Medical Mystery Cases are developed in conjunction with leading medical and scientific experts. The patient profiles and data presented contain realistic scenarios, data, and outcomes but are not taken from actual patients and should never serve as a substitute for professional medical advice. The cases are intended for healthcare professionals to gain insight into disease state diagnoses and treatments that are founded in evidence-based medicine.

23. A Painful Problem

Orthopedic Surgeon: Who’s the new kid? He is FAST.

College Football Coach: That’s Derek, the new transfer. Use your hands! Be physical!

College Football Coach: I’m glad you’re here. Derek is having problems with an old rotator cuff injury.
He was sidelined with it last year. It’s still causing him pain.

Orthopedic Surgeon: Hmm. Call in an appointment for him at my clinic and we’ll take a look.

College Football Coach: Okay, will do. Come on! Hustle!

Orthopedic Nurse: Follow me please? Here’s a gown to slip into. Wear the opening in the front. The doctor will be in soon.

Derek: Huh? Ah…okay…thanks.

Orthopedic Surgeon: Hello Derek.

Orthopedic Surgeon: Derek?

Derek: Oh hey. Sorry, I didn’t hear you come in.

Orthopedic Surgeon: Hi there, I’m Dr. Scott. Coach Cameron tells me you’re having shoulder pain. Can you tell me about your rotator cuff injury?

Derek: Sure thing. It happened during our first game of the season. I rushed about 8 yards…into the end zone…landed hard and had about 5 guys on top of me. Didn’t know I was even hurt at the time…too pumped about scoring… When I was in the locker room…realized my shoulder was messed up…had surgery, then out the rest of the season.

Orthopedic Surgeon: What meds are you taking?

Derek: I was taking oxycodone after my surgery but I quit. Now, I take Advil after practice and in the morning…when my head hurts.

Orthopedic Surgeon: Do you get dizzy?

Derek: Yeah, sometimes. Also constipated. I guess I need more fiber or something…

Orthopedic Surgeon Voice Over: Derek didn’t seem to be on his game. He looked drowsy and was slow to respond. When I examined him, his pupils were dilated.

Orthopedic Surgeon: I want to get an MRI on your shoulder. I also want you to see a neurologist about your dizziness.

Derek: Okay.

Orthopedic Surgeon Voice Over: The MRI of Derek’s shoulder came back so I planned to recommend surgery to repair a tear in the rotator cuff. The neurologist ordered a brain MRI and found evidence of mild TBI. I called her to discuss the case.

Orthopedic Surgeon: Hi Ruth, do you have a minute to discuss Derek’s MRI scan?

Neurologist: Yes and I’m glad you called. There is more to talk about.

Orthopedic Surgeon: I think I know where you are headed. You ordered a comprehensive drug screen?

Neurologist: You got it. Derek tested positive for THC, methylphenidate (Ritalin), and tramadol. With his shoulder pain, undiagnosed concussions and now, depression, he is self-medicating.

Orthopedic Surgeon: Don’t they run a drug screens when they transfer in?

Neurologist: Well they should but… The Bulldogs and the Wildcats have the most restrictive drug policies in the SEC but even if they test positive for any drugs on the list, they miss only one game.

Regular drug screens don’t detect tramadol. Student athletes know this. He might have received an exception for Ritalin. Tramadol will not be detected on a typical drug screening—an SAMHSA-5 panel—but it will show up on more advanced testing. Some are advocating for its inclusion. And methylphenidate won’t be detected either with routine drug screens. I see a lot of athletes given a prescription for it.

Narrator: It was determined that Derek had developed a dependency. To avoid further opioid use, the Orthopedic surgeon opted for preoperative pain management using IV ibuprofen Caldolor® and an opioid-free surgical procedure in coordination with the anesthesiologist. The orthopedist required, by written and signed agreements with the patient and his healthcare team, that the young man not be prescribed opiates for uneventful surgery, and that the athlete will not seek or accept opiates from other providers during post-op treatment.

Opioid addiction is becoming very common in high school, college, and professional athletes due to painful, recurrent injuries. It’s possible to perform a successful surgery without the use of opioids using multimodal pain management strategies. A team approach used by the multiple healthcare professionals involved can best serve the athlete’s recovery.

Orthopedic Surgeon Voice Over: IV ibuprofen Caldolor® administered pre-operatively should be considered in Enhanced Recovery After Surgery (ERAS) protocols for the management of postoperative pain including that of traumatic origin. Patients given Caldolor® have been shown to experience less postoperative pain and a decrease in their opioid use.


Narrator: Three days later, Dr. Scott examines Derek.

Orthopedic Surgeon: Hi Derek, good to see you up and around. How does the shoulder feel?

Derek: It’s a little tender when I roll over on it… but mostly good. No pain.

Orthopedic Surgeon: Derek, we need to keep the sling on another 2 weeks. Your first PT session is scheduled for the end of this week and we want you to continue this for 3 to 4 months. We might be able to get you back in at the end of the season but we want to make sure you are fully healed and ready to return to the field.

Derek: I feel good about it.

Orthopedic Surgeon: The neurologist and I have both spoken to you about the tramadol. We think with the physical therapy all you will need will be some Tylenol and she didn’t see a need for Ritalin. I didn’t use any opioids in your surgery. You have probably seen a lot of your peers get hooked. We don’t want that to happen to you.

Derek: My head is clearer now. I don’t want to go back to it.

Orthopedic Surgeon: So what are you studying in school now?

Derek: I am thinking now about going into physical therapy. I would like to help athletes recover from their injuries.

Narrator: Our star player had a complete recovery after surgery. He is looking forward to next season with a much clearer outlook.
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