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Expanding Young Athletes’ Potential Beyond the Court

Expanding Young Athletes’ Potential Beyond the Court

by | Dec 16, 2024 | Events, Sports Medicine

Picture courtesy from the Dallas Mavericks. 

Division Director of the Movement Science Laboratory Sophia Ulman, Ph.D. inspires the next generation of athletes to explore the wide range of opportunities in sports beyond the court.

The Dallas Mavericks organization hosted their annual Mavs Academy Fall Classic in November in Frisco, Texas. The tournament united 80 boys’ and girls’ varsity teams across Texas to compete at various Frisco ISD schools throughout two weekends. Scottish Rite for Children’s athletic trainers handled injuries on the sidelines, ranging from minor abrasions to significant joint injuries, like ACL tears.

While the teams showed off their high-quality skills on the court, Ulman represented Scottish Rite’s sports medicine team in the tournament’s off-court, educational enrichment. In a panel discussion, Ulman expanded young athletes’ perspectives of careers in sports through her own journey. Starting as a competitive basketball player herself, she acknowledged that she was like many young athletes — imagining a career that allowed her to stay connected to sports. Ulman shared how her career path evolved with her internship at Duke University’s Michael W. Krzyzewski Human Performance Laboratory (K-Lab). Since then, Ulman has conducted innovative research on lower extremity injuries,  as well as a variety of risk factors including movement quality, nutrition, sleep and early sport specialization in Scottish Rite’s state-of-the-art Movement Science Laboratory.

“I get to be around young athletes every day, and the work I get to do has the potential to impact thousands more,” Ulman says. “I can’t imagine a better place to be.”

Ulman’s perspective broadens young athletes’ views of sports, specifically through showing how it is possible to contribute to the game through STEM-specific careers. Panelists alongside Ulman included Mechelle Lewis Freeman — USA Track and Field Olympian, Olympic coach, CEO/Founder of TrackGirlz and partner with Ulman in Scottish Rite’s FAST clinics — and Dallas Mavericks legend Rolando Blackman, among others.

“I love talking to the kids because so many of them think that if they don’t go professional, that’s it with sports,” Ulman says. “Being able to share with them that it’s not just being a professional athlete, it’s not just production or being a broadcaster, but there are a lot of STEM-specific jobs as well.”

The Mavs Academy Fall Classic reinforces the relationship between young athletes’ physical performance, well-being and opportunities as they continue to develop. By having a sports medicine expert like Ulman, there is a touch of Scottish Rite’s principles of keeping children active and healthy well into adulthood.

“Over the years in our collaboration with the Mavs Academy, we have had the privilege of educating hundreds of young athletes and have engaged families in our injury prevention research,” says Ulman. “With a solid commitment to our mission of giving children back their childhood, we are dedicated to defining injury prevention standards and using evidence-based information in our care and in our community education so we can truly change the game for young athletes.”

 

 

Does Your Child Feel Like Their Shoulder Is Loose? Shoulder Popping Can Be a Sign of Shoulder Instability

Does Your Child Feel Like Their Shoulder Is Loose? Shoulder Popping Can Be a Sign of Shoulder Instability

by | Dec 10, 2024 | Sports Medicine

Crunching and popping are the sounds your child should make when eating carrots, celery and the occasional potato chip. They are not the sounds you want to hear when they move their arms and shoulders, but all sounds may not be bad. Shoulder popping can be a sign of shoulder instability, which is a condition that can affect kids and adolescents.

“Often times, kids will wait too long to receive treatment after a shoulder relocation,” sports medicine orthopedic surgeon John A. Arvesen, M.D., says. “In fact, the shoulder is one of the most mobile joints in the body. The more your shoulder dislocates, the most likely you will have additional injuries to the cartilage and labrum.”

 

What Causes Shoulder Instability?

The humeral head is a ball at the top of the upper arm bone. This ball rests in a shallow socket of the shoulder blade, which is called the glenoid. The glenoid is surrounded by soft tissue called the labrum, which deepens the socket side of the joint.

When the tendons and ligaments of the shoulder fail to securely hold the ball in the socket, the shoulder joint can feel loose. An injury to the labrum can result in a tear known as a Bankart lesion. Damage to the labrum makes it easier for the ball to slip out of the socket.

Slipping or instability of these conditions can range from a minor annoyance with slight discomfort and popping sounds to a painful shoulder dislocation that needs immediate attention.

Shoulder injuries, such as instability, occur most commonly in kids who play sports. The bones and joints of young athletes are not fully mature. Due to the stress that sports can put on the body, injuries are bound to happen. Some kids have naturally loose ligaments, making them even more prone to shoulder instability.

Other factors that can raise the risk of shoulder instability include having a previous subluxation or complete shoulder dislocation, hypermobility in the joint, and playing specific sports that put the shoulder in at-risk positions. High-impact sports, such as football, gymnastics and volleyball, increase the potential for shoulder instability.

 

What to Watch and Listen For in the Shoulder

Common symptoms of shoulder instability include the shoulder feel loose or feeling like it may slide or slip when bringing it over your child’s head. Certain motions or arm positions can aggravate the pain, and your child may describe the shoulder as feeling loose or unstable. Other symptoms that signal shoulder instability include:

  • Experiencing weakness in the shoulder
  • Having a sensation that the shoulder is slipping or popping out of the joint
  • Limited range of motion with daily activities or sports
  • Numbness and tingling in the arm

 

The Seriousness of Shoulder Dislocation

When the humeral head comes all the way out of the shallow socket of the glenoid, shoulder dislocation occurs.

If the shoulder is dislocated and does not immediately go back into place, your child may need emergency care right away. If the arm returns to its normal position and function, it’s best to follow up with a pediatric orthopedic surgeon. This condition is likely to happen again once it occurs the first time. If shoulder dislocations continue to occur, it can cause more serious damage inside the joint.

 

Treatment for Shoulder Instability

Diagnosing shoulder instability usually starts with a physical exam. This examination includes range of motion, strength testing and other special tests in the shoulder, such as apprehension sign, relocation test and load and shift tests, to confirm the diagnosis.

The treatment method is determined by the type of shoulder instability – anterior or posterior shoulder instability. Anterior shoulder instability is when a shoulder pops out of a place towards the front, and posterior shoulder instability is when the shoulder dislocates in the back. Arvesen and a team of researchers discovered children with anterior shoulder instability have more problems with their shoulder being unstable, while children with posterior instability usually experience more pain. This reveals that anterior shoulder instability injuries require more intensive treatment and rehabilitation.

Researchers at Scottish Rite for Children also found atypical injury patterns occur mostly in younger patients. Imaging, such as an X-ray or magnetic resonance imaging (MRI), may be recommended to get a closer look at the tissues inside the shoulder joint and to rule out specific conditions. In this population, changes to the surface of the glenoid bone or a Hill-Sachs lesion on the humeral head may be noted after a first or repeat instability incidents, these findings may influence the decision to have surgery.

Pain medications, including anti-inflammatory drugs such as ibuprofen, combined with rest and cold packs can help reduce pain and swelling. A sling may be recommended to help immobilize and support your child’s arm and shoulder as they heal. Additionally, a personalized physical therapy program may be recommended to help strengthen the muscles that control and stabilize the shoulder joint and the shoulder blade, known as the scapula.

 

Will Your Child Need Surgery?

Many patients have significant improvement in their shoulder symptoms after getting proper rest and performing a home exercise program or formal physical therapy. However, if instability continues to be a problem after trying nonoperative treatments, surgery may be recommended. Surgical treatments, such as Latarjet procedure, are frequently performed arthroscopically.

The goal of any treatment is to return your child to an active life as quickly and safely as possible, and this applies to surgery as well. Returning to sports with pain or too soon after a surgery may lead to long term problems

Every kid recovers differently. The pediatric orthopedic surgeon will work with you to determine when to let your child resume full activity. Regaining full range-of-motion, strength and improving the overall stability of the joint are the main goals of recovery.

 

Keeping Kids Moving: Protecting Shoulders from Injury

Kids are meant to move. Shoulder instability and pain can get in the way of moving at full speed. There are steps you can take to prevent shoulder instability and dislocation.

An exercise program can increase the strength and control of the muscles responsible for creating stability at the shoulder joint to provide the support the shoulders need to stay strong and in place. Stability in the shoulder and mobility in the upper back are necessary for activities that require extreme shoulder motion, such as throwing a baseball or hitting a volleyball.

Dr. Arvesen and Scottish Rite physical therapist Katie Sloma, P.T., D.P.T., CSCS, are collaborating to develop a return to play protocol. This will guide decision making for upper extremity athletes who have injured their shoulders or who are recovering from shoulder surgery. They have presented their initial recommendations at a national meeting for pediatric research in sports medicine and are currently testing the protocol in a research study with our movement science lab team.

Shoulder instability can slow your child down, but it doesn’t have to bring them to a full stop. Kids are resilient and heal quickly. The sports medicine experts at Scottish Rite for Children can help your young athlete get back to the games they love to play — on the field, in the pool or simply in your own backyard. 

Think shoulder instability may be affecting your child or teen? Request an appointment today by calling Scottish Rite for Children Orthopedic and Sports Medicine Center 469-515-7100.

Jammed Finger? Early Treatment Can Improve Outcomes

Jammed Finger? Early Treatment Can Improve Outcomes

by | Dec 4, 2024 | Sports Medicine, Therapy Services

When an injury occurs to a young athlete’s bones, ligaments and muscles in their hand, an evaluation is needed. A properly treated hand injury will most likely heal without complications.

In basketball and volleyball, fingers are at an increased risk of injury due to a variety of causes. Some children may snag their finger on a jersey, or others may hang on the rim or net. When an athlete says they have “jammed” their finger, there is concern for a volar plate injury.

 

What is the volar plate?

The volar plate is a thick ligament, located on the palm side of the finger. It connects two bones in the finger and stabilizes the middle joint of the finger, known as the proximal interphalangeal, which prevents the finger from bending backwards.

 

What is a volar plate injury?

A volar plate injury occurs when the finger is hyperextended or bent backwards, damaging the ligament. It is also commonly known as a sprained or jammed finger.

In some cases, the volar plate can be stretched and torn, pulling off a small piece of bone. This results in a fracture in the area called an avulsion fracture. With severe injuries, the joint may also be dislocated.

 

What are the symptoms in the injured finger?

  • Bruising
  • Immediate pain in the middle joint
  • Swelling of the middle joint
  • Decreased range of motion

 

What is the treatment for a volar plate injury?

Fracture Clinic provider Gerad Montgomery, M.S.N., FNP-C, sees and treats volar plate injuries frequently at Scottish Rite for Children Orthopedics and Sports Medicine Center in Frisco. “Treatment for a volar plate injury depends on the severity and can range from a short period of immobilization to surgery,” Gerad says.

With more than 15 years in providing pediatric orthopedic care, Montgomery has learned to warn families of the risks associated with not properly treating this injury. It’s important for families and young athletes to understand that volar plate injuries can worsen to the point of needing surgery without evaluation or treatment from an expert.

 

When should an athlete return to sports after a volar plate injury?

After a clinical provider has released the athlete to begin exercises, gentle range of motion progressing to strengthening exercises may be recommended. Some athletes may need guided exercise with an occupational therapist. “Before returning to sports, the hand and finger should have full strength and range of motion,” certified hand therapist Lindsey Williams says. “Otherwise, there is a risk of injury to the same or other joints nearby.”

Not sure what to do if your child gets a finger injury? Learn about our Fracture Clinic and Sports Medicine Clinic.

Miles of Motivation: Alice Races Ahead of AMPS

Miles of Motivation: Alice Races Ahead of AMPS

by | Nov 29, 2024 | Psychology, Sports Medicine

12-year-old Alice is racing towards her dreams, confidently managing each day and creating her own path! With a passion for running, she participates in cross country for her school and the Amateur Athletic Union (AAU). After securing fifth place in AAU’s 5K, Alice began experiencing knee pain, which worsened following an injury during P.E. class in 2022. Despite physical therapy and using crutches, her condition didn’t improve. Alice had moments of extreme pain that prevented her from even walking. Unable to find a solution, Alice’s mom, Lindsey, sought help from Scottish Rite for Children in May 2023.

Sports medicine physician Jacob C. Jones, M.D., RMSK diagnosed Alice with amplified musculoskeletal pain syndrome (AMPS). Defined by Psychology fellow Diana Tinsley, Ph.D., AMPS is a chronic pain condition that causes prolonged pain, even though there is no identifiable pain source. “The pain sometimes starts with an injury,” Dr. Tinsley says. “Even though the physical injury heals, the pain persists and can spread throughout the body or even worsen in severity.”

Her condition required a multidisciplinary team of experts in sports medicine, physical therapy and psychology to reintroduce her to her love for running. Lindsey says Dr. Tinsley and physical therapist Ashley Ratliff were key motivators throughout Alice’s care journey. “There were many tears and ‘What if?’ moments during Alice’s treatment,” Lindsey says. “It’s important to truly lean on your care team and follow through with the work they give you to do at home – no matter how hard it may be!”

Alice’s Scottish Rite team worked to create a comprehensive treatment approach that set her transformation into motion. Her goal was to learn how to move through the pain and get back to daily life. Dr. Tinsley provided Alice psychological support through pain management strategies and helped her set manageable goals to work into her day-to-day schedule, such as leaving her crutch at home when doing errands. Soon, Alice went from relying on crutches to walking without assistance altogether. “Her pain had taken over her life,” Dr. Tinsley says. “Pain flares can happen especially when stress increases. We try to put her immense progress into perspective and continue to encourage her.”

Physical therapy for Alice was trickier, as there was no clinical evidence of her injury. However, Ashley’s exercises focused on desensitizing Alice’s knee to decrease the pain signals to her brain and improve Alice’s knee function. Similar to Dr. Tinsley’s approach, Ashley slowly decreased Alice’s use of crutches to help her regain muscle in her knee from not bearing weight on it. “The focus was on making small goals at a time to gradually work to her overall goal of running again,” Ashley says. “This involved a lot of communication between Alice and I to ensure she was being challenged, but also that she had appropriate time to cope and work through new challenges.”

Since Alice was a competitive runner, they alternated between gym sessions and aquatic therapy to improve her pain tolerance for her running return. Alice’s care journey continued at home, with her Scottish Rite care team and family collaborating to decrease her fear of movement. “Alice had such success based on her participation with Dr. Tinsley and being diligent with her physical therapy exercises at home,” Ashley says. “Patients with AMPS need support at home to encourage their progress.” Alice slowly transitioned from running in the pool to the treadmill, eventually running 6 miles without discomfort. Due to her dedication to her passion, Alice made excellent progress and was discharged from physical therapy!

Alice

Inspired by her care, Alice is now encouraging other kids with similar diagnoses. She has published a journal titled “Today is My Day!”, a mindfulness journal dedicated to those who have anxiety or depression. It encourages self-reflection with the goal of taking steps to appreciate life more. Additionally, Alice safely returned to cross country and is continuing to build her strength to achieve her dream of being a professional runner! Her success is a testimony of the support from her Scottish Rite care team and family. “From the smiles we get from the front desk to excellent care, our overall experience has been amazing,” Lindsey says. “Without Scottish Rite, Alice would not be where she is today and doing what she loves!”

Do you have a story? We want to hear it! Share your story with us.

A Parent’s Guide to Contact Sports for Kids

A Parent’s Guide to Contact Sports for Kids

by | Nov 18, 2024 | Sports Medicine

Contact sports can be exciting for young athletes and parents alike. They also introduce an element of danger into the exercise equation. 

Any time a person participates in a physical activity, there’s a risk of injury. However, engaging in contact sports magnifies that risk. If your child participates in this type of athletic activity, following the proper safety precautions is critical.

What’s Considered a Contact Sport?

In a contact sport, players come into physical contact with each other or an object as part of the competition. There’s a risk of contact in nearly all sports, but the risk is higher in some than others. 

In basketball and soccer, for example, children are likely to knock into others athlete as they jockey for the ball. When they’re rebounding, taking a shot or defending on the basketball court, they’re in close contact with others and can accidentally (or otherwise) touch them lightly or with force.

Other sports have an even higher risk of contact. Some sports, such as ice hockey, football and lacrosse, involve techniques that have kids actively running into or making contact with an opponent. Making contact is not incidental in these sports. It is intentional. For that reason, this sports category is sometimes called “collision sports.”

While most contact sports are team sports, some contact is involved in solo activities, such as gymnastics. In that case, an athlete makes contact with the floor or an apparatus rather than a person.

How to Keep Your Child Safe in Contact Sports

To protect your young athlete on the court or field, begin with these basics, which can reduce the risk of sports injuries:

●      Get a sports physical. This specialized medical checkup helps ensure your child is healthy enough to participate in a sports activity. It’s a good idea to have your child have a sports physical before each season, even if their school or team does not require one.

●      Buy the proper protective gear. Every sport has specific equipment, so check with your child’s coaches to see what’s required and recommended. Depending on the sport, this may include a helmet, knee pads, shin guards, padding or a mouthguard.

●      Be sure your child learns the correct technique. Many sports injuries in contact sports occur because somebody incorrectly performed a move. Emphasize that your child should use proper form and follow the rules of the sport.

●      Mix things up. Overuse injuries are common among athletes, particularly young athletes who are still growing and developing. Encourage your child to participate in multiple sports or physical activities that use different parts of the body, which will lower the risk of overusing a specific muscle or joint. Overuse injuries can reduce your child’s range of motion and limit their ability to play at their best.

In addition to these tips, talk with the coaches or even the athletic trainer about other steps you can take to keep your child safe while playing contact sports. There is some risk, but you can also do many things to mitigate that risk.

The Scottish Rite for Children sports medicine team is committed to keeping kids healthy and in the game. Call 469-515-7100 to schedule an appointment with one of our sports medicine specialists.

Emily Claire’s Transformation: A Pain-Free Knee and a New Life Path

Emily Claire’s Transformation: A Pain-Free Knee and a New Life Path

by | Nov 7, 2024 | Sports Medicine, Therapy Services

Cover story previously published in Rite Up, 2024 – Issue 3.

by Kristi Shewmaker

Emily Claire, of Plano, spends most of her time raising two pigs — Dolly and Kenny, named after Dolly Parton and Kenny Rogers. Like the country legends, Dolly and Kenny are not related. Every morning and evening, the 17-year-old drives to the barn to take care of them where they show their affection for her in different ways. “Dolly gets the zoomies,” Emily Claire says. “She’ll run laps in her pen, but Kenny just sits there with puppy dog eyes looking at me. He also likes to cuddle. Dolly, not so much, but Kenny will lay across my lap.”

Emily Claire is president of the FFA Plano chapter and secretary of Area V’s District VII for the state of Texas, which is part of the National FFA Organization, historically known as Future Farmers of America. She recently attended the Texas FFA State Convention in Houston. “It’s a lot more than just showing animals or being a farmer,” she says. Through FFA, she has engaged in leadership and career development events that will serve her throughout her senior year of high school and beyond.

Dr. Henry B. Ellis

As a young teen, Emily Claire had her heart set on playing softball. She played for school and select teams and had dreamed of playing at the collegiate level. But, she started experiencing pain in her knee, leading to multiple incidents of partial dislocation. The first time, she was crossing the street. “My kneecap slipped out, and I fell to the ground, literally in the middle of the street,” she says. “It was embarrassing.” The second time, she fell at softball practice, but each time, her kneecap went back into place. Then, in the fall of 2021 during her freshman year of high school, her kneecap fully dislocated at catcher practice. “I was in my squat throwing down to second base, and I popped up to throw, and my kneecap just locked out,” she says. “I couldn’t move it. I didn’t know what was happening, and I was freaking out.”

TREATING KNEECAP INSTABILITY
An established patient at Scottish Rite for Children Orthopedic and Sports Medicine Center in Frisco, Emily Claire was initially treated with a brace and a specific exercise program. Unfortunately, she experienced increasing episodes of instability in her kneecap, or patella. Recurrent episodes of patellar instability often require surgery. Henry B. Ellis, M.D. — pediatric sports medicine surgeon, sports medicine fellowship director and medical director of clinical research — performed medial patellofemoral ligament (MPFL) reconstruction surgery on Emily Claire’s left knee.

“MPFL reconstruction is common for us in pediatric sports and those that take care of kids because kneecap instability is very common in kids,” Dr. Ellis says. “In our practice at Scottish Rite, it is one of the most common conditions that we treat.”

When Emily Claire’s kneecap dislocated, it tore an important ligament that holds the patella in place. In surgery, Dr. Ellis replaced the torn ligament with a new one to give her kneecap stability. However, patellofemoral instability is complicated. Sometimes, it requires more than simply replacing a ligament. At the end of the femur, or thigh bone, is a groove called the trochlear groove. The patella fits into this groove, and when the knee bends or straightens, the patella slides up and down in the groove. Emily Claire’s kneecap was not aligned in the groove because of the position of her tibial tubercle, the bony bump on the upper part of the shin where the patellar tendon attaches. “Her kneecap was living off to the side,” Dr. Ellis says. To mitigate this problem, he performed a procedure to shift Emily Claire’s tibial tubercle, which aligned her kneecap in the groove and ensured that it would track and glide correctly.

REHABILITATING BODY, MIND AND SPIRIT
MPFL surgery stabilized and corrected Emily Claire’s kneecap. What came next would change the direction of her life. Her knee injury and rehabilitation served as a catalyst that led her to discover her dream career. Throughout her care journey, she received treatment from Dr. Ellis and a multidisciplinary team, including physician assistant Ben Johnson, registered nurse Tammy Norris, physical therapist Katie Sloma, child life specialists, psychologists and athletic trainers, among others.

After surgery, Emily Claire met physical therapist Katie Sloma for a physical therapy evaluation. “I remember talking to Katie and asking her questions,” Emily Claire says. “I was really curious about her job.” For weeks, Emily Claire was on crutches, wore a brace and could not bear weight on her leg. “I got a really good tan line at the softball field with stripes going across my leg,” she says. “It was very humbling having two different size quads.”

Katie worked with Emily Claire on quad strengthening, range of motion and mobility through manual therapeutic exercises and aquatic therapy.

“Emily Claire always came in with a smile and ready to work,” Katie says. “She was curious about the process and liked to remain informed, which was cool for us to see.”

For several months, Emily Claire could not play softball. Then, slowly, she was reintroduced to the game part time, but ultimately, her team broke up during her sophomore year. “I was like, ‘OK, I don’t know what I’m supposed to do now,’” she says. She recalls trying out for other teams, but her knee had not fully recovered. “I wasn’t getting called back,” she says. “It was like nobody wanted me, and that was really degrading, and I was like, ‘Am I even supposed to play softball anymore?’”

Things began to change in 2023 when Emily Claire attended the FFA Collin County show. “Everybody there was just so nice and comforting. It felt like a place that I belonged,” she says. “So, I went home and cried about it a lot, and I was like, ‘I just don’t think softball’s for me.’”

OPTIMIZING CARE THROUGH EXPERT TEAMWORK
Emily Claire continued to gain strength and increase athletic conditioning by working with athletic trainers while participating in Scottish Rite’s Bridge Program.
“In our care of any youth athlete, one of the biggest advantages that we have at Scottish Rite is the ability to work together,” Dr. Ellis says. “When someone presents a problem, we offer solutions, but we do it not just as a physician to patient, but as Scottish Rite as a whole.”

Physician assistant Ben Johnson agrees. “The care we provide is a team-based approach with all team members focused on a singular goal of getting patients like Emily Claire back to doing what they love to do without limitations,” he says. The exceptional dynamic of Scottish Rite’s continuum of care results in optimal outcomes for patients. “The key to Emily Claire’s success is the fact that she had an opportunity to work with our team together,” Dr. Ellis says.

Emily Claire liked the team she worked with so much she decided to join it. Over the summer, she interned at the Frisco campus’ Movement Science Lab, processing data for a neurocognitive research study. “I have received so much at Scottish Rite — and not just care,” she says. “Everybody here is so kind and loving, and they want to help you not just get better and achieve your goals, but they’re willing to help you learn.”

Emily Claire’s time at Scottish Rite has inspired her to become a physical therapist. “Instead of something that I had to go to, physical therapy became something that I looked forward to,” she says. “Everyone was there for me.” Katie shares that Emily Claire’s interest in the field of physical therapy was rewarding to her as a provider. “It shows that her time at Scottish Rite made a positive impact on her even when things got hard,” Katie says.

Upon reflection, Emily Claire explains that her care journey also changed her mental health. “It showed me that I was more unhappy than I was happy playing softball, and that softball wasn’t for me,” she says. “I thought I was going to let so many people down
if I didn’t play, but it opened my eyes and showed me that I like doing FFA a lot more.”

Recently, Emily Claire received the news that she was accepted to her college of choice, Tarleton State University, where she will pursue a degree in kinesiology. Upon graduation, she plans to attend physical therapy school. But for now, she is enjoying her senior year, beginning this fall, when she shows her superstars, Dolly and Kenny, at the State Fair of Texas.

Read the full issue.