Chapters Transcript Leveling the Playing Field: Lessons from Sports Neurology Course: The Cutting Edges in Stroke and Neurology Updates 2025: Case by Case Well, thanks, and it's uh really great to be here. Uh, when I was looking at my talk yesterday and, and looked at the title, and I thought it was a rather clever title, but it's actually completely wrong. I'm gonna be really talking about peripheral nerve injuries in sport, and so you think that might be below the frame and magnum, but when you're talking about sport, you're talking about mind-body. So, uh, my title is uh wrong, but, uh, we'll get beyond that. And then, uh, just a minute ago, I, I, uh, you know, talked to my friend Chad GPT. And I asked the question, what was the first sports neurology center in the United States? And Chad GPT said, well, it was Kerlin Joves, and that was around 2012. Well, actually, there's a story about sports neurology, and this goes back to uh 1991, uh, when I was doing research in glioblastoma, so that was my primary area of neurological activity. And Orrin Devinsky, uh, who, uh, with whom I trained, he called me up because he was at the hospital for joint diseases, which was part of NYU. And was starting an epilepsy program and he said, Brian, I'm getting bombarded with all these weird entrapment, neuropathies, chronic pain, and can you come over and, and, and be director of clinical and sports neurology? And I said, Oren, I don't even know what sports neurology is. And he says, well, you're an athlete, you'll figure it out. So I, uh, I don't know what being an athlete has to do with an academic discipline, but NYU technically has the first sports neurology center in the country. So, uh, there we have it. Um, these are my disclosures and, uh, nothing I'm talking about today. I don't have any, uh, conflicts of interest. So we're gonna be taking a journey that's a non-concussion journey. People think of sports neurology as being concussion-related, uh, but when I was, uh, uh, co-founded the American Academy of Neurology, sports Neurology section, they called me the non-concussion sports neurologist because I wanted everyone to understand that there's a lot more to sports neurology besides concussion. And there really is. I'm just gonna give one case example, but the whole purpose of it is to try to help you understand what it means to be a sports neurologist when you're dealing with an athlete who has an overuse injury. And speaking of athletes, I just want to take a, a sidestep. So a sidestep is a very important tennis term. And that, uh, is the sport that, that, that put me through, uh, college, um, but I, I had, I've had the privilege really of working with, uh, some of the most recognizable athletes on this planet, and I was chief medical officer of the US Open tennis championships for 16 years and you realize when you're dealing with these wonderful athletes and you know we tend to live vicariously through, through athletes in, in our society, but these are all kids, they're human beings and they have the same sort of things that make them human as everyone else except that they're really gifted. In sport. But I will just tell you that during my 16 years as Chief Medical Officer of the US Open, I did fire 3 physicians because they asked an athlete for an autograph. And so no matter what we're doing in medicine and we're privileged to work with anyone who's a patient who comes to see us and their primary emotion is fear that they have something wrong, but as soon as you objectify someone, you ask for an autograph, and I told these three physicians when I fired them that what they were doing was no different than pornography. They were, they were living vicariously through someone. They were objectifying someone, and they were living through their fantasies that they had this special relationship with that person. And the doctor-patient confidentiality was completely eliminated once you do something like that. So, that's just a little uh sidestep here. The core references I'm, I'm using, uh, are real, I was uh author of them and I have been keeping very much up to date with the literature here, but these are really the sort of foundational articles. So, this is the clinical presentation. 25 year old right-handed tennis player, he complains of pain in the scapulotthoracic region. And he's unable to hit a backhand volley. So what's the most important question right now? Do you hit a one-handed or a two-handed backhand volley? If it's a one-handed backhand volley, we know the diagnosis right away. How do you hit a backhand volley? That's almost pure infraspinatus. So, That gets us thinking. But what we really do whenever we see a patient, and I, uh, the 1st 3 questions were what we had to do every morning in Morning Report with Fred Plumb. We had to ask and answer the question, is this patient ill? Pretty simple question, but someone with the worst headache of their life, it's a subarachnoid hemorrhage, they're ill. If it's a migraine, well, they're uncomfortable, but they're not acutely ill. Secondly, is there disease of the nervous system? And if so, what's the underlying pathophysiology? If you came into Morning Report and said someone presented with a, with a TIA, you were kicked out of the program, essentially, well, at least for a week, and then you had to go, uh, you know, rake leaves at his, his, at his old Westbury place for, for a week. But that was uh Doctor Plumb and Posner. So we ask these questions, but then in sports neurology, you ask other questions. If it's an injury, a musculoskeletal injury, is it acute or overuse? And if it's overuse, we have a whole group of questions we must ask. What's their training regimen? What are their biomechanics? What's their equipment like? And then finally, we must define the pain. We think that all pain is related to injury, but it's not. In fact, almost all pain in sports neurology has a central component, really in all aspects of life. We overplay nociceptive pain. So I'm gonna walk you through all of these um in, in this history. So, is this person ill? Well, no, he's not. Is there disease or dysfunction of the nervous system? I strongly suspected there was. The more focused history is the idea of gradual onset of pain and weakness. Without an identifying and citing event, so this was a progressive overuse sort of problem. Importantly in the history, he had a severe left ankle sprain a year earlier. For which he never properly rehabilitated. Nothing else was per, pertinent, and the targeted exam showed that he had atrophy without fasciculations of the infraspinatus. He was weak on the infraspinatus, and otherwise the segmental neurological exam was normal. So now we can positively say just on that exam alone, that this individual is not ill. He has disease of the nervous system. And we can localize it. So you see here uh the tracking of the suprascapular nerve, which innervates the supra and infraspinatus muscle, but when it traverses under the spinoglenoid notch, notch, it's purely infraspinatus. And that's an area of considerable traction movement of the scapula. And so there's a gliding force that can potentially entrap that nerve. So I was highly confident that this individual had uh infraspinatus weakness because of entrapment or lesion of the suprascapular nerve under the spinal glenoid notch. So now we ask, well, OK, this is, he's not ill, he has an overuse injury. What are the sports-specific biomechanics? Well, it wasn't acute, this has been going on for many months, and if it's overuse, we ask these questions. What's the periodization? Is there a functional kinetic chain continuum? Are the sport biomechanics proper and is the equipment appropriate? Well, what's periodization? It may be the most important word in all of sports medicine. And it's probably the most common cause of physical injuries. Mental health, symptoms and disorders, and spiritual malaise. Because for periodization, what it means is that for every amount of overreach, there must be compensatory recovery. That's something we do daily, weekly, monthly, and on an every four-year cycle when you're working with Olympic athletes. If you don't recover, you move into overtraining, you move into overuse, and you can move into burnout. For those of you who lift weights in the room, if you lifted weights yesterday and in your upper extremities, you didn't lift weights in those same muscle groups today because you break down the myofibroils and you need to recover properly. Well, this patient had no sense of periodization whatsoever. He just traveled from tournament to tournament. And what was interesting is that we found out that he never really recovered from his left ankle sprain. And that gets us to the next question, what's the kinetic chain continuum? So I'm just gonna show you a tennis serve right now. So I'm gonna step away from the mic. So you're getting ready to serve. You may have some ticks right now. You may be picking at things, doing this and that. Actually, about 80% of athletes have some sort of tip. But you're getting ready. And right here, 50% of anything that's gonna happen from my serve is coming from the ground forces up through my hips. That's critical. Same thing when you're throwing a football. Same thing when you're throwing a baseball. 25% comes from my trunk rotation, and that's the final 25%. So the kinetic chain continuum is incredibly important. And when we work with youth athletes, we find that their kinetic chain is way off because they're trying to imitate the pros, but they don't have the body function to do that. Why was this important in this patient? So, here's a professional tennis player. He ended up becoming top 10 in the world. And you couldn't even do the most simple of balancing. And When I asked him just to raise his shoulders. He had incredible scapular dyskinesia. So he had no ability to maintain any balance with his left foot. And as a right-handed tennis player, That's the primary force generator, and his left ankle was so unstable that he was forcing everything to happen through an overhead motion. And because that overused so much of the functional posterior stabilizers in the scapula, his scapular movement was way off. That led to the abnormal slinging activity of the scapula. That's why he had the entrapment of the suprascapular nerve under the spinal glenoid notch. And he had pain. And in sports, it's very important to understand. Is your pain nociceptive? So we all learned nociceptive pain in medical school, the classic thing, you put your hand over a candle and you draw away from an evolutionary point of view, it's protective. We have our chemical nociceptors, our mechanical nociceptors, our, our hot and cold nociceptors. It protects you from tissue injury. And inflammation is a type of nociceptive pain, but pain can persist. And go beyond nociception, and it happens much more commonly than we think. So we have to think of neuropathic pain, which means there's actually a lesion of the nervous system or disease, or we think of nociplastic pain. What's an example of no see plastic paint? Fibromyalgia, myofascial pain, chronic pelvic pain, chronic back pain, chronic daily headache. It's where you have an oversensitization of the nociceptors, which is mediated centrally. So for this individual, he had gradual pain onset. It unequivocally was nociceptive at first, but then he started getting this burning pain, never with autonomic dysfunction, so he didn't have complex regional pain syndrome. And what we need to understand in sports, neurology, is that You can have ongoing pain. And it can even be severe. But it doesn't mean you still have an ongoing injury. And so that's a key differentiator. So we looked at this patient's history. He had been on NSAIDs, he had had shoulder injections, was taking tramadol, and so on and so forth, and someone recommended exploratory surgery. But when we worked him up, there was no reason to do exploratory surgery. MRI didn't show a lesion. And we made a firm diagnosis. You're not ill. You have a right suprascapular nerve lesion at the level of the spinal glial knot, secondary to repetitive gliding and stretch of the nerve. And that was because of scapular dyskinesia, secondary to a poor kinetic chain, ineffective periodization, and a maladaptive service motion. Let me just take you through that service motion again. Because this player wanted to maintain at that time it was a 110 mile an hour serve. If you can't do it through the force generators. You're going to overdo it. Just by the last 25%, which normally it should be, and it becomes 50%, that's why he developed the overuse problem with the scapular dyskinesia and ultimately, The nerve lesion. And then finally his pain. There was essentially mediated pain. Do you wanna, wanna know what one of the primary drivers of pain in athletes is after an injury? It's fear-based pain. The athlete all of a sudden believes. That he or she is not capable of a certain activity and is overwhelmed with fear. On one of the papers we wrote for the International Olympic Committee, we talked about psychologically informed physical therapy. You really must address fear avoidance behavior because that's a driver of centrally maintained pain. So with this patient, We gave him great education on his kinetic chain, periodization, pain expectation. He had a multidisciplinary approach, he had a full recovery. And moved to top 10 in the world. So whenever we're dealing with A nerve injury, a sports-related nerve injury, we're looking at the entire human being. First of all, understanding even at the most elite level, these are human beings who are afraid. And they put their trust in you. And then we need to work comprehensively to under, you know, anyone can diagnose a supracapiar nerve palsy. I mean, jeez, that's like takes one minute, not even. But to go through everything and put the athlete in the place of everything that he or she does, that's the job of the sports neurology, and that's how we move athletes forward. So again, thanks for the opportunity to uh be with you and um look forward to hearing more. Thank you. Published December 11, 2025 Created by
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