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

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



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

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


Filtering by Tag: pediatric sports knee injuries

Seven Tips to Protect the Arms, Knees and Careers of Young Catchers

There is a great demand for willing and talented catchers, and many great demands are placed especially on the shoulders, elbows, and knees of those who toil behind the plate.

From bullpen warm-ups to bunt defense to gunning out runners at second or third, catchers are a focal point of both practices and games.

All while doing the routine return throwing of the ball to the pitcher with most of this work done in the squat position with foul balls coming right at them.

In all, no player makes more total throws than a catcher.

Yes, the majority of those are fairly easy tosses back to the pitcher.

However, there are those harder pick-offs or throws to catch steals that only add to the cumulative stress.

And when pitchers get tired, they get replaced- unlike the catcher who tends to stay out there even for both ends of a doubleheader.

While there are pitch count limits and required rest days for pitchers, the only such formal guidelines placed on catchers are by Little League Baseball which mandates that any player who throws more than 41 pitches in a game cannot move to catcher in the same game.

So what other guidelines can help protect the overall health and longevity of catchers?

1. Have catchers alternate standing and being in the squat position with return tosses to the pitcher.

  • Throwing from the squat is quicker and looks pretty cool, but the lack of lower body involvement in the throw places more stress on the shoulder. Coming out of the squat not only gets the legs involved in the throw but also reduces lower leg cramping.

2. Have catchers sit on a bucket for practice and bullpen sessions- allows them to give a consistent target while putting less deep squat-induced pressure on the lower legs. The "knee saver" products are designed in theory to similarly reduce deep knee bending in the squat position.

3. Try to limit unnecessary throwing during practices or bullpen sessions. Let catchers roll balls back or drop them in a bucket- less throwing means less overall stress and likely better throws when they matter.

4. Have a regular rotation of catchers. While inning counts or throw counts like for pitchers do not exist, monitor catchers for signs of fatigue such as slower to come out of squat, weaker throws back to pitchers or to bases, and giving a lower target due to shoulder fatigue. Better even to plan ahead with catcher substitutions rather than waiting for more obvious signs of overload.

5. Select sensible alternate positions- first base is attractive as there is a limited throw demand which then allows some arm rest, and also takes advantage of the fact that most catchers are taller and used to providing good targets for balls coming at them.

6. Caution with the pitcher-catcher combination that results in too many throws and increases the risk of injury.

7. Limit seasonal or annual arm overuse. Catchers playing for more than one team or not taking at least 2-3 months a year off from throwing are at higher risk of shoulder or elbow injuries.


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": inward movement (valgus) and straighter 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?

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?

Three Causes to Consider with Chronic Knee Pain in Young Athletes

Pain in the front of the knee is a very common and often frustrating occurrence in children who participate in running, jumping/leaping and turning activities. When sensible treatment strategies such as rehabilitation exercises, ice, activity modification, and time just don't seem to be creating pain, consider the following three causes of chronic anterior knee pain.

1) Osteochondral Lesions

Articular cartilage is thin tissue that covers the ends of the thigh bone (femur), shin bone (tibia) and backside of the kneecap (patella). An osteochondral lesion is damage to that creates crescent-shaped fragments (look like "shark-bites") of bone and cartilage that is most extreme cases may separate from the bone of origin and float within the knee joint. Symptoms may mimic more common anterior knee pain, though locking, catching, and local swelling are more suggestive of osteochondral damage. 

Osteochondral lesions can be initially identified on plain x-rays, which must include the tunnel view which best visualizes the lower thigh bone.  Have seen cases where not obtaining the tunnel leads to missed opportunities to identify injury, such at the osteochondral lesion identified on the inside of the femur seen on the x-ray image above.  Magnetic Resonance Imaging (MRI) is often used to better characterize size and nature of lesions.

Management of osteochondral lesions depends on several factors:

  • Age of the patient: children with open growth plates tend to have better chance of non-surgical repair
  • Size of the lesion
  • Present of separation of fragment from bone of origin
  • Location: fragments on the inside of the femur tend to have the best outcomes, while fragments on the outside of the femur tend to have less optimistic outcomes and those on the back of the patella tend to have the most difficult outcomes.

2) Anterior Fat Pad Impingement

Image courtesy of

Image courtesy of

Located below the patella and behind the patellar tendon between the femur and tibia (see yellow shaded region in adjacent picture), an enlarged or irritated anterior fat pad can become trapped and cause pain especially with bending of the knee.  More commonly seen in adolescents, this is often best identified by direct finger-tip pressure placed on either side of the patellar tendon with the knee bent to about 90 degrees.

While identification of fat pad impingement can be a challenge, treatment is also fraught with unique potential challenges. Direct injection of anesthetic and anti-inflammatory medication can help both with diagnosis and pain relief, but often the initially promising results wear off within a few months. Surgical excision of the fat pad is a reasonable next option, but regrowth of the fat pad commonly can occur.

3) Placing Too Much Focus on the Knee

When the knee hurts, seems logical to put direct emphasis on correcting problems at that joint. However, failing to evaluate and respond to mechanical issues above and below the knee can slow progress and prolong pain and frustration.

  • Hip/Buttock: Inadequate strength of the buttock gluteal and hip external rotator muscles can lead to abnormal positions of the knee and place undue forces particularly on the patella. Proper attention to the hip and buttock is essential for long-term resolution of anterior knee pain.
  • Great Toe: Amazing to realize how much dysfunction can occur with limited motion of the metatarsophalangeal joint of the big toe. Restricted movement can also place unnecessary forces on the patella.

This article is not designed to provide any diagnosis or treatment recommendations. Seek qualified pediatric sports medicine speciality evaluation to help young athletes properly identify factors causing chronic anterior knee pain and provide potential solutions. 


Potential Signs of a Serious Knee Injury in Young Athletes

Suffering a knee injury can put a sudden damper on athletic activities and even influence the ability to get around the house and attend school. The following article does not attempt to make individual diagnoses, but rather to list some potential findings that suggest a more serious knee injury in a younger athlete.

  • Immediate and large swelling above the knee cap
    • Rapid onset of swelling within the first hour after an injury that is located about the kneecap is called a suprapatellar effusion and may be the result of significant damage within the knee joint.
    • Common injured structures that lead to a suprapatellar effusion include:
      • Torn ligaments (Anterior or Posterior Cruciate Ligaments)
      • Dislocated kneecap
      • Fracture of the lowest part of the thigh bone or the top part of the shin bone
      • Disruption of the cartilage that covers the end of the thigh bone or top of the shin bone
      • Torn meniscus (shock absorbing pad on inside or outside of joint between thigh bone and shin bone) may occasionally lead to a large swelling, but not as common as other injuries
    • Any large scale swelling of the knee accompanied by fever, chills, redness at the knee joint and/or obvious warmth to the touch may suggest an infected joint and is a medical emergency requiring immediate medical evaluation in an emergency room equipped with orthopedic specialist coverage.


  • Inability to fully straighten the injured knee
    • Lack of full knee extension may be caused by the following injuries:
      • Disruption of the knee extensor apparatus, which includes the quadriceps muscles in front of the thigh, the kneecap, and the patellar tendon which connects the kneecap to the shin bone.
      • A torn meniscus or ligament that is displaced and is trapped between the thigh bone and the shin bone
    • Trying to walk on a knee that lacks full extension may cause further and possibly permanent damage to the joint cartilage. Thus, any injured athlete who cannot fully straighten the knee should use crutches until having an appropriate medical evaluation and regaining the ability to fully straighten the knee


  • Open skin at the injury site
    • Disruption of the skin, even the smallest of cuts or abrasions, may represent an open fracture that requires immediate medical attention from an emergency room visit to prevent more serious infection and a complicated recovery course.


  • Big time pain, numbness, weakness, or tingling below the knee
    • Any pain that seems out of control, or any findings of numbness and tingling below the knee or weakness of the foot or ankle muscles could suggest more serious damage to the knee or the nerves and blood vessels around the knee and indicates the need for emergency medical evaluation.


  • The young athlete who tries to play on an injured knee but just isn't as fast, as aggressive, or as graceful and ends up limping during activity
    • There may not be swelling, lack of extension, fever/chills, open skin, or big-time pain, weakness or numbness and tingling, but still seeing young athlete limp and not play at the best due to knee injury are both signs of a potentially more serious knee injury. 
    • Removing the athlete from play and seeking pediatric sports medicine specialist evaluation is highly recommended before allowing a return to play.

In any case of a suspected serious knee injury in young athletes, removal from play, placing on crutches, and seeking appropriate medical attention are all sensible initial steps for parents and families. Obtaining an accurate diagnosis and comprehensive treatment plan in an efficient manner is paramount for optimal long-term function and healing.  If any doubts after a knee injury to a young athlete, do not hesitate to contact your sports medicine specialist provider or head to the emergency room if necessary.