Articles & Resources

Male Testicular Emergency by Eric Gahan

Posted by Boston Sports Medicine and Performance Group on Jan 30, 2011 4:00:00 PM

Here is the situation:

You are in bright and early for an early morning practice.  It about an hour and a half before the team’s 8:00am go time on the court.  Normal practice prep is on your mind along with some rehabilitation notes you are documenting before the players arrive.  One of the players happens to report a little early this morning with a distressed look on his face.  You meet him at the treatment table and listen as the player describes an intense testicle pain.  The pain is described as nothing he has ever felt before.  He reports to your athletic training room with acute onset of unilateral scrotal pain, scrotal swelling, nausea, abdominal pain, fever, urinary frequency.  He tells you he woke up with the pain and it has been getting worse over the course of the past 2 hours.  Do you recognize the male medical emergency, if not this young man could potentially loose his testicle………

Given the population that Boston Sports Medicine and Performance Group reaches out to and focuses on it is important to examine male emergencies in men’s basketball.  A male emergency all athletic trainers working with basketball should be aware of is testicular torsion.

Testicular torsion is a true urologic emergency and must be differentiated from other complaints of testicular pain because a delay in diagnosis and management can lead to loss of the testicle. Though testicular torsion can occur at any age, including the prenatal and perinatal periods, it most commonly occurs in adolescent males; it is the most frequent cause of testicle loss in that population.

The testicle is covered by the tunica vaginalis, a potential space that encompasses the anterior two thirds of the testicle and where fluid from a variety of sources may accumulate. The tunica vaginalis attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum.
In patients who have an inappropriately high attachment of the tunica vaginalis, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, can result in the long axis of the testicle being oriented transversely rather than cephalocaudal. This congenital abnormality is present in approximately 12% of males, 40% of whom have the abnormality in the contralateral testicle as well.1 The bell clapper deformity allows the testicle to twist spontaneously on the spermatic cord. Torsion occurs as the testicle rotates between 90° to 180°, causing compromised blood flow to the testicle.

Complete torsion usually occurs when the testicle twists 360° or more; incomplete or partial torsion occurs when the twisting is less than this. The twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle. How tightly the testicle is twisted appears to correlate with how quickly the testicle becomes nonviable from ischemia.

Causes of testicular torsion may include the following:
•       Congenital anomaly; bell clapper deformity
•       Undescended testicle
•       Sexual arousal and/or activity
•       Trauma
•       Testicular tumor
•       Exercise

Emergency Department Care
•       Early diagnosis and prompt urologic consultation is essential since time is critical in salvage of the testicle.
•       Analgesic pain relief should be administered as testicular torsion is typically very painful.
•       Attempt manual detorsion with pain relief as the guide for successful detorsion. The procedure is similar to the "opening of a book" when the physician is standing at the patient's feet.
•       Most torsions twist inward and toward the midline; thus, manual detorsion of the testicle involves twisting outward and laterally.
•       Consultation with urology is a must since most testicular torsion need surgical intervention. 

The unique aspect of being an athletic trainer is that it involves being well educated on all aspects of medical emergencies in the population we provide care.  Medical emergencies related to orthopedic and internal medicine.  It is all about early recognition to provide efficient and appropriate care.

        Dogra V, Bhatt S. Acute painful scrotum. Radiol Clin North Am. Mar 2004;42(2):349-63. [Medline].

        Ringdahl E, Teague L. Testicular torsion. Am Fam Physician. Nov 15 2006;74(10):1739-43. [Medline].

        Beni-Israel T, Goldman M, Bar Chaim S, Kozer E. Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. Sep 2010;28(7):786-9. [Medline].

        Cattolica EV, Karol JB, Rankin KN, Klein RS. High testicular salvage rate in torsion of the spermatic cord. J Urol. Jul 1982;128(1):66-8. [Medline].

        Coley BD. The Acute Pediatric Scrotum. Ultrasound Clinics. 2006;1:485-96. [Full Text].

        Hayn MH, Herz DB, Bellinger MF, Schneck FX. Intermittent torsion of the spermatic cord portends an increased risk of acute testicular infarction. J Urol. Oct 2008;180(4 Suppl):1729-32. [Medline].

        Creagh TA, McDermott TE, McLean PA, Walsh A. Intermittent torsion of the testis. BMJ. Aug 20-27 1988;297(6647):525-6. [Medline].

        Schmitz D, Safranek S. Clinical inquiries. How useful is a physical exam in diagnosing testicular torsion?. J Fam Pract. Aug 2009;58(8):433-4. [Medline].

        Brenner JS, Ojo A. Evaluation of scrotal pain or swelling in children and adolescents. UpToDate [web site]. 2006.

        Eyre RC. Evaluation of the acute scrotum in adults. UpToDate [web site].

        Doehn C, Fornara P, Kausch I, et al. Value of acute-phase proteins in the differential diagnosis of acute scrotum. Eur Urol. Feb 2001;39(2):215-21. [Medline].

        Prando D. Torsion of the spermatic cord: the main gray-scale and doppler sonographic signs. Abdom Imaging. Sep-Oct 2009;34(5):648-61. [Medline].

        Dogra VS, Bhatt S, Rubens DJ. Sonographic Evaluation of Testicular Torsion. Ultrasound Clinics. 2006;1:55-66.

        Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, et al. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. J Ultrasound Med. Jan 2010;29(1):11-21. [Medline].

        Turgut AT, Bhatt S, Dogra VS. Acute Painful Scrotum. Ultrasound Clinics. 2008;3:93-107. [Full Text].

        Cassar S, Bhatt S, Paltiel HJ, Dogra VS. Role of spectral Doppler sonography in the evaluation of partial testicular torsion. J Ultrasound Med. Nov 2008;27(11):1629-38. [Medline].

        Blaivas M, Sierzenski P, Lambert M. Emergency evaluation of patients presenting with acute scrotum using bedside ultrasonography. Acad Emerg Med. Jan 2001;8(1):90-3. [Medline].

        Bomann JS, Moore C. Bedside ultrasound of a painful testicle: before and after manual detorsion by an emergency physician. Acad Emerg Med. Apr 2009;16(4):366. [Medline].

        Capraro GA, Mader TJ, Coughlin BF, et al. Feasibility of using near-infrared spectroscopy to diagnose testicular torsion: an experimental study in sheep. Ann Emerg Med. Apr 2007;49(4):520-5. [Medline].

        Terai A, Yoshimura K, Ichioka K, et al. Dynamic contrast-enhanced subtraction magnetic resonance imaging in diagnostics of testicular torsion. Urology. Jun 2006;67(6):1278-82. [Medline].

        Moschouris H, Stamatiou K, Lampropoulou E, Kalikis D, Matsaidonis D. Imaging of the acute scrotum: is there a place for contrast-enhanced ultrasonography?. Int Braz J Urol. Nov-Dec 2009;35(6):692-702; discussion 702-5. [Medline].

        Baker LA, Sigman D, Mathews RI, et al. An analysis of clinical outcomes using color doppler testicular ultrasound for testicular torsion. Pediatrics. Mar 2000;105(3 Pt 1):604-7. [Medline].

        Blank BH, Goldsmith G, Schneider RE. Recognizing a testicular emergency. Patient Care. 1997;31(13):117-35.

        Brenner JS, Ojo A. Causes of scrotal pain in children and adolescents. UpToDate [web site]. 2006.

        Caesar RE, Kaplan GW. Incidence of the bell-clapper deformity in an autopsy series. Urology. Jul 1994;44(1):114-6. [Medline].

        Cattolica EV. Preoperative manual detorsion of the torsed spermatic cord. J Urol. May 1985;133(5):803-5. [Medline].

        Flanigan RC, DeKernion JB, Persky L. Acute scrotal pain and swelling in children: a surgical emergency. Urology. Jan 1981;17(1):51-3. [Medline].

        Kadish HA, Bolte RG. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Pediatrics. Jul 1998;102(1 Pt 1):73-6. [Medline].

        McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am. Nov 2003;21(4):909-35. [Medline].

        Schwab R. Acute scrotal pain requires quick thinking and plan of action. Emerg Med Rep. 1992;13(2):11-7.

        Wan J, Bloom DA. Genitourinary problems in adolescent males. Adolesc Med. Oct 2003;14(3):717-31, viii. [Medline].

Weber DM, Rosslein R, Fliegel C. Color Doppler sonography in the diagnosis of acute scrotum in boys. Eur J Pediatr Surg. Aug 2000;10(4):235-41. [Medline].

Topics: Health & Wellness, Eric Gahan

Do We Focus Too Much On The Saggital Plane by Craig Liebenson

Posted by Boston Sports Medicine and Performance Group on Jan 23, 2011 11:01:00 AM

Click HERE to view this article by Craig Liebenson.

Topics: Health & Wellness, Craig Liebenson

Breathe Through The Brace by Art Horne

Posted by Boston Sports Medicine and Performance Group on Jan 16, 2011 1:36:00 PM

by Art Horne


In a recent interview with Sue Falsone from API on (see link below), Sue discusses the concurrent roles that the diaphragm must operate as - both a RESPIRATOR and STABILIZER.  She mentioned that Stu McGill talks about "Breathing Through The Brace" and the importance of breathing while also stabilizing the core.  Clearly, one cannot come at the expense of the other and when the diaphragm does have to choose, breathing will always win.  As Stu has shared with me in the past, it is possible to both evaluate and train the diaphragm to concurrently provide stabilization while also bringing air into the body. 

See the below video for an example of training the diaphragm to act as both a respirator and stabilizer. 

Check out this great interview with Sue Falsone on




Topics: Art Horne, Health & Wellness

Foot Mechanics - Made Simple by Logan Schwartz

Posted by Boston Sports Medicine and Performance Group on Jan 9, 2011 8:49:00 AM

Click HERE to view this video of University of Texas Strength and Conditioning Coach Logan Schwartz.

Topics: Guest Author, Health & Wellness

Charlie Weingroff's "The Core Pendulum Theory" Webinar

Posted by Boston Sports Medicine and Performance Group on Dec 26, 2010 7:58:00 PM

Watch Charlie Weingroff's Webinar on Strength and Conditioning Webinars by clicking HERE.

For more presentations by Charlie Weingroff, visit our Past Conference page to purchase the 2010 Basketball Specific Training Symposium DVD or sign up to see Charlie speak at the 2011 event, June 3/4 in Boston.

Topics: Health & Wellness, Charlie Weingroff

University of Texas Strength Coach, Logan Schwartz Talks Foot Mechanics

Posted by Boston Sports Medicine and Performance Group on Dec 19, 2010 6:48:00 PM

Click HERE to view this video.

Topics: Guest Author, Health & Wellness

Why McConnell Patellar Taping May Work by Mike Reinhold

Posted by Boston Sports Medicine and Performance Group on Dec 19, 2010 6:22:00 PM

When working with basketball athletes there is one thing that is certain and that's knee pain. See why Mike Reinhold thinks McConnell Patellar Taping my work by clicking HERE.

Topics: Guest Author, Health & Wellness

Fascial Manipulation from Mike

Posted by Boston Sports Medicine and Performance Group on Dec 12, 2010 2:10:00 PM

Click HERE to view this article.

Topics: Guest Author, Health & Wellness

Principles Of The Knee by Logan Schwartz

Posted by Boston Sports Medicine and Performance Group on Dec 6, 2010 7:34:00 PM

Click HERE to view this video by Logan Schwartz, University of Texas.

Topics: Guest Author, Health & Wellness

Are You Making The Right Decision by Eric Gahan

Posted by Boston Sports Medicine and Performance Group on Nov 28, 2010 3:33:00 PM

by Eric Gahan

More and more as research develops and studies get published athletic trainers acquire tools to be more efficient and evidence based.  One such tool established is the clinical prediction rule.  Clinical prediction rules have been developed for many areas.  One such area is the Canadian C-spine Rule (CCR) that has been published since 2003.  With the publication of this clinical prediction rule we have evidenced based guidelines to send our patients for radiography of the cervical spine.

These guidelines give athletic trainers an evidenced based approach to sending an athlete for radiographs of the cervical spine.

The CCR first evaluates suitable patients for any of three high risk criteria:
• The first of the three is an age-factor, deeming any patient who is 65 years old to be at high risk.
• The second factor looks for any dangerous mechanism, including a fall from a height greater than 3 feet, a high-speed motor vehicle collision (greater than 100km/hr, with or without rollover or ejection), an accident involving a bike or motorized recreational vehicle, or a direct axial load that would place the patient at high risk for a C-spine injury.
• The third high-risk factor is paresthesias in any or all extremities. If any of the three high-risk factors applies to the patient, the CCR mandates radiography.

If the patient lacks any high-risk factor, the CCR then evaluates the patient for the presence of any low-risk factor that will eventually allow for safe assessment of cervical range of motion.
• The published low-risk factors are simple rear-end motor vehicle collisions, a patient found sitting in the Emergency Department or ambulatory after the accident, delayed onset of neck pain or absence of any midline cervical pain. If none of these low-risk factors applies to the patient, the CCR mandates radiography.

If, however, the patient has no high-risk factor and does have at least one low-risk factor, the CCR then assesses the patient’s ability to actively rotate their neck, both left and right, at a 45° angle, with or without pain.
• If the patient is physically unable to perform this exercise, radiography is indicated. If the patient can perform this manipulation, however, the CCR recommends that no radiography is necessary to rule-out significant cervical spine injury.

basketball resources

There are several situations where the CCR could be utilized in your practice as an athletic trainer: 
• Athlete is under cut while coming down from a dunk.  Athlete lands on the head, cervical, and thoracic area of the neck and upper back.  While clearing head and neck and calming the injured athlete the CCR flow cart could easily be used in your clinical on-court evaluation.
• Athlete is diving for a loose ball and collides with another player.  This is a situation that could pass the athlete on the first area of the flow chart, but when assessing for cervical mid-line pain and also active rotation is not possible, you send for radiographs.

Given this clinical prediction rule we have peer reviewed research to make decisions requiring radiographs of the cervical spine.  This is an area where error cannot come into our clinical practice and can only make us better.  Of course with every clinical prediction rule it is important to remember these are only tools to help give efficient and effective health care to our athletic population.  As the profession of athletic training continues to gain respect in the health care community it is important remember some words of wisdom shared with me as an athletic training student at Canisius College, “Always practice as a clinician and not a technician.”    



1. Bandiera G, Stiell, IG, Wells GA et al. The Canadian C-Spine Rule performs
better than unstructured physician judgment. Annals of Emergency
Medicine 2003; 42, 395-402.
2. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine
radiography in blunt trauma: methodology of the National Emergency XRadiography
Utilization Study (NEXUS). Annals of Emergency Medicine
1998; 32, 461-9.
3. Stiell IG, Wells GA,Vandeheem K, et al. The Canadian C-Spine rule study
for alert and stable trauma patients. JAMA 2001; 286: 1841-8.
4. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine rule
versus the NEXUS low risk criteria in patients with trauma. New England
Journal of Medicine 2003; 349: 2510-8.
5. Hoffman JR, Schriger DL, Mower WR, et al. Low-risk criteria for cervical-
spine radiography in blunt trauma: a prospective study. Annals of
Emergency Medicine 1992; 21:1454-1460.
6. Dickinson G, Stiell IG, Schull M, et al. Retrospective application of the
NEXUS low-risk criteria for cervical-spine radiography in Canadian emergency
departments. Annals of Emergency Medicine 2004;43: 507-514.
7. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study
of cervical spine injury in children. Pediatrics 2001;108: e20.
8. State of Maine Spinal Assessment Protocol. Maine EMS 2002.
9. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical
criteria to rule out injury to the cervical spine in patients with blunt trauma.
New England Journal of Medicine 2000; 343: 94-99.
10. Heffernan, DS, Schermer, CR, Lu, SW. What defines a distracting injury
in cervical spine assessment. Journal of Trauma Injury, Infection, and
Critical Care 2005; 59: 1396-1399.
11. Ngo, B, Hoffman, JR, Mower, WR. Cervical spine injury in the very elderly.
American Society of Emergency Radiology 2000; 7:287-291.
12. Eyre, A. Overview and Comparison of NEXUS and Canadian Spine Rules. American Journal of Clinical Medicine 2006; 3: 12-15.

Topics: Health & Wellness, Eric Gahan