Dealing with Detours- Lessons Learned as a Sports Medicine Physician

I have become more comfortable dealing with detours

Detours are going to happen.

We like to live in the ideal world where performance and recovery both travel a straight line ahead without and obstacles or set-backs. After carefully evaluating a situation, we thoughtfully construct a comprehensive plan, then look to execute it with frank precision.

Then reality kicks in, and the detours begin.

When I was asked to speak on behalf of friend and colleague Benjamin Strack, PhD on his installation as 2017 President of the Orange County Psychological Association, I shared insights that have been taught as part of the team behind the team learning from our best teachers- our patients and their families.

My focus was on Dealing with Detours.

Let’s be real.

Our athletes certainly also do not like to admit that detours occur.

How many athletes when asked about the start of season are going to tell you anything other than they're going to have an awesome time, the youngsters are going to come through, the opponents aren’t that tough, and big accomplishments on the horizon.

Does anyone ever say that they're going to anticipate obstacles, team dissension, untimely injuries, more talented and prepared opponents, bad losses and maybe even firings?

Detours come in the crucible of athletics that often place unique demands on young athletes.

While some athletes can handle detours without the blink of an eye, others will suffer from anxiety, depression, and other challenging coping behaviors.

Those of us who serve as the team behind the team are charged with the task of helping build a supportive culture focus on big picture outcomes such as success in sport translating to success in life, building healthy habits, and yes, navigating those detours.

Our presence as a sports medicine team is based on reacting to detours. 

Just like no one athlete can emerge victorious to win all by him or herself, no good sports medicine effort is a solo performance. It is the ultimate function of a team that will often lead to the best possible outcomes.

Building the team behind the team and our relationships with athletes is a dynamic process.

The process starts with being available and that might be nothing more than hanging out at a practice, chasing volleyballs before gold-medal match, or helping fold towels between points. Those menial tasks are often the pathway to a higher level of engagement.

That availability also means being dealing with atypical situations at atypical times (before 9 AM and after 5 PM for certain) in atypical venues (on fields, over the phone).

No matter your level of availability to the team and athlete, you must keep your eye on the goal.

Developing trust that contributes to the ultimate short-term and long-term health of each individual patient.

This takes building a relationship.

When meeting with “the athlete” I attempt to separate the person from the the athlete identity.  I may also separate from my team physician role- first and foremost, my priority is to be the medical provider for the athlete, above any team or group commitments. 

Before asking about sports, I want to know what is going on in the life of the athlete: school, grades, outside jobs, family and friends, changes, substance use, sleep, appetite.

Once I get to know someone's goals, fears, and what truly is important in their life, then I feel I can make a greater impact with them. It often takes listening to the kid, independently from the parent, to meet these goals.

Be alert for transitions such as end of eligibility/career, injury, new team, new coaches, higher level of participation (intensive, summer camp, showcase). 

Remember to emphasize confidentiality. Teenagers especially are quick to shy away from anything that will cause embarrassment or public scrutiny. They may Instagram multiple things about their life, but then can hide behind a wall of silence when they feel necessary.

When I eventually get to the sports thing, I ask about:

• Demands of the sport- time, intensity, and level
• Team Dynamics
• Multiple coaches and teams
• Flux of rosters, positions, starting spots
• Travel
• Financial/time commitment
• Perceived role
• Perceived voice

 If you don't know exactly when an athlete does with the demands of their activity ask them. If they won't tell you then Google or YouTube it.

If there's been an injury, ask how the athlete is dealing with the new found free time away from sport demands.

Some find it liberating...don't be surprised.

Some don't  miss their sport.

This leads into one big thing I have learned- don’t assume anything. Let me repeat that. Don't assume anything.

Believe in the art of negotiation. Our job is to advise and offer suggestions not unilaterally dictate a treatment plan. Amazing how sufficient discussion leads to the best answers, and often the athlete is the one coming up with the best answer.

Be ready to be pummeled for specifics- "what exactly can I do"? This can be painstaking but is absolutely necessary.

 Allow exit strategies.

The ultimate best outcome of your professional involvement may not be wins or titles- it very well may not even be a return to sport. 

Sometime a preconceived detour is actually a path towards something more rewarding.

Offer to take the hit for the athlete- if decision not to play, put all the blame on the medical team.

Give athletes the opportunity select how they want to mourn an injury or decision to retire. Some will totally distance themselves from the sport or team, while others want to have an active role. Help them in this choice

Don't feel the need to be a hero or go solo. Feel free to share the burden of difficult cases.

Always keep common themes and consistent messaging with athletes, families and other professionals.

Respect the hard work, past efforts, goals, dreams and commitment of the athlete and their schedule, but don't make decisions strictly based on the next big event.

Even if it's the Olympics. 

Develop rapport before dropping bombs

Focus initially on performance enhancement. No kid will shy away from wanting to get better. Once you've built their trust and rapport, then you can delve into more of the sensitive emotional or behavior issues.

Learn to deal with uncertainty, with taking appropriately aggressive decisions that may work, or may run into those detours.

When confronted with setbacks or plateaus in recovery, continue to encourage the athlete. Try to limit conveying disappointment.

Finally, never wondering how to do something better, to keep learning, to keep finding more people to add to the team and help negotiate those detours.

Injuries Seen in Soccer Goalkeepers and How to Reduce the Risk

There is little doubt that goalkeepers are just a bit different than field players.

From being able to legally use their hands to the array of jumping and diving skills needed to keep the ball out of the net, goalkeepers develop a skill set that differs from their counterparts on the field.

Thus, it shouldn’t be surprising to learn that goalkeepers injuries can also be different in terms of causative factors and mechanisms that create risk.

The good news is that goalkeepers statistically don’t get hurt as often as field players, but when some of the goalkeeper-specific injuries do occur, they can significantly interfere with ability to play.

Here is a concise review of common soccer goalkeeper injuries and tips for reducing risks:

• Shoulder/forearm/wrist: Fairly intuitive that after diving and trying to stop balls with the hands, goalkeepers have a far higher chance of suffering shoulder or arm injuries compared to field players

o   Fractures to the radius bone are most commonly seen in child and adolescent goalkeepers who have their hands driven backwards towards the wrist when trying to make a save on a direct shot.

§  There is intriguing evidence that balls shot by adults or use of adult size balls (size 5 versus child-based size 3 or 4 balls) may contribute to an increased risk of radius fractures.

§  Risk Reduction Tips: Playing with age-appropriate balls and having adult/older players exercise caution when shooting on younger goalkeepers might reduce radius factures. There is no solid evidence that use of goalkeeper braces or gloves provide adequate reduction for wrist or forearm injuries.

•  Hip/groin: Soccer players of all positions are well-versed in the perils of hip and groin pain, and goalkeepers are not immune from this malady, though the mechanisms and types of injury do differ somewhat from field players.

o   Side-diving can lead to abrasions (cuts) and bruises on the outside of the thigh region. Most of these are a nuisance, though open skin wounds can become infected and thus need to be watched and cleaned carefully.

§  Older, more professional level players may develop bursitis, which is inflammation of fluid-filled cavities that normally exist around the hip region

§  Risk Reduction Tips: Many goalkeepers used padded shorts for protection, though there is little evidence that both indicates that such padding reduces injury or helps guide selection of particular materials, sizes, or brands to reduce injury risk. Using a rolling motion with diving may reduce loading forces on the hip and thigh region.

o   Some studies suggest that injuries to the adductor muscles on the inside of the thigh bone are more apt to occur in goalkeepers than field players, especially on the kicking leg. This might be due to the frequent rotational and leaping movements required in goalkeeping, and also might be worsened by repetitive oversue due to longer goal kicks or punting of the ball.

§  Risk Reduction Tips: Highly recommend the FIFA 11 Soccer Injury Prevention Program which has been developedfor all soccer players above age 14 (not just goalkeepers) to reduce not only hip/groin issues, but also injuries to the thigh,knee and ankle regions.

Limiting the number of longer goal kick repetitions, especially in early season practices with younger players, may reduce the cumulative burden on the hip adductor muscles. Allowing the player to gradually build strength and proper kicking technique may afford more repetitions later in the season.

•  Concussion/Head Injury: While goalkeepers do not routinely head the ball, the mere act of jumping or diving in the air places any soccer player at increased vulnerability for head injury due to risk of head impact with other players, the ground, or even the goalposts.

o   Goalkeepers also have the additional risks of having close-distance shots directed at them with little time to react or protect the head, or having other players kick them in the head when diving head-first to gain possession of a loose ball.

§  Risk Reduction Tips:

·         Using a fist to punch the ball rather than attempt to make a catch in traffic may reduce the risk of either direct contact with other players or limit change of feet being taken out from below

·         When going up in the air for a catch, raise elbows to protect the head (but not extending the elbows to impact or injury an opponent)

·         Avoid going head-first into ball challenges, better to use feet first approach.

·         Officials should enforce a reasonable protective halo distance around diving goalkeepers trying to collect balls to reduce risk of kicks or other direct blows to the head

·         With potential close-range shots, teach goalkeepers to have hands up near the face for more immediate potential protection

·         Soft protective helmets might reduce the risk of bruises, cuts, and even skull fractures, but they may not be able to limit rotational forces that are thought to contribute the most to concussions. There are also concerns that a player might play more aggressively when wearing a helmet and in theory actually increase rather than decrease the risk of head injury.

Watch Video Below on Reducing Knee Anterior Cruciate Ligament Injuries for ALL Soccer Players!

How Can Children Enjoy Safe Participation in Martial Arts?

What should families know about Martial Arts to maximize the benefits of this vigorous physical  activity that develops balance, strength and body control while best minimizing injury risk?

• Be aware of the difference between non-contact and contact Martial Arts
  • Non-contact forms or movements are fairly safe and will give all the benefits of increased body control and strength that lead to development of overall athletic ability without greatly amplifying acute injury risk.
  • There is no doubt that incorporating contact, often known as sparring, definitely increases the injury risk, Free sparring is more risky than controlled sparring where an instructors oversees and potentially limits the overall amount of contact.
  • When selecting a studio and instructor, do not be hesitant to ask about how contact is included in the program.
  • May opt to delay introduction of contact until a child is more physically and emotionally ready with a greater grasp of basic skills and movements.
• Grouping of children participating in all forms of of Martial Arts, and especially with contact disciplines, should take into account physical size, development, and experience
  • Decisions on pairing children for sparring are often a challenge and should not simple rely upon age or "belt color". While having children participate with peers a few years older or younger is generally discouraged due to significant physical or emotional differences, there may be situations where experience or overall aptitude may warrant matching kids who are at different ages, 
  • This is another area where discussions with instructors can be insightful and helpful
• Soft protective helmets are often used, but do they provide sufficient protection for head injuries and/or concussions?
  • he current medical literature does not have evidence that soft protective helmets reduce the risk of concussion, head lacerations, and facial trauma. 
  • Do not rely on soft helmets to prevent concussion or think that one can engage in more risky activity simply because a soft helmet is being worn.
  • Improving defensive block maneuvers to protect the head may be helpful, but discouraging and ultimately eliminating direct  impacts  to the head (kicks, arm strikes, etc) are likely the only true ways to reduce concussion in the Martial Arts.
  • Rapid head thrusts to the floor (even a padded floor) should also be discouraged due to the risk of head or neck injuries
• There is also insufficient evidence proving that other types of soft protective padding (arm, chest, foot) can prevent injuries.
• Rules prohibiting contact or excessive force to certain areas (head, throat, stomach, groin) must be enforced
  • f a family elects to participate in contact forms of martial arts, appropriate instruction and rule enforcement has been shown to reduce to risk of more serious injuries.

Are there any other recommendations you have to increase safety and enjoyment of the Martial Arts?

How to Protect the Knees of Young Athletes

What is going on with all these serious knee injuries in youth sports?   Why do young women seem to tear their Anterior Cruciate Ligaments more than young men?  

If your daughter (or son) lands with the knee caving in towards the other knee, then this article is a must read

The Anterior Cruciate Ligament (ACL) is a support ligament inside the knee that travels from the femur (thigh bone) to the tibia (shin bone), limits excessive forward motion of the tibia, and is crucial to overall knee stability.

Seemingly innocent, non-contact movements such as landing from a jump, twisting, cutting, or knee hyperextension are the most common mechanisms for ACL tears.

Studies involving several sports (basketball, volleyball, soccer) indicate that young women tear the ACL at a higher rate than young men. Several theories abound as to the reason, and a more popular thought is that abnormal landing mechanics can increase injury risk.

A preferred landing or turning occurs with the hip, kneecap and second toe lined up. Land or turn with a knee that "collapses" inside of the hip and second toe (much like the picture above) and the knee injury risk goes higher.

Tearing an ACL brings up some difficult decisions.  The athlete can select sports that do not involve cutting or jumping, or if they wish to continue higher-risk activity, surgical reconstruction with 6-9 month rehabilitation periods may be needed. Without activity modification, very few young, active athletes can return to high-level sports without frequent knee pain, instability and swelling.

Does the increased chance  of injury mean that young athletes should not play higher-risk sports?

Of course not.

I definitely think that the higher risk potential requires that certain precautions be taken to help protect the knees.

How can an athlete protect his/her knees?  

Sports-specific ACL injury reduction and knee neuromuscular training programs have been developed based on good studies that show significant reduction in ACL injuries.

Contact me for further details and specific drills/exercises particularly designed for use in weekly soccer practice warm-ups and can be applied to other jumping sports such as basketball and volleyball.

Other Knee Friendly Techniques include:

• Land from a jump on both legs as single-leg landing brings about a higher risk for ACL tear
• Land or cut with the knee slightly bent (not completely straight)
• Strengthen the hamstring muscles- these support the ACL in reducing forward tibia (shin bone) motion
• Controlled plyometric exercises (bounding and leaping) may strengthen the legs and reduce risk of ACL tears
• Make certain the athlete has good basic jumping and landing skills before starting full speed on-field play
• Knee braces have not been shown to prevent an ACL injury

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

The following blog post was originally written for a collegiate audience for ConcussionConnection.com, 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.

Solid Tips on Preventing Swimmer's Ear

To water sport participants such as swimmers and water polo players, the pain of swimmer's ear can not just ruin good times in the water but also put a damper on regular life activities.

http://images.onset.freedom.com/ocvarsity/gallery/ndrbkf-wedpolo.jpg

Known in medical circles as Otitis Externa, swimmer's ear results from infection and inflammation of the external canal of the ear often due to prolonged exposure to moisture (such as in pools). Typical symptoms include pain and discharge from the outer ear along with difficulty chewing due to local swelling in front of the ear.

Once in full bloom, antibiotic and anti-inflammatory ear drops are often used for treatment, though in some instances oral pain medicines or antibiotics are needed for more severe cases. Many athletes will need a minimum of 2-3 days out of the water before being able to return.

To prevent the pain and disruption caused by swimmer's ear, follow these important tips:

• Regularly use of 2 drops of preventative ear drops in both ear canals after each and every water exposure. The combination of rubbing alcohol (isopropyl alcohol) and acetic acid (vinegar) can be purchased over-the-counter as premixed solutions or can be made at home with a 50:50 mixture of the rubbing alcohol and vinegar. 
• Don't be over-aggressive with cleaning out wax from the ear canals. Sufficient wax is the friend of a swimmer as a lack of wax in the ear canals increases the risk of infection, especially if small abrasions are left after vigorous attempts at wax removal.
• Dry out those ear canals after swimming. Tilt the head toward each shoulder to try and allow water drainage from the ear canals. Using a hair dryer at lowest settings can also help dry out the canals (just don't get too close for concerns over excessive heat or risk of hearing damage).
• Careful with metal earrings that could sensitize the ear to higher risk of infection. If possible, remove any piercings before swimming, especially in cases of recurrent swimmer's ear infections.

Can ear plugs or tighter swim caps help reduce swimmer's ear infections?

The use of hypoallergenic ear plugs with our without tight swim caps to reduce the risk of initial or recurrent infections is controversial. No substantial evidence exists to support strongly recommending plug or caps as absolute preventative devices.

Best to use the above prevention tips to reduce the risk of missing out on favorite water sport activities!

Resource: Pediatric Sports Medicine: Essentials for Office Evaluation (Koutures and Wong eds), SLACK Publishing, 2013

When Can Kids Throw a Curveball?

Want to ignite baseball passions perhaps even more than a Yankee-Red Sox or Dodger-Giant rivalry?

Ask the question “When should young pitchers throw a curveball?” and then stand back.

The basic concern is that the still developing bone and soft tissue structures in the shoulder and elbow may not be able to adequately handle the rotational forces needed to throw a curveball. A wicked curveball thrown early in a career could potentially lead to wicked damage and early termination of said pitching career.

Do scientific studies and articles offer any substantial help?

The USA Baseball Medical and Safety Advisory Committee has the recommendation that a curveball should not be thrown until age 14, with only fastballs and change-ups thrown before this age.

Why age 14? Most likely because most pitchers at this age have nearly full if not complete maturity of growth centers around the elbow and shoulder and thus these joints can better handle the forces of throwing a curveball.

• Now, not every child develops at the same point, and in pediatrics we are often trained not to use an absolute age to determine maturity, but rather to use certain milestone to better gauge individual development.
• A pretty solid (and simple) recommendation that maintain this spirit comes from a Major League team physician who states “Don’t throw breaking pitches until you nave shaved".
• The age or development-based recommendations are primarily based on baseball expert opinion and have no significant evidence-based supporting data.

On the other hand, a systemic review of published studies by Grantham et. al in Sports Health concluded that limited biomechanical and most epidemiologic data do not indicate an increased risk of injury when compared with the fastball in pitchers from Little League through professional ranks.

• The epidemiologic evidence to support limitations on the curveball is lacking rigor in study design
• The current biomechanical evidence (kinematic and kinetic analysis of the torso, shoulder, elbow and wrist) does not support limiting the use of curveballs at any level of baseball

         However, before one rushes off to the local diamond to teach the curveball to young throwers, I must share some other important conclusions:

• A young pitcher has a wicked curveball very likely will be perceived as a better pitcher and thus be asked to throw more often, leading to higher pitch counts which have been shown to contribute to  arm overuse injuries.

o   In my experience, anything that makes a young pitcher stand out (taller than peers, good control, stronger fastball) put more pressure on coaches and families to protect those talents and not let them be overused at too young an age.

• The “over the top” wrist snap motion routinely used to increase curveball spin may overload certain forearm supinator muscles, so training these muscle groups along with the shoulder rotator cuff muscles for the curveball.

o   Share this opinion, and would also recommend addressing any limitations in shoulder internal rotation range of motion that can also overload the elbow and wrist regions.

•  Do not underestimate the often unsung virtues of the change-up pitch. The authors found two studies found that throwing a changeup pitch reduced the incidence of elbow and/or shoulder pain and voiced support for USA Baseball’s recommendations to use the change-up to prevent arm injuries.

My bottom line: use stage of development, not simple a specific age, to help determine when a child is ready to throw the curveball. Realize that a good curveball sets a kid up for being asked to pitch more frequently, which can lead to overuse. Assessing shoulder, elbow, and arm strength and range of motion can reduce risk of injury when throwing a curveball.

Multiple Sports for Kids Translates into Multiple Benefits

Should my child play more than one sport? 

Most definitely.

Courtesy of the Franklin Institute (www.fi.edu)

Childhood is a time for challenge and exploration with a variety of sporting activity developing multiple skills and interests, usually leading to more overall sport enjoyment. 

Unfortunately, the concept of single-sport specialization is becoming more commonplace at increasing younger ages.

In fact, the American Academy of Pediatrics Committee on Sports Medicine and American Medical Society for Sports Medicine caution against early sport-specialization.

The concerns of physical injuries and emotional burnout often outweigh the benefits of concentrating on one particular sport.

Yes,there are the unique "early entry" sports such as gymnastics, figure skating, and swimming where early specialization is considered essential. 

However, those are considered more the exception rather than the rule.

More types of sport exposure often leads to more types of movement patterns and the development of a better athlete who ultimately may focus on baseball or soccer.

The cross-over potentials are endless.

Jumping skills developed in basketball can make for a more productive soccer goalkeeper.

Lower body control of wresting allows a football lineman to stay lower and be more productive with blocking technique.

Have seen the balance and body control learned in gymnastics translate into great success with diving or pole vaulting.

My ultimate example was a college baseball coach relating on how Greek Folk Dancing helped his middle fielders with their footwork when turning a double play (yes, he was Greek so bonus points there).

These more diverse athletes are less apt to get hurt or burned out, and they may have particular value for high school and college coaches. 

A multi-sport athletes can be perceived to have  more up-side potential versus the athlete who has focused on one sport for many years.

They are seen to be more receptive to higher level coaching, have less bad habits to break, and ultimately a higher ceiling.

Exposure to multiple sports may also identify previously under appreciated talents or passions.

In my work with the US Men's National Volleyball Team,  I routinely hear of how our athletes came into volleyball after first trying other sports.

As you would probably expect,  most of these taller individuals growing up in the United States were initially attracted to basketball. 

Others tried soccer or even water polo.

Now, while they might have made solid athletes in basketball or those other sports, they probably would not have achieved opportunities to play on an elite, international level and represent their country.

Had they not had the opportunity to branch out and try a new sport in middle or even high school, so much might have been lost.

Now, one more cautionary tale.

This multi-sport advice does not mean that children should participate in so many different sports that the parents feel like virtual taxicab drivers.

Make ample time for schoolwork, family time, friends, and just being a kid.      

And don't forget some simple guides to reducing injury:

• The hours per week of organized sport should not exceed the age of the child in years
• Children who less than twice as many hours per week of play compared to organized (adult driven sport) have more injury risk.

Can Vision Training Reduce Concussions?

While laudable efforts have been put into recognition, evaluation and treatment of a concussed athlete, those are all secondary prevention things done after the injury has already occurred.

Ideally, anything that can be done in the primary prevention world to stop concussions in the first place would be held in the highest of regard.

Helmets and other types of head gear unfortunately haven't served a sufficient protective role.

Now, there are efforts to look at the potential role of Visual Training to Reduce Concussion Incidence in Football, and pardon the pun, the results are eye-opening.

Over the course of 4 football seasons, researchers at a Division 1 Football institution used light board training,  strobe glasses, and tracking drills during pre-season summer camp and followed with weekly light board training during the season.

Findings indicated an association of a decreased incidence of concussion among football players during the competitive seasons where vision training was performed as part of the preseason training. The authors suggest that better field awareness gained from vision training may assist in preparatory awareness to avoid concussion-causing injuries.

The research team did caution  that this is an exploratory study and asked that future large scale clinical trials be performed to confirm the effects noted in this preliminary report.

What are my thoughts on this study?

1. I recall a discussion with a colleague regarding apparent increased in both number and complexity of concussed young athletes compared with 5-10 years ago. There is little doubt that increased concussion awareness accounts for higher patients numbers, but what about the complexity?  One offered answer surrounded the extent of visual stimulation required of students today- from tablets to smartphones, from more screen time and power point presentations- visual overload can lead to lower threshold for  head  injury. While this hasn't been strictly proven, the findings of the above study could lend support to more effective visual processing and perhaps less overall eye strain may be protective against concussions.
2. The study does compare head injury rates in the four years prior to the study and those found in the four years with the visual training intervention. There were coaching changes  and thus possibly differences in contact exposures between the before and after groups. Trying to compare the reported rates of concussion between this institution and other Division 1 school can be difficult- many programs are very guarded with injury rates, especially when it comes to concussion.  All reported concussion numbers (pre/post) seem somewhat low, but again, hard to make an exact statement due to lack of comparison data.
3. If these results are validated, I have to wonder if teams will invest the time and energy to adopt such a program. Knee injury reduction programs have been  developed with solid supporting evidence, but use by teams lags sorely lags. Concussions are obviously a big deal, so I'd like to think that credible prevention programs would be readily put into place, but part of me has doubts from this past experience.
4. Agree with the study authors that this is a preliminary study that merits further investigation with more schools and players of different ages.  Not ready to run out and ask schools to invest in the visual training equipment and protocols just yet, but quite eager to see if others can reproduce these results.

I think all of us in the sports medicine world are looking for evidence-based techniques to reduce/prevent concussions. Do the results of the above study seem reasonable to you?  Would your team or group be willing to put in the time investment if such a program proved able to limit concussions?

Three Cheers for Cheerleading Safety Tips

Cheerleaders such as bases, flyers, backspots and tumblers need agility, strength, and frequent practice to fine-tune routines and prevent injury. Unfortunately, the frequency of cheerleading injuries is rising with the increasing complexity of stunts. 

How can cheerleaders, advisors, parents and coaches reduce these injury risks?

• Practice should take place in proper environments: use mats to practice landings and dismounts, and have high ceilings for jumping and throwing routines.
• Experienced and knowledgeable instructors should be consulted to teach the basics of cheerleading in an individualized and step-wise fashion for all participants.
• Coaches should be trained in first aid, CPR, and not hesitate to collaborate with sports medicine personnel such as certified athletic trainers to prevent, evaluate, and properly manage cheer-related injuries.
• A base must know how to support a flyer without hurting him/herself, while the flyer must know how to land safely.
• Teach flyers rolling and landing techniques over and over again.
• Bases need to work on using their legs, buttock and posterior hip regions for proper lifting and holding techniques that reduce cumulative trauma to shoulders and the back.
• Tumblers should develop appropriate strength in the back of the shoulders and hip regions to take pressure off elbows, wrists, and knees.
• Pre-season conditioning is essential with focus on shoulder, hip and back strengthening exercises. An athletic trainer, physical therapist, or sports medicine physician can demonstrate and recommend appropriate conditioning programs.
• Encourage necessary recovery by regularly scheduling rest periods (at least one off day a week during season and at least 2-3 months a year off of cheerleading activities).
• Avoid multi-level pyramids or throwing of cheerleaders unless all participants are comfortable and well-trained in these skills. One weak link can ruin the routine for all others.
• If there is pain or discomfort with any portion of a routine, do not compromise personal safety or the safety of teammates. Work with a coach or obtain medical evaluation before returning to practice or competition.
• Once returning from a injury, a cheerleader should go through a progressive step-wise return by first working on individual skills such as tumbling, kicks, and tucks before moving to group activities and finally stunting.

Click here for more cheerleading safety tips.

Do you have any more suggestions for cheerleading safety tips? 

Great Advice on Preventing Teeth Damage in Sports

Thanks to Miller Orthodontics in Orange, CA for providing some key information on teeth health during sports participation.

Article one summarizes key points about the use of mouth guards and retainers during sports. it also describes in depth what to do if a tooth is knocked out on the field:

1. Find the tooth
2. Hold the tooth by the crown (the surface farthest from the gumline), not the root
3. If it is an adult tooth, try to put the tooth back in the socket right away
4. If the tooth can not be put back in the socket, store it in cold milk (do not store in tap water)
5. Bite down on a gauze pad to relieve bleeding and pain
6. Call your dentist immediately

Article two focuses on how teeth may be damaged by sugars found in juices or other sports beverages, with the following key tips:

Even one drink a day is potentially harmful, but if you are absolutely unable to give up that sports- or energy-drink habit, we encourage you to minimize your consumption, use a drinking straw or rinse with water after drinking. As odd as it may sound coming from us, do not brush immediately after drinking sports and energy drinks; softened enamel due to acid is easier to damage, even when brushing. Remember, it takes your mouth approximately 30 minutes to bring its pH level back to normal. The best thing to do is to wait an hour, then brush to remove sugar that lingers on your teeth and gums. 

An Intensive Effort to Reduce and Prevent Dance Injuries

Always a leader in cutting edge dance, Backhaus Dance is also front and center with promoting health dancer practices. Proud to be part of their Summer 2016 Intensive faculty and proud to share tips below with all dancers and dance educators.

Thrilled to have DR. CHRIS KOUTURES, MD, FAAP @dockoutures joining us! #healthy #dancers #BDSI2016 #faculty #support pic.twitter.com/30zipRd20w

— backhausdance (@backhausdance) July 12, 2016

Click on each slide to advance.

 

10 Interesting Facts About Lower Body Injuries in Youth Soccer

1.       In youth soccer, most lower body injuries come from non-body contact and occur more in competition than training or practice sessions.  While training injury incidence rates usually do not change with increased player age, match injury incidence tends to increase with age through all age groups

2.       The time of the adolescent growth spurt (girls usually age 12-14 and boys usually age 13-16) seems to have an increased vulnerability for traumatic injuries.  Afterwards athletes seem to be susceptible to cumulative overuse injuries.

3.       Knee injuries occur in 7% to 36% of injured players and are seen more frequently in females  Middle school soccer playing females have a higher rate of anterior knee pain issues than volleyball or basketball players. Any single-sport adolescent female has a higher risk of anterior knee pain issues.

4.       Adolescent female soccer players suffer a roughly 3-6 times increased risk of ACL rupture compared to boys playing the same sport. Several factors have been proposed for the increased risk, such as anatomic differences, hormonal contributions with menstrual cycles, and higher-risk single-leg landing, turning, and jumping positions.

5.       Female adolescent players who completed certain Neuromuscular Training Programs intended to reduce knee injuries have been shown enjoy significantly reduced ACL injury rate compared with players with low compliance.

6.       Ankle injuries account for 16% to 29% of injuries and are more frequent in male and older players   Ankle contusions more common in younger players due to the more ground-oriented game, while in older players ankle sprain tend to occur due to the more aggressive and faster game.

7.       Taller players are more likely report more overall injuries than shorter players, and more apt to suffer knee injuries often by playing more physically demanding positions with jumping and abrupt turning.

8.       Shorter players are often recipients of intense and often violent direct contact to the foot and ankle regions.

9.       Greater exposure to training and competition leads to a greater risk of injury due to the high intensity of the activities.

10.   The higher incidence of injury during matches than training highlights the need for education and prevention programs in youth soccer. These programs should focus on coach education aimed at improving skills, techniques, and fair play during competitions with the goal of reducing injuries.

What ideas do I have to help reduce these risks?

• Find ways to make evidence-based injury prevention programs standard practice for all young players
• Ensure proper Certified Athletic Trainer or other medical coverage
• Place large emphasis on fair play and rule enforcement
• Caution with players tending  toward year-round or single-sport emphasis at/near their peak growth periods

What ideas would you add to help young soccer players reduce lower body injuries?

Use Young Athletes Age "2" Prevent Overuse Injuries

Do you know your child's age in years?

Can you remember the number "2"?

Good.

Those basic pieces of information allow you to make key decisions that can reduce the risk of overuse injuries in your young athlete.

If the number of hours of organized sport activity per week exceed the number of years of the age of a young athlete, then there is a statistically higher chance of suffering a serious overuse injury.

If the ratio of organized sports to free play is greater than 2:1, then there is a statistically higher chance of suffering a serious overuse injury.

That's it.

Pretty simple. Pretty easy to remember.  Pretty easy to put into practice.

Thanks to  Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes: A Clinical Case-Control Study by trusted colleagues Neeru Jayanthi, Cynthia LaBella and their co-authors in Chicago, these simple decision rules can now provide evidence-based guidance to an area where concrete recommendations were sorely lacking. Over 800 injured 7-18 year-old athletes who were treated at two sports medicine clinics were compared to similar aged healthy children who came to the same clinics for pre-participation sports physicals.

Now, what are organized sports?

Any sport activity which is organized and supervised by an adult.

This does include games, practices, conditioning, speed training, weight training, and individual skills training sessions. Probably fair to extrapolate to technique courses, choreography courses, rehearsals, and individual skills sessions for dancers and other performers.

Not only do we get those two helpful decision rules from these findings, but also an emphatic reminder of the value of free play in the safe development of young athletes.

That's another simple thing to remember and put into regular practice.

Is Weight Training Safe and Productive for Children?

There is no magic age at which a child can begin weight training. Readiness for weight training depends on the willingness of the child to lift weights, follow directions, and maintain the program for several months to see results. Remember, this is for the child, not for an adult or coach.  

Weight training should supplement regular sport activity. It is not acceptable to have weight training injuries keep an athlete away from his/her sport. I recommend qualified supervision by a performance or physical trainer who routinely works with children and adolescents. The focus should be on appropriate-sized equipment, meticulous weight lifting technique, starting with low weights/high repetitions, and working multiple body parts. In appropriate program, a child will often lift weights 2 or 3 days a week with at least 48 hours of rest between sessions. 

The physical results, such as muscle enlargement and weight gain, depend on the gender and developmental stage of the child. Routine weight training can make a child somewhat stronger by increasing nerve and muscle communication. However, if the child is looking for larger and more bulked muscles, then they must wait until after their growth spurt. Androgens are a particular hormone, produced more in boys than girls, which produce muscle and strength gains. Since androgens increase late in puberty right after the growth spurt (age 11-12 in girls, age 13-14 in boys) lifting before this time will not result in massive muscle bulking or extreme strength gains.

Does this mean one should not lift before the growth spurt? No, but just place the emphasis on good technique and reduce the expectations for big-time muscle gain. Remember, due to lower androgen production than boys, girls will have less increase in muscle mass.

Is weight training safe for children?    

Studies have shown that a properly designed and supervised resistance training program can be safe for children and young adults. Contrary to popular belief, weight training at a young age does not stunt growth as long as proper techniques are utilized.  There are reports of overuse injuries with back strains the most common but at no greater frequency than what is seen on the athletic field. Again, placing the emphasis on a properly designed and supervised resistance training program will help reduce injuries and maximize enjoyment.

Click here to learn about:Proper post-lifting recovery, focusing on nutrition and sleep, can greatly enhance the results and safety of a weight training program.

Does weight training work?  

Both published studies and personal experience have shown impressive strength, speed, and endurance gains with an appropriate weight training program. There is no good scientific data to show that this directly translates to better on-field performance, but it does contribute to overall athletic ability. The athlete needs to be aware that he/she must stay with the program or risk losing the gains. 

To produce optimal results, recommend starting a program during break periods between sport seasons and not initially scheduling weight training sessions on same days as practices or games. Once the athlete is more comfortable with the demands of weight training, can incorporate lifting sessions with regular training and competition activities.

Can weight training reduce injuries?    

High school-based studies indicate a resistance training program could decrease the number and severity of injuries, and also reduce the rehabilitation time once an injury has occurred. These benefits may be due to stronger supporting joint structures, muscle absorbing more energy before tiring out, and greater muscle balance around a specific joint.

Can weight training help with weight loss or weight control in children?

Weight training programs that feature higher repetitions, lower weights and limited rest between sets have been shown to contribute to both weight loss and weight control in children. Appropriate professional supervision in designing such a program can be of significant help.

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

Be a Smart Coach- Use CoachSmart App to Make Athletes Safer

I have accessed CoachSmart while on the sidelines, and no longer have to guess or try to remember suggested adjustments for practice and games in hot or humid weather.  The information is concisely presented in the palm of my hand.

The iPhone app CoachSmart was developed by colleagues at Vanderbilt Sports Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt and is billed as the ultimate resource for coaches, offering real-time information on heat index and lightning strikes, frequently asked sports medicine and safety questions, and a group contact feature.

The The app is free to download in iTunes with an annual in-app subscription to live lightning data for $1.99.

• If lightning strikes nearby, the app sends an alert to the phone and the resource section provides information on what to do.
• The Home Screen gives current temperature, humidity, heat index and lightning strike information.
• The Map Screen is based on the user’s GPS location. One map shows lightning strikes within 25 miles, while another uses information from nearby weather stations to post current conditions, including heat index and wind chill.
• The Contacts function allows the user to compile team members’ contact info and send a message to the entire team with the touch of a button.
• The Resources section includes information that athletic trainers commonly dispense, such as hydration tips, injury prevention, concussion guidelines, and when to go to the emergency room. The resources will be updated as more information is needed or guidelines change.
• The app includes the Tennessee Secondary School Athletic Association (TSSAA) heat index guidelines.

Developed by Sports Medicine Physicians and Athletic Trainers with close guidance from coaches, the CoachSmart app brings many important topics into one easy location.

Recommending CoachSmart is now part of my pre-season safety talks to coaches, parents, and administrators, and will also be part of an upcoming lecture on Heat Illness.

The CoachSmart App was recently upgraded and returned to active status. I do not have any financial relationship with the CoachSmart App.

Baseball Safety Tips for Coaches and Parents

Important for parents to carefully monitor pitch counts, innings pitched, number of teams, and rest months.

Immediately contact your pediatric sports medicine specialist with any concerns with pain, fatigue, change in slot angle or overall performance.

Repetitive Ankle Sprains or Recurrent Ankle Swelling- Three Common Causes

When an athlete presents to me with concerns over multiple ankle sprains or on-going ankle swelling, what thoughts go through my mind?

• Inadequate Rehabilitation of Previous Ankle Injuries
  • The number one risk factor for future ankle injury is under-rehabilitation of a past ankle injury.
  • Ankle sprains are defined as stretching or partial/complete tears of the ligaments that connect bones on the outside and inside of the ankle joint. The majority of ankle injuries are caused by rolling in of the foot (called an inversion ankle injury) and cause damage to the anterior talofibular and calcaneofibular ligaments on the outside of the ankle. Injuries with rolling out of the foot are less common and cause injury to the deltoid ligament on the inside of the ankle.
  • The healing process with a damaged ligament leads to scar tissue formation at the site of the tear. Trying to come back too soon after an ankle sprain will limit the scar formation and predispose the ankle to future injury. 
  • Even with appropriate recovery time for scar formation, a sprained ligament is never completely as strong as prior to injury. Undertaking an appropriate rehabilitation program that builds up the strength and proper firing patterns of the peroneal muscles on the outside of the ankle can help compensate for the reduced ligament strength and reduce risk of later injury. Increasing strength of the muscle above the ankle, including the hip rotators, can also reduce the risk of future ankle problems.
• Underlying Structural Abnormalities such as Tarsal Coalition
  • The ankle joint is defined as the "upside-down U shaped mortise space" between the tibia (shin bone), fibula (thin bone on outside of lower leg) and the talus (first bone of foot). Below this mortise ankle joint are the sub-talar joints which include connections between the heel bone (calcaneous), talus, navicular (bone on top of inside foot arch) and cuboid (bone on outside of foot).
  • Abnormal bone or fibrous soft tissue bridges between these tarsal and sub-talar region bones can develop as part of on-going foot development or after an injury and can lead to restrictive motion of those sub-talar joints causing increased stress and higher risk of ankle sprains.
  • What are physical exam findings that suggest tarsal coalition?
    • Ask patient to walk with the feet turned in- they cannot turn feet in sufficiently to walk on the outside of the feet
    • Ask the patient to stand on toes with heels raised- when viewed from behind, the heel bone will not turn in (invert) suggesting reduced subtalar motion
    • Often these subtle physical exam findings are the best initial clues for discovering tarsal coalition
  • X-ray examination may show osteophytes (extra bone) on the front aspect of the talar neck (white arrow below), a prominent lateral process of the calcaneous, and narrowing of the joints below the talus (black arrow below). In many cases, Magnetic Resonance Imaging (MRI) or CT Scan might be needed to better define the anatomy

• Osteochondral Lesions of the Talar Dome
  • The top part of the talus bone (known as the dome) is covered by articular cartilage, and one or more ankle injuries can cause damage to the cartilage and underlying bone known as an osteochondral lesion.
  • Osteochondral lesions are notorious for not appearing on initial x-rays taken at the time of injury. Don't be fooled or lulled into complacency with normal early x-rays and an ankle that isn't getting better.
  • A classic presentation is the case of an ankle sprain which never fully recovers and results in chronic swelling of the ankle joint associated with clicking, catching, or locking sensations.
  • Often, repeat x-rays taken weeks to months after the injury may reveal signs of an osteochondral lesion (black arrow) with separation, fragmentation, and irregularity seen at the talar dome. MRI might be used to better categorize the nature of the injury.

This blog post is not intended to diagnose or treat any ankle or other injury.  If you have concerns over repetitive ankle injuries or recurrent ankle swelling, please contact me or your sports medicine specialist for a proper evaluation or treatment plan.

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.