, I think theater goes back just as far, if not farther. I think there's way more similarities than even I thought of. Most people think sports are one thing, theater's another thing, philosophy is a third thing. I think if they can coexist, and I think it helps see the bigger picture of the person and why sports are what they are.

SPEAKER_01 1:01:31

I hadn't thought about that, but you're right. They're both, or you know, or all three are extremely like ancient things, right? They they precede written history.

SPEAKER_00 1:01:38

Yeah. Why do you think that is? I mean, because there's only a handful of things like that.

SPEAKER_01 1:01:42

Right. There are there are ideas that that some people talk about that a that a shared mythology and ability to buy into a story is one of the reasons that human beings have been able to cooperate on such a broad scale. Yeah. If you look in the animal kingdom, even at higher order mammals, the limit for meaningful relationships is about 150 per individual. So like you or I could know about time. But no, that's the limit. That's top end. I mean, you just can't, you can't, it's it's it's hard for any individual to know more than that. And most people don't, right? And so you see like troops of chimps, for example, as they get bigger, they fracture at about that number of individuals. You no longer can create a cohesive group where every individual knows every other individual. And so one of the ways in which it's it's it's thought that we were able to build towns and societies by is by having common mythologies, common stories that pass together. Even though you know you and I aren't related as far as we know. Um go back far enough, we gotta be closed. That's a good point. But I mean, but we're both we're both American, we're both, I think, lovers of sports, and I think that there are qualities that that unify us, that allow us to cooperate.

SPEAKER_00 1:02:54

Yeah, it's interesting. I still, the more I think about it, the more similarities I I find. But let's let's shift and talk about you as a father. Sure. You just became a dad. Does that change anything for how you look at youth sports now?

SPEAKER_01 1:03:08

Um, maybe it's like a tiny bit early for me to be thinking practically about it. But I think it hasn't changed it a ton because this is my whole world. I think about I think about youth sports constantly. Every day I'm having conversations with kids of all ages in all sports, trying to help them to navigate their lives.

SPEAKER_00 1:03:25

And I think I I can pick this up just from this interview, but I think it helps that you really care about the athletes that you're treating. It's not just a patient to you, it's not just a number to you. I think it really makes a difference. You care about the athlete and you want them to be okay both on the field and off the field. Um so yeah, I I I think that's great for you, and I wish more doctors were that way.

SPEAKER_01 1:03:47

But it's yeah, I mean, it's it's a good pathway for people. You know, if there are any if there are any would-be, you know, erstwhile sports physicians out there, this is a this is a good path. Yeah, I mean, it wasn't uh I'll if I can share just a really brief anecdote. It was it was not it was not always my plan. Like I as an undergraduate, I was not so focused on going to medical school. I thought, I thought that I would. I had taken the the MCATs, like the entrance of the test, and I did well enough that I believed that I could get in. But when my like college advisor called me in as a senior to like have a conversation about it, like what I what I want to do. And this is as a as a as a senior, right? Like I'm like about to graduate. He's like, so what do you, you know, what do you what do you want to do? And I was like, I think I'll take a year off. And like, what do you what do you like like doing, you know? And I was like, I guess I like sports. And he's like, why don't you be a why don't you be a gym teacher? And yeah, yeah. And then I was like, I was like, yeah, maybe you know, maybe that. Yeah. Yeah. And then I think like I, you know, I don't know, like I took the year, I ended up getting into medical school, I went, and then somehow I found myself 10 years later like back working in sports, despite, you know, not not anticipating that this is.

SPEAKER_00 1:04:48

Do you think your parents had any sort of influence on that? Or like on being a physician or being a sports doctor in particular?

SPEAKER_01 1:04:55

Either one. I you know, it's hard to say that they they couldn't have. I mean, my dad was a doctor, so it's it's it seems like it's probably much more than just a coincidence that my dad was. Probably. It was never it wasn't express in my family. Yeah. You know, no one was saying, like, you better do this. Yeah. I've I've three brothers. One one of my brothers is all is also a doctor, he's an ophthalmologist, but I have a brother who's a lawyer, and a brother who's uh an assistant principal.

SPEAKER_00 1:05:19

No kidding. Kind of got it all covered then. Just yeah, just any major issue that you might have. We could injury, legal, like a mechanism. An engineer of some sort. So, what would you tell every sports parent listening right now?

SPEAKER_01 1:05:34

I guess without getting too critical, I think make sure that you're you're doing this for the for the right reasons. Yeah. Make sure that you're not secretly harboring to the extent that you're able some some sense that you want your kid to do the sport that you yourself did or wanted to do, or that that it's really that it's really your kid who's exploring and making a a choice to do that. I mean, like the chance that any kid makes it to the NFL, the NBA. MLB in the United States is the industry. I think it's like one in five thousand to the NFL. Sorry, amongst high school football players, it's about one in five thousand.

SPEAKER_00 1:06:09

And even the average NFL career is what? Two years maybe? Yeah, I think it's like 18 months or something. So then what do you do after that? Who are you after that? I mean, if you do make it there.

SPEAKER_01 1:06:17

Yeah, I think you know, I think guys like bounce around right to like the XFL to other to other leagues. Yeah. I I think it's hard to emerge from that world though and feel absolutely whole. The best chance I think is baseball. I think they think that's one in thousand high school baseball players. Wow, man. What a deal.

SPEAKER_00 1:06:34

I know, right?

SPEAKER_01 1:06:34

But no, right, totally. If one in five thousand high school football players makes it out of play. You're talking about like a couple couple guys per century from a school.

SPEAKER_00 1:06:43

Ready for some rapid fire questions? Yeah, let's do it. First thing that comes to your brain. Don't think about it. All right, just let it go. Ice or heat? Ice then. Ice for the first week then.

SPEAKER_01 1:06:51

After the first week. After the first week. After the acute inflammation is settled, then go to heat. Okay. Stretching before or after? Never. Never. No, stretching is bad. Why? Static stretching seem with static stretching is where you're not doing like ballistic or dynamic stretching. Like if it's like standing there and like pulling your arm to one side or doing like a hurdler stretch, it doesn't do the things that we want it to do. So we're gonna have to do a whole nother episode on that. I've given lectures about stretching before. I'm really I'm really down on stretching. Yeah, basically, it doesn't help with injury prevention. It doesn't over at least like a two-month period change range of motion, it doesn't help older people with balance. And it may, and and predictably actually, for certain explosive sports, it decreases performance in the 30 minutes or so after you stretch. So if you're like a hundred-meter stretcher and you stretch out, like limber up by like doing static stretching, yeah, you're you're gonna decrease your ability to be explosive in your in your sport. The best thing to do would be more like dynamic movements, dynamic warmups are the best. Interesting supplements necessary or overhyped? Generally overhyped creatine positive predictably gives like one to two percent increased lean body mass. If you were talking about muscle that is is coming over.

SPEAKER_00 1:08:00

That was actually the next one. Creatine for teens.

SPEAKER_01 1:08:02

Oh. Yes or no? Yes. Yes, yes, why lean body mass? I mean, like you're adding muscle for free, basically. There's no reason that you shouldn't be just making sure that your body is replete with the protein that exists, anyways, you could get from somewhere else. Even if even if you don't work out, still I mean, I think so long as you're not like uh taking in like the amount of calories from it, like as long as you're not like you know taking on an onboarding an additional 500 calories a day or something. Yeah, interesting.

SPEAKER_00 1:08:27

We already kind of touched on this one, but I want to bring it up again. Multi-sport athlete versus special asset specialization.

SPEAKER_01 1:08:34

For almost all sports, multi-sport is is gonna be better. There's some evidence that potentially things like gymnastics or or figure skating, maybe you have a better performance if you are truly specialized into that early, but the range of most sports, most athletes better off for having done other things. And this is written about actually by this author, I think wrote two really good books about this. His name is David Epstein. He wrote Sports Gene and Range and examines this question about specialization versus being a multi sport athlete, and about whether sport ability comes from an inherent or intrinsic quality that you have versus training and how much that can be affected.

SPEAKER_00 1:09:17

I just watched a video from Nick Saban who was talking about this, and he said he almost always exclusively recruits multi-sport athletes simply because he thinks they're more competitive, right? They go out and they try new things and they try different sports and they do all of these different skills, whereas you do the same specialized skill over and over and over again and you're in your environment. He wants competitive kids that that can adapt to different situations. I think it makes sense if if only from a mental perspective.

SPEAKER_01 1:09:48

I mean, you can't argue with the guy for having had some demonstrable success. Like whatever whatever ideas he's got about how to recruit, I feel like you've probably I'm gonna listen. Yeah, I'm certainly intrigued at why he why he thinks something like that, right?

SPEAKER_00 1:10:00

Don't take my advice, take his advice, right? Yeah. So next one, it's a quote no pain, no gain. Truth or trash? True. Interesting. Why?

SPEAKER_01 1:10:09

I I think that becoming good at almost anything takes some grit. You have to challenge where you think you can tolerate things, and you have to find where, I would say you have to find where your edge is, but often you find your edge by going past where is appropriate, yeah, actually. But I think it's the price that you pay for becoming good at something. That if you that if you live a life, and this maybe gets gets more towards like a philosophical discussion, but if you live a life in which you don't challenge yourself, it sounds too cliche. If you don't try to exceed in some way what you think you're capable of, if you don't ever put yourself in a situation in which you feel uncomfortable, I think you can get through life without having maybe experienced the range of what life has on offer.

SPEAKER_00 1:10:50

Yeah.

SPEAKER_01 1:10:51

Right? Like no one feels ready exactly to be a parent. Oh never a perfect time. You roll the dice, you try, you try to go through it, and you hope that because it's happened for billions of years, that probably you'll be okay, also, right? Your parents presumably had you and you were okay.

SPEAKER_00 1:11:07

Turned out all right, I think most days, anyways. Did it, you know, I'm here, podcasts. One sports trend that needs to die.

SPEAKER_01 1:11:17

Boy, sports trend. There's a bunch that I, you know, I don't know if I should say stretching or these, you know, these list them off. Yeah. So I think stretching before or after sporting events, especially in a static way, needs to needs to go away. The lack of regulation around supplements should go away, just as well, list more. The concussion equipment probably needs to go away. All right. It's yeah, I mean, it just in until somebody can create. I'm not saying that there couldn't exist something that's that's compelling that makes a big difference, and and I will sing a different tune the next time that we that we speak if that if that happens. But until that happens, I'm just I'm waiting for the for the next big for the next big product. The issue, by the way, with some supplements is that you know if you're if you're a creatine company, let's just say, right? There are two dozen companies you can get creatine from just on Amazon. Right? And because it's not regulated, what you'll find is that some companies will add things that they're not supposed to add into it, won't list them.

SPEAKER_00 1:12:16

But if you take a low dose anabolic steroid with your team, you're solidine. So, what do you recommend for a high school athlete, creatine-wise? Is there is there one brand that's better than another? I hesitate to name a single brand that's better.

SPEAKER_01 1:12:32

I think what you want to look for is a company that tries to go through its own regulatory process to demonstrate their commitment to having a pure product. And so they often would list that on the website, like the testing that they put their product through in order to know be sure that it's free of certain like quote unquote contaminants, but many of which they're they're adding themselves. I would tend to get an American-made product rather than getting one from overseas. Those are the those are the those are the biggest ones. Yeah.

SPEAKER_00 1:13:00

Interesting.

SPEAKER_01 1:13:00

The last one most underrated recovery tool. I think I think is is is movement, is use, actually. I think people are generally under the impression that still blows my mind. Absolute rest is good. And it for most injuries is not beneficial. For most injuries, movement is better early. Doesn't have to be crazy, it shouldn't be necessarily like like painful movement, but but use seems to be better. And and and it seems like it helps to correct this. Are these still the rapid fire ones? I'm answering this in way too long. No, no, no, you're fine.

SPEAKER_00 1:13:30

Whatever this is, it works.

SPEAKER_01 1:13:31

So it helps because it allows people to immediately retain or remain athletic. And so you don't feel like you are just sidelined waiting for this injury to improve. You have an active part that you can play in improving it. Like for the concussions, for example. Like you can go out every day with a concussion and do aerobic exercise and know that you are going to shorten the amount of time that you're suffering from the concussion. And for I mean, for it for a football player who's just been pulled out a foot bomb, telling them, like, look, there's a way to remain in shape, actually, right now. You want to you want to play the next couple of weeks, right?

SPEAKER_00 1:14:04

Work out every day. You better do it. You know? Well, so why do you think there's such a misconception about that?

SPEAKER_01 1:14:10

I think it's it probably starts from the medical side where I think people just don't get blamed for being too conservative. Yeah. You know, you don't lose your medical license for saying you stay out for longer and you'd lose your medical license. But you could get sued for giving somebody bad advice for saying, you know, you went they they went back, a jury could find you credibly as having too cavalier with the person's health.

SPEAKER_00 1:14:30

Interesting. All right, I know I said that was the last one, but I promise this is the last one. If you could give one piece of advice to every athlete listening, what would it be? Well, I I should I should hope at some point to have such a big audience that I can talk to, that I can talk to a lot of.

SPEAKER_01 1:14:42

I think that I'll keep it with the same theme that I was bringing up earlier around I guess to which is to make sure that you have different things you feel comfortable with, even if it's another sport, even if it's some other activity, that it's the sort of thing that's gonna make you overall have a happier, probably fuller life. Yeah. It'll keep you from feeling as at risk if you if the sport gets taken away from you.

SPEAKER_00 1:15:05

At some point it's going to, right? Even if you make it to the highest level, you're not gonna play forever. It's gonna leave at some point. You better just fall back on. Yeah. You know, there are there are very few athletes. If any Aaron Rodgers, maybe.

SPEAKER_01 1:15:19

But there's like right, there's like six that we can name, right? And most people live past the age of 40. You're gonna have to fill those next few decades with something. You better have something going on.

SPEAKER_00 1:15:28

Yeah, that's and people don't think about that. I don't think I did either. I don't I definitely didn't.

SPEAKER_01 1:15:33

I think maybe that's maybe that's where the parents come in, which is to help their kid foster multiple identities in sports or something.

SPEAKER_00 1:15:39

Absolutely. That's great advice. But look at you. Fresh dad giving parenting advice and just killing it. I'll be curious to see what they say in 10 years if I say something totally different. But specialize, just do one sport, that's all you gotta do. Only. Well, this was awesome. Thanks for coming in. I really appreciate it. This is When Pain Isn't Normal, Sports and Injury Truth with Dr. Max Camerman of UHS for the pressure proof podcast. That is all. This episode is sponsored by Curly Wealth Management out of Oneana, New York. So special thanks to them for helping out with everything on this podcast, in this episode.