Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

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Filtering by Tag: Overuse Injuries in Children

Why a Sports Physical Should Take More than 10 Minutes


AUTHOR: Cindy Sanders

Often a perfunctory visit, the sports physical offers providers a golden opportunity to share information and listen to young patients.

Frequently viewed by parents and young athletes as more annoyance than necessity, it’s easy for the sports physical to devolve into automatic answers to a list of questions, a quick check of vital signs and then out the door with a signed permission slip for another year of organized activity.

But it doesn’t have to be … and really shouldn’t be … this way, stressed Chris Koutures, MD, FAAP, a board certified pediatrician and sports medicine specialist who sits on the American Academy of Pediatrics (AAP) Council on Sports Medicine & Fitness.

Instead, he continued, providers should look at the sports physical as a prime opportunity to address important issues with children, teens and parents. “There are a host of things we can look at … both sports specific and medically in general,” he said. “Every opportunity we get to sit down with a family is a chance to educate … whether with a sports physical or routine physical.”

Koutures, who is based in Anaheim Hills, Calif., is co-author of “Pediatric Sports Medicine: Essentials for Office Evaluation” and served as medical team physician for USA Volleyball and Table Tennis at the 2008 Beijing Summer Olympics. He pointed out providers have the opportunity to not only identify and fix current problems but to delve deeper to discover and address underlying issues that could prevent or reduce the impact of future injuries or illness. “One thing that pediatricians and primary care providers do so well is anticipatory guidance,” he said.

Koutures said there are a host of reasons families rely on retail clinics for a sports physical ranging from convenience to cost to the drop-in nature of such facilities. However, he pointed out, seeing your regular provider has a value-added proposition that shouldn’t be ignored. “If we do our job right, we are providing such a higher level of care,” he said. “If you have a relationship with that family, you can look at past history. We can see a history of asthma. We can look at a growth scale and see if there’s been a tremendous amount of growth. We can see immunization records,” Koutures enumerated.

He added the long checklist of issues, ailments and conditions on sports medicine forms makes it easy to simply answer ‘no, no, no’ to everything. However, those answers aren’t always accurate … whether by accident, oversight, or fear of being sidelined.

“You look at the sheet, and it says ‘no history of asthma.’ Really? There was an episode two years ago,” Koutures outlined an example of the benefit of going to a provider who knows a child’s history. “If you know the child has asthma, they can actually have a better sports experience because you are addressing and controlling the issue.”

He added, “Having that background knowledge is one more checkpoint to making sure we’re giving the best care we can.”

As important as it is to use the time to educate young athletes and their families about issues ranging from nutrition and hydration to concussion and overuse, Koutures said a sports physical is also a great time to listen. Particularly with older adolescents where part of the appointment is without the parent, Koutures said it’s a great time to open dialogue about alcohol, drugs and supplements and to allow kids to ask questions. “We need to take the time to educate ourselves,” he added of hearing a patient’s thoughts and concerns.

Listening, he continued, also plays an important role in an area where he believes providers could do a better job – assessing and addressing mental health issues. “It’s a silent epidemic,” Koutures noted of the number of adolescents feeling overwhelmed, anxious or depressed.

“If you get that one time a year to sit down with a family and address these things, you can make a big impact,” Koutures concluded of the sports physical. But, he added, “That’s not going to happen in 10 minutes.”


AAP Council on Sports Medicine & Fitness:


Addressing Common Questions & Concerns

Pediatric sports medicine specialist Chis Koutures, MD, FAAP, shared insights and advice on several common questions and concerns parents might have regarding their active offspring.

How Much is Too Much?

“The minimum the American Academy of Pediatrics recommends is one day off a week from organized activity,” Koutures said.

Furthermore, he continued, there are additional time limits on adult-directed activity that should be considered. “If you take the age of a child, that’s the number of hours of organized activity they should not exceed in a week,” he said of recommendations based on new data. Therefore, a 12-year-old shouldn’t participate in more than 12 hours of organized sports and practices in a week. However, Koutures stressed, this time limit doesn’t apply to additional free play with friends.


“I think we’re seeing more overuse injuries,” Koutures said. In part, he thinks the increase is due to more children becoming one-sport athletes, which leads to repetitive motion. He added that when a child plays a number of sports, different muscle groups are engaged, and children mentally learn different movement patterns.

While physicians might not be able to change a child’s activity preferences, they can help mitigate overuse injuries through evaluation and education. “With my throwing athletes, I look at the shoulder range of motion. There are great studies that show if we can make sure they have appropriate follow through, we can reduce the risk of injury,” he pointed out.

Hydration & Nutrition

Koutures noted the AAP released a statement on sports drinks several years ago. “The belief is that for most times, water is sufficient,” he said. Koutures added that a sports drink might be appropriate when exercising for over an hour, particularly if it is hot and humid, or right after an activity to replace salt and sugar.

“We like to think of hydration as being a full time job,” he continued, noting proper hydration doesn’t occur during the small window of practice or playing. Instead, children should be drinking water regularly to prepare for … and recover from … activity.

He also tells young athletes to look at their urine to gauge their level of hydration. “If it’s really dark, that’s a sign of dehydration,” Koutures reminds them.

As for pre-activity nutrition, he said that somewhat depends on the child, time of day and personal preference or tolerance. Recognizing some kids really can’t eat much shortly before competition, he suggested trying fruit because of the liquids and quick energy it provides.

“The most important meal of the day isn’t breakfast, lunch or dinner,” he continued, “It’s what you eat right after you exercise. Getting some sort of protein mixed with carbohydrates in that first half hour after you exercise is essential for recovery.” Koutures added chocolate milk has a great protein-to-carb balance. Greek yogurt and peanut butter are also good options.

Detective Work: 5 Culprits Causing Young Athlete's Bone Stress Injuries

As a sports medicine specialist, here 5 important factors that should be included in every evaluation of a bone stress injury:

1. Timing

  • Early in a new activity (especially within the first 3 weeks), stepping up to a higher level (first weeks of high school or travel team), or increasing amount or intensity of workouts (double days or more difficult routines) all can lead to acute overload and bone stress injuries.
  • Cumulative stresses from months of training are another frequent contributor to bone stress injury and can also reduce overall immunity. Tend to be very cautious with any local bone pain that comes up right after a major accomplishment (end of long season, finished lead role in major performance) and especially when a performer reports "I'm at the top of my game."
  • Too much load, too fast of increasing load, or too long of sustained load 

2. Technique

  • Inappropriate technique or attempts to modify mechanics can lead to bone overload. Examples include:
    • Longer stride with slower stride rate: evidence shows that a shorter stride and faster stride cadence may reduce overload on bones of the foot and lower leg in runners
    • Poor activation of gluteal muscles in the lower back/buttock region can place rotational forces on the thigh and shin regions
    • Gymnasts with poor stabilizing strength of upper back and shoulders may place undue forces and increase cumulative stress on the forearm bones
  • Any under-rehabilitated past injury of any type can change technique and place abnormal forces on a particular bone or region of the body, increasing risk for stress injury. 
  • Comprehensive review of technique and biomechanics, often involving coach insight, can be extremely helpful in addressing these issues.

3. Appropriate Energy Intake

  • Insufficient caloric intake to meet training demands can lead to a decreased ability to repair/build bone structure. The International Olympic Committee published a recent paper outlining the concept of Relative Energy Deficiency in Sport that pertains to all athletes. 
  • For female athletes, reviewing the elements of the Female Athlete Triad (includes absent/infrequent menstrual periods, disordered eating habits, and weaker bone structure) is absolutely essential to identify common and correctable causative factors for bone stress injury.
  • A focused diet history combined with targeted physical and laboratory evaluation can be performed by a sports medicine specialist to provide greater insight.

4. Not enough rest

  • Bone needs time to remodel after physical activity, thus insufficient rest can lead to a higher risk of stress injury. Acute (showcase events, tournaments, intense auditions) or chronic (playing on multiple teams, playing a single sport more than 8-9 months a year) cumulative stress is not ideal for allowing sufficient recovery time.
  • The American Academy of Pediatrics Council on Sports Medicine and Fitness recommends taking at minimum one day off per week for acute recovery and limiting participation in a particular sport to no more than 8-9 months per year to allow longer-term recuperation.

5. Growth spurts

  • A growing athlete often suffers from a lack of central upper back/shoulder and lower back/pelvic strength which causes the now longer arms and legs to have less control and coordination. Even with emerging increases in muscle strength, the immature developing bones are at an increased risk for injury.
  • The entire body needs additional calories to foster growth, which might create a relative deficiency in caloric delivery to working bone and muscle, further increasing overload stress opportunities.

This blog post does not intend to diagnose or provide any management tips for a particular stress injury, or any other injury or illness. If you suspect a stress injury, please immediately contact a sports medicine specialist for appropriate evaluation and treatment recommendations. 

Overload injuries to bone are aptly called stress injuries as their often untimely presentation and unpredictable healing times can provoke high levels of emotional stress for patients and medical providers. While the actual diagnosis can require some detailed investigation, trying to identify root causes of stress injuries is a necessary detective game that can ultimately reduce the risk of future stress injuries and assess the overall bone health of the athlete.

Stress Fracture of the outer lining of tibia (shin bone) in a young dancer

Stress Fracture of the outer lining of tibia (shin bone) in a young dancer

Do Colder Climates Foster More Sensible Development of Pitchers?

For years, I have heard claims that some Major League Teams favor drafting pitchers who grew up in colder climates.

The reason?

Fewer months able to be spent outside likely means fewer competitive pitches thrown, fewer innings pitched, and perhaps less risk of cumulative stress to shoulders and elbows. Practicing pediatric sports medicine in almost too sunny Southern California (yes indeed, we desperately need rain) I commonly encounter young throwers who pitch most if not almost all months of the year.

Now, thanks to the recent study Is Tommy John Surgery Performed More Frequently in Major League Baseball Pitchers From Warm Weather Areas?, there might actually be some scientific confirmation to these concerns.

Based on rates of elbow medial ulnar collateral ligament (UCL) reconstruction (commonly known as Tommy John Surgery) in Major League pitchers who played high school baseball in warmer vs. colder climates (defined by latitude on map and mean average temperatures), those who grew up in the warmth were found to have a more frequent and earlier UCL reconstructions than players who grew up in the colder environments.

I also found another interesting finding that almost 2/3 of the Major League pitchers in the study pool from 1974 to June 1, 2014 were from colder climates, while by the definitions utilized of warmer vs. colder climates, almost 2/3 of the 73 total studied areas were in colder climates while only 23 of 73 areas were defined as warmer. This correlation does make sense from a general statistical model, but when considering that the warmer areas contain purported baseball hotbeds such as California, Florida, Texas and countries in the Caribbean, Central and South America, the 2/3 proportion coming from colder climates again might support the higher risk cumulative stress and injury in warmer, more possible year-round baseball climates. Perhaps hibernating from too much pitching is ultimately a protective and positive thing and not just another reason to complain about bad weather in certain regions.

The published results on Major League pitchers should not be directly correlated with injury risk to pitchers at the pre-high school, high school and even collegiate or minor league levels. However, if similar studies were conducted at those levels with comparison of UCL reconstruction rates between  climates, I wouldn't be too surprised if the surgical frequencies were higher in warmer climates and possibly starting at younger ages as well.

The upshot of this post is not an endorsement or call for relocation to colder climates to foster a potential Major League Pitching career, but rather a cautionary tale that even in those fortunate and talented enough to pitch in the Major Leagues, the potential blessings to have year-round chances to competitively pitch must be tempered with the need for adequate rest and recovery. I think this need to not take undue advantage of virtually unlimited pitching opportunities does definitely correlate down to school-age and collegiate/minor league pitchers.

Once again, we are getting the message that more is not often better, especially in the long-term development of young athletes.