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

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Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


Filtering by Tag: concussion connection

Dr. Koutures Reviews New Mexico Concussion Return to Play Case

The mere fact that a return to play decision ended up in court is in itself a big shame.
And that shame is definitely rooted in a lack of preparation and breakdowns in communication leading to an oversimplified attempt to make a complex decision.

Reducing Injury: Focus on Exam Schedule as Much as Game Schedule?

The following blog post was originally written for a collegiate audience for, but the theme of exam stress increasing injury risk applies to all student-athletes. Please read through to the end for some additional thoughts on the link between academic burdens and injuries.

While most collegiate athletes and coaches dissect game schedules as a matter of habit, taking time to analyze exam schedules could pay off in reduced injury and illness risk. 

This news is probably not too surprising for many collegiate athletes who would readily acknowledge that any time of increased stress lead to a higher risk of injury.

Physical stress burdens are more readily acknowledged in pre-season training periods, often noted for two-a-day practices and passionate efforts to make the team or earn a starting position.

Often once taxing practices come to an end, many will take a collective deep breath and figure "the worst is behind me". While reading, writing papers, and taking exams is no walk in the park, those academic efforts seemingly should be less of a burden than heavier practice loads.

Well, perhaps those mental stressors present a fairly similar, if not higher risk to their physical counterparts.

Thanks to some inquisitive work at the University of Missouri, collegiate football players were 3.19 times more likely to have an injury restriction during weeks when they had high academic stress, such as midterms or finals, than during weeks where they had low academic stress. This increased injury risk during periods of academic stress was more noted in starting players, and the overall risk of academic stress was actually a bit higher than the injury restriction risk from physical stress during training camp (2.84 times higher risk compared to a low academic stress week).

These findings are from college football, where pre-season practice sessions take place before the academic year begins. Imagine the results for a winter sport like basketball or wrestling, where more intense pre-season sessions take place during the fall term academic sessions. Can anticipate a higher overall burden of physical and mental stress if mid-term exams (and papers) are due during heavier audition or training periods.

While it is virtually impossible to eliminate academic stressors or completely re-align practice or game schedules to better account for  mid-term and final exam periods, some creative suggestions could attempt to reduce the cumulative physical and mental burden for collegiate athletes:

  • Making reduction in overall practice times, reducing more demanding conditioning sessions, and focusing on maintenance of previous learned skills/techniques while holding off on introduction of new items could be rewarding. This might have to be done on an athlete-by-athlete basis depending on particular academic schedule demands. While this might appear to place a onerous burden on coaching and training staffs,  it is in line with the growing fascination with "big data" and more individualized training and recovery programs.
  • For athletes who are experiencing higher levels of physical or mental unease even before exam periods, recommend earlier intervention with mental health specialists and medical staff. As the study authors recommend, coaches should watch the attitudes of their athletes. If attitudes head south, be alert and ask for exam concerns among other stresses.
  • Take advantage of flexibility afforded by on-line learning or open exam periods to schedule exams or assignments to be due during possible bye weeks, weeks without travel, or a week with limited or reduced competition.
  • Work with winter or spring sport teams to give plenty of advance notice for audition or heavier practice periods to allow any possible rescheduling of mid-term exams.

I have also seen a relationship between academic stress leading to both new injury risk or more often prolonged healing times after injury especially in middle school and older patients.

When patients and families ask about adding new activities to their schedule, or how to pace a return to play after an injury, I will routinely ask about school demands (exams, papers, projects). Periods of heavier academic load are probably not the best time for increased or new training. Especially in cases of a concussion, I will often recommend waiting until academic demands are completed before allowing further return to high-risk sporting activity.









Why University Athletes May Hide Concussion Symptoms

I often encounter athletes who continue to practice or play in a game despite suffering concussion signs and symptoms and since hiding this information is not considered advisable and potentially quite dangerous,  have to admit that my initial response is along the lines of "what were you thinking?"

We as medical professionals have a pretty set initial response to a concussion- any suspicion of concussion, immediately remove from activity.

Pretty certain that athletes may view the initial response to concussion in a different light than us medical types.

As I find myself more often hearing of athletes hiding symptoms, my response still is a "what were you thinking?" but rather than asked in a frustrated or ready for a lecture tone, it is asked more in a sense of wanting to appreciate their mindset.

Is it lack of appreciation for the risks of concussion? How about denial? What about worry about losing a role on the team or not wanting to "bother" anyone?

Thus, it was interesting to see that Delaney and colleagues addressed this issues with their study Why University Athletes Choose Not to Reveal Their Concussion Symptoms During a Practice or Game.

The objectives of this paper were to  better understand why athletes who believe they have suffered a concussion while playing their sport “hide,” or decide not to volunteer, their symptoms to medical staff by identifying:

  • specific reasons why athletes who believed they had suffered a concussion during a game or practice decided not to seek attention from medical staff at that time, how often these reasons occurred, and how important these reasons were in the decision process
  • whether there were individual variables that may have made an athlete more likely to not volunteer his or her symptoms to a therapist/trainer or physician during a game or practice.

Findings of anonymous questionnaires that asked only about "self-diagnosed" concussions revealed that almost 20% of the 469 males and female athlete respondents believed they had suffered a sport-related concussion within the past 12 months. Of great interest was the fact that 78.3% of those athletes reporting a concussion did not seek medical attention either during the practice or game.

Why not?

Main reasons for "keeping quiet" were:

  • “Did not feel the concussion was serious/severe and felt could still continue to play with little danger" 
  • "Had similar symptoms of a concussion in the past and felt that there was little or no danger as had no problems with previous concussions or similar symptoms in the past"
  • "Fear that being diagnosed with a concussion would affect standing with the current team or future teams”
  • “Fear that being diagnosed with a concussion would result in negative of repercussions from the coach or coaching staff”
  • "Felt that would be removed from the game by the medical staff and did not wish this to happen”
  • “Fear that being diagnosed with a concussion would result in missing future games"

So, it appears that common human emotions- denial, minimalization and fear- are playing a big role.

All are understandable and none aren't surprising.

Not saying that they legitimize hiding symptoms or make it acceptable practice.

But rather they give unique insight into the psyche of university athletes and perhaps open particular in-roads to improving the culture of reporting concussion symptoms.

We need to recognize the fear of being removed, and attempt to address this fear by underscoring importance of early admission and treatment hopefully leading to a less complicated recovery and potentially an appropriately quicker return.

We need to have teams and coaches limit any negative responses to concussion diagnoses and provide essential support to any concussed or any injured athlete for that matter.

We need to acknowledge the competitive drive of our athletes and channel this into a competitive drive to protect their brains by offering such comprehensive diagnostic and management programs that athletes wouldn't think of missing out on getting such essential care.