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

Please Check Our New Brand and Website:

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: injury prevention advocacy

Dr. Koutures Co-Authors American Academy of Pediatrics Report on Martial Arts Safety


Nation’s pediatricians offer guidance on injury risks among various forms of martial arts, including mixed martial arts

Karate, taekwondo, judo and other martial arts can boost fitness, motor skills and emotional development for the estimated 6.5 million youth participants in the United States. But these increasingly popular activities also come with injury risks, which are strikingly higher for some techniques and movements within various disciplines.

A clinical report from the American Academy of Pediatrics (AAP) in the December 2016 journal Pediatrics, “Youth Participation and Injury Risk in Martial Arts” (published online Nov. 28), promotes safer participation in martial arts by guiding families to choose non-contact forms of martial arts that provide health benefits but lower risks of serious injury.

"There are so many different types of martial arts for families to consider and enjoy, but such a difference in injury risk between the different non-contact and sparring forms,” said author Chris Koutures, MD, FAAP, a member of the AAP Executive Committee on Sports Medicine and Fitness. “We hope that this report will enable pediatricians to help families select the most appropriate options for their child and realize how strongly certain practices and rules can impact a participant’s safety.”

Most martial arts injuries, such as bruises and sprains, are not life-threatening. But more serious injuries such as neck trauma, concussions and fractures do occur, especially during free sparring in competitions. Injury rates vary from 41 to 133 injuries for every 1,000 athletic exposures, depending on the form of martial art. Protective equipment such as soft helmets and mouth and face guards are not proven to prevent concussions and may provide a false sense of safety, according to the AAP.

The AAP recommends martial arts competition and contact-based training be delayed until children and adolescents demonstrate adequate physical and emotional maturity. The AAP calls for the elimination of certain rules, such awarding extra points during tournaments for kicks to the head, a rule recently enacted in taekwando, that can have particular impact on concussion rates.

The AAP strongly discourages youth participation in practices common in mixed martial arts (MMA) such as direct blows to the head, repetitive head thrusts to the floor and choking movements, which can dramatically increase risk of concussion, suffocation, spine damage, arterial ruptures or other head and neck injury. The AAP also cautions against excessive media exposure to MMA contests, which can put children at risk of injury if they imitate what they see.

Sports Experts Answer Key Questions about Early Sport Specialization

I strongly recommend that parents, coaches, and other youth sport stakeholders review the clinical report Sports Specialization and Intensive Training in Young Athletes written by trusted colleagues with the American Academy of Pediatrics Council on Sports Medicine and Fitness led by good friend and passionate advocate Dr. Joel Brenner.

As a big fan of relevant question/practical answer format to best translate scientific studies to meet real-world challenges (see my Children and Sports Guide for example), was pleased to see common questions addressed and I will summarize their thoughtful responses below:

Does Specialization Lead to a Successful Performance and Career?

Most authorities agree that sports specialization, in general, leads to higher athletic “success,” but the optimal timing of specialization is only now becoming clearer. Studies have shown that Division 1 NCAA athletes are more likely to have played multiple sports in high school and that their first organized sport was different from their current one. Many examples exist of professional athletes who have learned skills that cross over to their sport by playing a variety of sports into high school and even college. There were 322 athletes invited to the 2015 National Football League Scouting Combine, 87% of whom played multiple sports in high school and 13% of whom only played football. Other studies in elite athletes have shown that intense training did not start until late adolescence and that these athletes played other sports before specializing. Reviews of studies of elite athlete specialization history revealed that, for the majority of sports, late specialization with early diversification is most likely to lead to elite status. In addition, athletes who engaged in sport-specific training at a young age had shorter athletic careers.

Are 10,000 Hours Needed to Succeed in Sports?

It has often been misquoted that to succeed, an athlete needs to have 10 000 hours of practice/competition over 10 years. The media have incorrectly extrapolated studies of chess players to a formula for sports success. Many examples exist of successful athletes who have <10 000 hours and others who have not succeeded despite having >10 000 hours of practice/competition. Other factors come into play besides sports exposure time. These may include physiologic construction (ie, a high jumper with elastic Achilles tendon) and genetics.  For some athletes, elite status may be achieved with 10 000 hours of total deliberate play (child determines activity)  and deliberate practice time (adult determines activity) in all sports combined but only 3000 hours of sport-specific training. Evidence is lacking that specialization before puberty is necessary to achieve elite status, and in fact, specialization before puberty is more likely to be detrimental.

When Is It Appropriate and Safe to Specialize?

Current evidence suggests that delaying sport specialization for the majority of sports until after puberty (late adolescence, ∼15 or 16 years of age) will minimize the risks and lead to a higher likelihood of athletic success.Only 0.3% of German athletes in Olympic sports selected at the youngest level were ranked internationally, and most elite athletes specialized in their primary sport later in life. Specialization can be divided into early versus late, with the inclusion of early diversification of multiple sports for those who specialize later. Early diversification allows the athlete to explore a variety of sports while growing physically, cognitively, and socially in a positive environment and developing intrinsic motivation. Young athletes can learn many important fundamental physical movement skills with early diversification that can then transfer over to their primary sport if they decide to specialize later. By learning these skills during their developing years through deliberate play (child directed activities), athletes will require less deliberate practice (adult directed activities) to acquire expertise in their chosen sport. Studies have also shown that deliberate play is crucial to normal development and attainment of elite status.Athletes in late adolescence have the cognitive, physical, social, emotional, and motor skills needed to invest into highly specialized training. They can understand the benefits and costs of intense focus on 1 sport and, just as importantly, are able to make an independent decision about investing in 1 sport.

What Are the Risks in Specializing Too Soon or at All?

Young athletes who specialize too soon are at risk of physical, emotional, and social problems.  Specializing early with intense training can lead to overuse injuries, which can cause pain and temporary loss of playing time or may lead to early retirement from the sport. The risk of injury is multifactorial, including training volume, competitive level, and pubertal maturation stage. One study in high school athletes showed an increased risk of injury when the training volume exceeded 16 hours per week.. Another study determined that sports specialization was an independent risk factor for injury and that athletes who participated in organized sports compared with free play time in a ratio of >2:1 had an increased risk of an overuse injury. This same study found that young athletes who participated in more hours of organized sports per week than their age in years also had an increased risk of an overuse injury. Burnout, anxiety, depression, and attrition are increased in early specializers. Social isolation from peers who do not participate in the athlete’s sport and lack of being exposed to a variety of sports also are concerns. Restriction in exposure to a variety of sports can lead to the young athlete not experiencing a sport that he or she may truly enjoy, excel at playing, or want to participate in throughout his or her adult life. An additional concern is the risk of physical, emotional, and sexual abuse by the adults involved in the young athletes’ lives as a result of overdependence. Dietary and chemical manipulation are also possible. The combination of these adverse outcomes could lead to a decrease in lifelong physical activity.

Which Sports Require Early Specialization and Are Those Athletes at High Risk?

Figure skating, gymnastics, rhythmic gymnastics, and diving may require early specialization, because peak performance occurs before full physical maturation.However, it is not known whether the training required for such sports poses a risk for athletes’ long-term health and well-being. Studies in gymnasts and figure skaters found that their training did not affect pubertal growth and maturation or adult height. First menstrual period occurred later but within a normal range. However, other studies have shown that female athletes who participate in sports requiring early sports specialization are at higher risk of overuse injuries as well as bone stress injuries, disordered eating and menstrual irregularities.

How Much Training Is Adequate to Succeed Versus Too Much?

The exact amount of training needed to succeed has not been described. The threshold to avoid injuries, burnout, and attrition has not been elucidated. The possible rule of participating in fewer hours of organized sports per week than their age in years or restricting training to <16 hours per week to decrease the chance of injuries needs to be validated by other long-term studies.

Do Sports-Enhancement Programs Lead to Success?

Young athletes need to learn motor development skills, social skills, and psychological skills to succeed. No studies on sports-enhancement programs in youth that only teach sport technique or “conditioning” have shown a greater chance of success despite their increased time and financial investment.

What Are the Effects of Early College Recruitment?

Talented youth are starting to be ranked nationally as early as sixth grade. As colleges start to look at middle school and early high school athletes, more pressure is created for the athlete and parent to do everything possible to succeed. This situation may push athletes into playing year-round and possibly on multiple teams simultaneously to get more exposure and specializing in a single sport sooner for fear of missing their opportunity to impress a college coach. Given what is currently known about early sport specialization, this changing paradigm should be discouraged by society. The AAP, NCAA, pediatricians, parents, and other stakeholders should advocate banning national ranking of athletes and college recruitment before the athletes’ later high school years.

Schedule Dr. Koutures to Speak to Your Soccer Club or Team


With more and more kids and teens playing soccer, so comes the risk of injury. Today, players are suffering from head injuries, groin injuries, knee injuries, hamstring pulls and broken bones.

Schedule Dr. Koutures to come speak to your coaching staff or families!

Some common topics he can address include:

To schedule a one hour session with Dr. Koutures for coaches and/or parents, click here or call 714-974-2220

Best Warm-Up Programs for Young Soccer Players Reduce Injuries and Save Money

Adds to a growing list of studies supporting evidence-based neuromuscular training programs to reduce burden of both injuries and their associated economic costs.

Looking for neuromuscular training programs for young soccer players?

Check out these links:



More Dr. Koutures Thoughts on Heading and Helmet Use in Youth Soccer

The United States Soccer Federation decision to not have players under age 12 engage in heading activities and to limit heading exposure in players between age 12 to 13 has fueled many interesting exam room discussions about soccer-related concussions that have led me to develop particular thoughts on the topic, including a very unexpected and somewhat troubling take on the use of of soft helmets.

Many of my ideas have been incorporated in two thoughtful articles written by Lindsey Barton Straus, JD  from Mom'sTEAM.  Highly recommend taking the time to read both, as she very adeptly captures my experience and research with this important topic:

One of the main take-home points that underlies my philosophy and is echoed by several other interviewed authorities emphasized an individualized approach to determining readiness to initiate heading.

While certain categorical age-based decisions are far easier to implement, as we are continually taught in pediatric medicine, the focus should more often be placed on each child's developmental age rather than their chronologic age.

Another maxim in pediatrics- never hesitate to have  a realistic discussion about a difficult topic- in this case, a dialogue between player, coach, family and medical professionals as needed to make the best decision for each athlete.

Having several such realistic discussions about preventing head injuries and making return to play decisions after concussion has also brought a unique, if not cynical insight into a related controversial topic, the use of soft helmets to reduce head injuries in soccer.

From a professional standpoint, I have always been somewhat unconvinced about the true protective value of soft helmets in soccer, and have never mandated that an athlete must wear one in order to continue playing the sport. 

It didn't take long for me to learn that most of my young athletes shared my apprehension about helmet use.

However, their lack of interest wasn't due to their reading of the medical literature, or a more typical adolescent rebellion against parent/coach/medical professional authority. 

Rather, they were afraid to wear them for fear of being a target.

"If I am the only one, or only one of a few that are on the field with a helmet, my opponents will come after me."

After hearing this concern several times over, I must admit that now when asked by a parent about my opinion on helmet use, I reflexively turn to the child and ask them to truthfully tell me their opinion.

Sure enough, I get reminded of the fear of being a target. Definitely makes the parents think a bit differently about helmet use, and given the lack of consistent evidence supporting their use, definitely influences my decision.

This may not be the most scientific way to form a response, and definitely is a sobering reflection on the competitive environment faced by many young players, but it does provide a practical and necessary real-world platform to best address each individual player's needs, concerns, and future expectations.

Curious if others have encountered hesitation to wear soft helmets based on perceived risk of being singled out on the playing field? Does this information change opinion on possible helmet use?






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?

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.

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

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



Getting Defensive about ACL Injuries in Soccer

Soccer players, coaches and families take notice:  two video analysis reviews of Anterior Cruciate Ligament (ACL) injuries confirmed long-time suspected vulnerability with off-balance single-leg landing, but also added a new twist: certain defensive movements may also be a previously unrecognized culprit.


Both the April 2015 British Journal of Sports Medicine (analyzed males only) and May/June 2015 Sports Health (analyzed both males/females) articles found that around 3/4 of all ACL tears occur when the opposing team had the ball and the injured athlete was defending. The Sports Health group found that females were more likely to be defending when they injured their ACL in comparison to male counterparts.

Now, while certain forwards who are reluctant (or lazy) to come back on defense may be silently rejoicing at this news, let's take a deeper look at the particular defensive situations that produced ACL injuries:

  • Tackling to separate the ball from an opponent, which often requires last minute adjustments in body position and technique
  • Cutting to track an opponent
  • Pressing situations where the defending player typically made a sidestep cut in order to reach the ball or to tackle an opponent
Non-contact pressing mechanism (right knee). (A) At−160 ms, the defending player is running forward at high speed towards the opponent in possession of the ball. (B) At initial contact, he strikes the pitch with his right heel and makes a sidestep cut in an effort to reach the ball or to tackle the opponent, but no player contact. (C) At 80 ms, he rotates the trunk towards his left leg and puts the entire load on his right leg. (D) At 240 ms the right hip and knee joints are in abducted positions and the ankle joint is in eversion (dynamic valgus without collapse). From  Walden, et al,BJSM, April,2015

Non-contact pressing mechanism (right knee). (A) At−160 ms, the defending player is running forward at high speed towards the opponent in possession of the ball. (B) At initial contact, he strikes the pitch with his right heel and makes a sidestep cut in an effort to reach the ball or to tackle the opponent, but no player contact. (C) At 80 ms, he rotates the trunk towards his left leg and puts the entire load on his right leg. (D) At 240 ms the right hip and knee joints are in abducted positions and the ankle joint is in eversion (dynamic valgus without collapse). From Walden, et al,BJSM, April,2015

In addition to defensive play, being out of balance with single-leg movements was also a more common culprits:

  • Regaining balance after kicking
  • Landing after heading

In both the defensive or out of balance situations, the injured knee was more apt to be in a valgus (bent inward towards the opposite knee) and straight position.

"Danger position":&nbsp;inward&nbsp;movement (valgus) and straighter&nbsp;right knee relative to right hip and ankle.

"Danger position": inward movement (valgus) and straighter right knee relative to right hip and ankle.

So, what teaching points can be made for younger soccer players?

No, we are not going to give any excuses justifying not playing defense (probably much to the chagrin to some players....).

The results of both studies indicate that ACL injury preventive interventions should place focus on keeping the knee in a flexed (bent) position and having the kneecap centered right under the hip and over the foot without any collapsing inward through:

  • General postural and neuromuscular control of the core and lower extremities;
  • Footwork and running technique during changes of direction in defensive playing actions, mimicking the pressing situation;

  • Maintaining balance during shooting, passing and ball clearing;

  • Jumping and landing technique during heading duels;

  • Promoting fair play in order to avoid fierce tackling from behind

The findings of these two studies further underscore the importance of evidence based ACL injury prevention studies that can readily be found without charge on the web.

Players and parents, do you ask your coaches and trainers to include these training techniques? Coaches and trainers, are you adding value to your program by emphasizing injury prevention? Any other drills that you think would contribute to proper balance, defensive postures, landing and tackling techniques?

Sorting out Causes of Elbow Pain in Young Throwers

Any type of elbow discomfort in a young thrower is not a good thing, and while the easiest kids to worry about are those who will openly report elbow pain or limited motion, other more subtle signs of a potential elbow issue might be:

  • "shaking" of the arm between throws
  •  less interest in throwing
  •  throws going higher than usual
  •  not being as accurate with the location of throws.

I get particularly concerned about kids who can use a fingertip to identify the exact location of pain and those throwers who have swelling around the elbow joint. I'm also particularly careful with any case of limited ability to straighten the elbow compared to the non-throwing arm; while this might be more acceptable in an adult thrower, it definitely is not normal in a child or early teenage thrower.

Likely culprits leading to elbow pain can include excessive throwing both in one game and over the course of season(s), poor shoulder internal rotation, lack of strength in the legs and back, and trying to snap the wrist or straighten the elbow with too  much force after releasing the ball.

I'll list several common causes  by organizing them according to location within the elbow. Of course, this post is not intended to diagnose or treat any form of pain and should not be considered formal medical advice, but rather should be used as a guide to seek care from a qualified pediatric sports medicine specialist.

A few definitions:  INSIDE OF THE ELBOW is above the pinky side of the hand, and the OUTSIDE OF THE ELBOW is above the thumb side of the hand.

Keeping in mind the following visual about the unique forces that throwing places on the elbow can greatly simplify thinking about potential elbow injuries:



  • Structures on the INSIDE OF THE ELBOW (BLUE ARROWS) are stretched when a ball is thrown
  • Structures on the OUTSIDE OF THE ELBOW (RED ARROWS) are compressed or pushed together when a ball is thrown


Inside (Medial) Elbow Pain (again, most often caused by that stretching motion)

  • Irritation of growth plate (aka: medial apophysitis or "throwers's elbow")
    • he medial apophysis is a growth center separate from the rest of the humerus bone (upper part of elbow). Both ligaments (connect bones together) and tendons (connect muscle to bone) have attachment sites to the medial apophysis, so any stretch of these attachments can pull on the growth center and cause a range of injury from more simple irritation to a frank fracture and increased separation of the growth plate
  • Irritation or strain of flexor/pronator  muscles
    • These muscles start on the inside of the elbow and allow snapping and/or rolling over of the wrist. Often can be injured after learning new breaking pitches or throwing too many breaking pitches with improper form
  • Stretching of Ulnar Nerve
    • The ulnar nerve runs along the inside of the elbow and repetitive stretching can lead to damage with numbness and tingling sensations that travel down into the ring and pinky fingers.
  • Ulnar Collateral Ligament (UCL) Tears
    • opularly known as the "Tommy John ligament", the typical story of a UCL tear is immediate pain after one throw with inability to continue throwing. Less common in throwers who haven't completed growth- the apophysis tends to be the weaker link. In more mature throwers (high school and above), the UCL is at greater risk of injury. 

Outside of the Elbow Pain (caused by compression)

  • Capitellum Injury
    • ocated at the end of the humerus bone, the capitellum can be damaged by repetitive compression leading to either damage of the entire bone (usually in throwers age 5-10) or more local areas of bone and overlying soft tissue cartilage injury (usually in thrower over the age of 13).
  • adial Head Injury
    • Also caused by repetitive compression, injuries to the radial head can involve damage to the growth plate that could affect long-term growth
  • xtensor-supinator muscle injury
    • These muscles control straightening and rolling of the wrist. requently known as "tennis elbow", injuries to these muscles are much more common in adults and if suspected in a younger thrower, damage to the capitellum or radial head must first be excluded before making diagnosis of extensor-supinator muscle injury.

Back of the Elbow Pain

  • Olecrenon impaction syndrome
    • Repetitive straightening (extension) of elbow can cause irritation of triceps muscle insertion into the olecranon, or even bone spur formation in the olecranon region. Often caused by trying to whip the arm into the straightened position with too much force.

No matter the location of pain, any possible elbow injury in a young thrower deserve urgent and specialized evaluation to determine exact cause, review contributing factors, and provide appropriate recommendations for treatment and recovery. Trying to throw through pain may lead to more damage and ultimately reduce future ability to return to throwing activities.



How to Keep Volleyball Knees Healthy

Kudos to accomplished writer and volleyball coach Eric Hammond for an insightful article on keeping knees healthy in volleyball players. I appreciated the opportunity to work with him and USA Women's National Team ATC Jill Wosmek on this important article.

The following table summarizes some key points, but I highly recommend you click here to read the entire piece originally published in VolleyballUSA.

Healthier knees: 5 tips
 - Avoid landing on straight knees. Always land and move "softly" 
 with hips, knees and ankles bent.
 - Try to land in good alignment, with the hips and knees lined up 
 with the second toe. Don't let your knees collapse in or rotate.
 - The best time to stretch is after practice or after a match when the 
 muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors 
 and calf muscles.
 - Don't hesitate to ice sore knees for 20 minutes after practices 
 or matches.
 - Knee pads help reduce bruises and pounding, especially 
 with repetitive diving drills. 

New California Football Contact Limits Provide Unique Opportunity to Study Effect on Concussions

According to the findings of a study published in the May 4th online edition of JAMA Pediatrics, practice periods are a major source of concussion for the high school football player

While the actual rate of concussion is higher in game play, just over half of the reported concussions took place during practice times.

The authors suggest that strategies should be implemented to evaluate technique, limit player-to-player contact and overall head impact exposures, and reduce other higher risk practice situations.

While the jury is still out on what constitutes proper technique, the mandates of California Assembly Bill 2127 will afford a vital opportunity to further study the influence of practice time limitations on concussion rates in high school football players.

The bill prohibits high schools from conducting more than 2 full-contact practices per week during the preseason and regular season, and prohibits this full-contact portion of the practice from exceeding 90 minutes in a single day.

To clarify, "full-contact practice" means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game.

Based on the findings of the above JAMA Pediatrics study, the hypothesis is that these new restrictions should reduce concussion rates in practice simply by limiting exposure time and cumulative risk.

Now, one might ask, why would there possibly not be a reduction in concussion rates?

  • Is there a chance that limited practice times could lead to less comfort with tackling that could result in an actual higher game rate of concussion?
  • Could football programs feel pressure to get in as much contact as possible during the 2 allocated 90 minutes practice periods, possibly leading to more cumulative exposure during that time?

A multi-location review of concussion rates (game and practice) is essential to confirm the effects of California AB 2127. 

In such a study, I would also suggest that concussion rates be broken down by academic grade of player, and even take into account years of experience of tackle football.

I wonder if neophytes (namely incoming freshman) who have never previously played tackle football could be at higher risk from contact practice time limits.  Would the contact time restrictions have less influence on upperclassman who have played tackle football for a longer period of time?

All stakeholders will be eager to see if indeed there is a documented reduction in overall concussion rates, and if such a reduction is seen across all levels of high school football.

Multiple Sports for Kids Translates into Multiple Benefits

Should my child play more than one sport? 

Most definitely.

Courtesy of the Franklin Institute (

Courtesy of the Franklin Institute (

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?



Recommendations for Children and Distance Running

The risks of injury and illness in distance running may be related to the total mileage and number of hours training per week. There is no agreement amongst sports medicine professionals about distance limitations for children. Until further data are available concerning the relative risk of endurance running at different ages, the American Academy of Pediatrics recommends that if children who enjoy distance running and make the individual choice to train free of injury or ailments, there is no reason to preclude them from training for and participating in such events.

Let me re-emphasize that bold point.

Children should be the ones selecting to run, free of any pressure from peers, parents, coaches or other influences.

Most running injuries include overload injuries to muscles and bones of the legs and feet, and there is the real emotional "burnout" injury from excessive exposure to running.

Concerns have been raised over possible damage to bone growth plates from high amounts of running, but examples of this type of injury have not been consistently found in medical studies.

Looking at running injury patterns and statistics, it is fair to say that when the young athlete is generating the interest and eagerly participating in a sensible training progression, there is a fairly low risk of physical or emotional injury.

To help develop an appropriate program, many recommend using the 10 percent rule is an appropriate guide and considering certain variables:

  • Weekly running distance
  • Intensity (range includes long slow runs to hill training to speed work)
  • Number of training days per week

An athlete should only increase one of those three variables, and no more than a 10 percent increase from the previous week.

Not having number of training hours per week exceed the number of years in the child's age has also been shown to reduce the risk of overload injury.

A comprehensive program should also ensure adequate sleep and nutritional support that can assist with recovery from training.

Studies have shown that sleeping less than 8 hours per night may lead to an increased risk of injury or illness.

Consuming protein right after exercise (one gram of protein for roughly every 2 pound of body weight) can assist with muscle repair and recovery. Chocolate milk is a particularly good choice along with Greek yogurt or peanut butter.

Finally, putting more focus on developing the running experience and less on competitive outcomes (medals won, finish times) very likely will reduce the risk of injury and foster a more productive healthy outlook on running for the young athlete. 

Protecting Adolescent Pitchers

If you happen to know an adolescent pitcher who has the fortune of being taller or throwing harder than his peers, chances are that he is perceived as a valuable asset on the diamond.  Often this attention and demand may lead to requests to play on  multiple teams at the same time.

Unfortunately, these unique characteristics may also lead to an increased risk of shoulder and elbow injuries that could derail the promise of future enjoyment of  baseball. 

video analysis of 420 adolescent baseball players along with review of pitching and injury histories found that for each 10-inch increase in a pitcher's height, 10 mile-per-hour increase in pitch velocity, or play for more than one team all significantly increased the risk of arm or shoulder injuries.

Does this mean that having a gun for an arm is a bad thing? Is being tall a negative in the injury world?

I think the reality is that anything that makes a young thrower stand out from peers leads to the temptation of overload and the resultant overuse arm and shoulder injuries. 

If proper perspective and patience is exercised, then less chance for badness down the road. However, if combination of all those talents mean requests for more appearances on the mound, playing for more than one team, and thus less overall rest periods, then that is when  the problems begin.

It is a natural to want to showcase talents, but for those who are blessed with certain gifts, ensuring appropriate rest during key developmental years can ward off those unwanted outcomes and lead to more enjoyment down the road.


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? 

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 sessionsWhile 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"?


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.