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


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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.


USA Volleyball Sports Medicine Experts Present at CHOC Children's Sports Cardiology Conference

The 2017 CHOC Children's Sports Cardiology Conference asks the question "What is the Role of the Cardiologist in the Sports Medicine Team?"

Our USA Volleyball Sports Medicine Team will be there to share our experience and provide our expert answers.

Several years ago, expert pediatric cardiologist Paul Grossfeld offered his services to USA Volleyball.

The results have been eye-opening and intriguing.

Focused elite athlete screening evaluations have not just provided insights for our players, but for all volleyball athletes and even other taller athletes participating in high level sport.

The process has not been without challenges.

Informing athletes of higher risk conditions  and making decisions about career status and potential termination is never easy.

However, thanks to our on-going study, we have been able to contribute necessary data and experience to the conversation about screening and risk stratification in elite, taller athletes.

Our team looks forward to sharing this knowledge and extending our collaboration with important colleagues.

Pointing Out the Top 10 Pediatric Sports Musculoskeletal Injuries

The Top 10 Sports Musculoskeletal Sports Injury list is a ranking that I'm guessing most athletes don't want to make, and most parents don't want to miss.

How to best know if you belong on this list?

Trust your finger tips.

Speaking at the 2016 American Academy of Pediatrics National Convention and Exhibition, I was asked along with good friend and colleague Hank Chambers to share insight on identifying and managing the Top 10 Pediatric Sports Musculoskeletal Injuries with a Case-Based Review.

Our Top 10 aptly started at the top of the body (neck) and ran down to the bottom (foot/ankle) with several injuries in between.

We looked at:

Some were fairly serious and activity threatening, others were more of a nuisance.

A pretty diverse offering of injuries, so one would tend to think that there would be little that actually brings them together.

However, for those listening to the talk, they heard us mention a similar refrain over and over again.

The value of your finger tip.

In helping to determine a type of pain that merits medical attention in the first place, and helps sort out the particular diagnosis, the more localized the pain, the greater the potential concern.

For example,. if a child is reporting pain in the lower leg and uses a wave of the hand to indicate that the discomfort runs along the entire inner shin, then there is one level of concern.

However, if that same child takes the tip of their index finger and points directly and emphatically to a single spot on the inside of the shin bone, my concern is amped up several degrees.

While none of us have x-ray vision, that finding of finger-tip pain is a pretty good surrogate and does tend to correlate with a higher potential of a bone injury, be it a fracture, stress injury, or damage to a apophysis where a tendon attaches to a bone growth region.

So, no matter the body part, from elbow to wrist to foot or ankle, if any young athlete opts to use a finger tip to identify their pain, then use your finger tips to dial up your sports medicine specialist and seek out immediate and appropriate evaluation.



Dr. Koutures Publishes on Dancers and Concussion in Journal of Physical Education, Recreation and Dance


Dancers are “artistic athletes.” They must possess the strength, agility, power and flexibility of any athlete and perform with perfect musicality and emotion, demonstrating the artistry of the dance. As an art form dance continues to push the physical boundaries of the human body, increasing the inherent risks to the dancers. Most injuries are readily acknowledged as a possible outcome of being a performing artist; however, the possibility of a concussion continues to receive little attention by leaders involved in dance education. The majority of dance and physical education instructors continue to be oblivious to the prevalence, diagnostic procedures, symptoms and appropriate reintegration into the dance environment after a concussion. Adapting the existing knowledge regarding concussion and sports, this article provides fundamental information to support the recovery and return to performance of a dancer with a concussion.

Click here to read the remainder of this important article to learn about:

  • Evaluation of concussion symptoms and severity
  • Treatment protocols for dancers
  • Dancer reintegration after concussion

Should Soccer Goalkeepers Wear Helmets?

Received an email from a colleague asking my opinion on her 9 year-old son wearing a helmet when playing goalkeeper in soccer.

When it comes to soccer helmets and preventing concussions, my usual response is that there is inadequate science to support risk reduction. I am also concerned that some players wearing a helmet may be over aggressive, or that opponents may target a player wearing a helmet.

However, these thoughts are mostly for field players.

When it comes to goalkeepers, there are some similar and yet different thoughts.

Decent evidence that soft helmet use could reduce lacerations, bruising, and potentially skull fractures that may result from the diving actions or contact with the goalposts.

However, we do not have sufficient evidence documenting helmet use can lead to less rotational injury to the brain after close-range impact.

Would still be cautious about goalkeepers feeling a false sense of over-confidence using helmets and then putting their heads in risky positions.

Helmet or not, would strongly recommend the following head injury risk reduction techniques for goalkeepers:

  • Do recommend going feet first rather than head first into a challenged ground ball situation.
  • Raising elbows and knees to protect the head when in challenge situations can also be protective, as long as not done with intent to harm another player.
  • Keeping the hands up near the face while in the ready position to anticipate a shot allows quicker reaction of hands protecting the head.
  • 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 chance of feet being taken out from below leading to uncontrolled head impact with the ground.
  • 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.

If selecting a helmet, I do recommend finding one that doesn't adversely affect peripheral vision and also one that properly fits and continues to fit with use. A recent study indicated that improper football helmet fit may lead to more complicated concussion outcomes. Changes in liner, sweat pattern, and  hairstyle among other things were found to affect helmet fit. While study was done in football, do think it would apply to helmet use of all types.

Click here for more injury prevention tips for soccer goalkeepers



Teens: 7 Essential Tips to get 8-9 Hours of Sleep and Decrease Injury Risk

Not quite able to get that elusive 8-9 hours of sleep per night?

Figure there will be catch up on the weekend, or once summer starts, or after the upcoming tournament ends?

Maybe you just don't think that sleep is that important in general safety, training and competition?

Well, if your goal is to optimize overall performance while limiting risk of injury, then wake up and take notice of the following studies on the importance of sleep:

  • Colleagues from Children's Hospital of Los Angeles found that adolescent athletes who slept more than 8 hours a night were 68% less apt to be injured than peers who did not get that much sleep per night. Athletes who reached higher grade levels in school actually had higher injury risks, so the additional sleep recommendations are even more important for older adolescents versus younger adolescents.


  • The USA Centers for Disease Control reports that teenagers who got 7 or fewer hours of sleep a night had a higher prevalence of risky behaviors such as not wearing bike helmets or seatbelts, driving a car after drinking or riding in a car with a driver who had been drinking, or texting while driving when compared with teenagers who got 9 hours of sleep a night.
  • Check out the wonderful infographic below from that compares a well rested athlete with a tired counterpart in a visual description of how poor sleep directly leads to poor performance. The graphic also illustrates the sleep habits of several well-known athletes and gives sensible tips on how to increase the quantity and quality of your sleep.


  • For those who must deal with frequent long-distance travel and the demise of regular sleep habits, there's an App for that. Researchers at the University of Michigan utilize smartphones to monitor circadian clocks and make recommendations on lighting and other tips to more rapidly adjust to new time zones with travel.

Now, even when young athletes try to get this adequate amount of sleep, It is very common to have struggles with falling asleep, especially in the junior high or early high school years. If this scenario sounds familiar, start with the following recommendations:

  1. Use bedrooms only for sleeping and changing clothes

  2. Eliminate or reduce electronic exposure (TV, DVD, smartphones, computers, etc) in the bedroom

  3. If must have electronic devices in bedroom, set to silent mode and turn upside down so screen is not visible
  4. Try to go to sleep within 1/2 hour of the same bedtime every night, even on weekends and other days without school

  5. Stop all electronic exposures at least one hour before bedtime

  6.  Limit caffeine use at or after dinner time

  7.  If having trouble falling asleep, turn your clock/timer around so you can't see the time

Many teenagers report awaking frequently during the night, or even more perplexing, getting the recommended 8+ hours a night, but still awakening tired or feeling fatigued during the day. In in these cases, highly recommend scheduling a medical evaluation to review sleep habits and hygiene, with focus on possible tonsil/adenoid enlargement, overtraining, uncontrolled asthma or allergies, depression/mood disorders and other illnesses that might contribute to interrupted sleep or poor sleep quality.

Dr. Koutures Writes on ConcussionConnection about Ivy League Eliminating In-Season Full Tackling

Six Common Indoor Volleyball Injuries

Working with Olympic level male and female volleyball players has allowed a unique appreciation for common injuries patterns seen in this wonderful yet demanding sport. Since there are six players on the court, I will identify six  frequently seen injuries and will also focus on key prevention tips for players at all ages.


1) Concussions

Most of the concussions I encounter are seen in liberos or defensive specialists, usually from direct impact either from attempted passes of hits at the net or collisions with other players or objects (poles, chairs on courtside) when diving for a ball. I have also seen a fair amount of concussions resulting from mis-matches on the court, namely defensive players trying to return serves or hits from much stronger and older players.

Any new sign of concern (such as dizziness, headache, blurred vision) or behavior change after head trauma should mandate removing the player from all activity and not returning until appropriate clearance from a sports medicine specialist who is familiar with concussion care. 

For more information about dealing with sports-related concussions, click here.

Prevention tips for the volleyball player include calling  for balls before starting a dive, ensuring defensive players are aware of incoming balls during hitting/serving drills, limiting older and stronger players from hitting into younger players, and protecting the boundaries of the court to limit impact with chairs or other objects.

2) Shoulder injuries

Between serving, setting, passing, hitting, blocking and diving, the shoulders receive an amazing array of demands, so it should be no surprise that shoulder injuries are among the most common volleyball-related concerns.

Most shoulder injuries are due to repetitive use and overload stress  leading to common abnormalities. Tightness in the front of the chest leading to a more forward position of the dominant shoulder can reduce normal function of the rotator cuff muscles, leading to pain and decreased hitting and serving accuracy and speed.  Tightness in the back of the shoulder glenohumeral joint can decrease the follow-through phase of hitting or serving and lead to problems with the labrum (soft tissue past between the ball and socket), the inside of the elbow, and even the lower back.

Appropriate stretching exercises combined with strengthening exercises of the scapula (wingbone) can reduce the risk of shoulder overuse injuries. Avoid hitting and serving with signs of fatigue (balls tend to go long with reduced speed) or any form of shoulder pain. Reducing the overall number of hits/serves can help, but more formal hit or serve count recommendations have not been studied at this time.

3) Finger/Hand Injuries

Tend to see finger joint sprains and dislocations mostly with blocking at the net. Rigid wrists with widespread  and relaxed fingers not only allow better ball placement down in the opponents court, but also reduce the chance for acute injuries.

The widespread finger position does place unique stress on the skin web spaces between the fingers that can lead to lacerations or breaks in the skin that are extremely difficult to heal, even with the placement of sutures. Better to prevent these lacerations in the first place by moisturizing the skin between the fingers on a daily basis. 

4) Low Back Pain

Volleyball-related back pain can come either from leaning forward such as with passing or following through on a serve/hit or more with leaning back such as in setting or initiating a serve or hit. Pain that is more with leaning forward could cause issues with the discs between the bones of the lower spine, while pain leaning back could lead to stress injuries of the posterior spine or joints.

It is amazing how much shoulder dysfunction (discussed above) can lead to back problems in volleyball players. If you haven't already, take the time to review post linking shoulder issues to back problems.

Learning how to initiate movements with the gluteal muscles in the buttock area can reduce stress on the lower back, especially with jumping. Single leg gluteal strengthening activities are particularly recommended. Certain technical errors, such as reaching too far for passing or hitting, can also increased forces on the lower back. Setters should attempt to make contact with balls right above their head- reaching too far forward for front sets or backwards on back sets is not the best for long-term back health.

5) Knee Pain

If you are a volleyball player who doesn't have knee pain, then either you are extremely fortunate or perhaps in a bit of denial. 

The repetitive jumping in volleyball often leads to pain in the front of the knee, especially in the patellar tendon connecting the kneecap to the shin bone. Throw in frequent knee contact with the hard wood court surface and you have a recipe for knee problems.

For healthier volleyball knees, pay attention to the following recommendations:

  • Avoid landing on straight knees. Always land and move "softly" with hips, knees and ankles in a bent position.

  • Try to land in good alignment, with the hips and kneecaps lined up with the second toe. Don't let your knees collapse in or rotate.

  • Initiate jumps with the gluteal muscles in the buttock region. This will improve knee and also lower back function.

  • The best time to stretch the muscles that support knee function is after practice or after a match when the muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors and calf muscles.

  • Knee pads help reduce bruises and pounding, especially with repetitive diving drills. 

6) Ankle Sprains

Ankle sprains are the most common acute injury in indoor volleyball, and very few things spark intense debate in the volleyball community more than the question about using ankle braces to prevent these type of injuries. 

The majority of ankle sprains are when the ankle inverts (rolls in) and this most often occurs with play at the net where athletes make contact with another players foot when landing from a jump during hitting or blocking. More chaotic play such as with bad passes or plays out of system can also put ankles at risk.

The theory behind bracing is to reduce abnormal ankle motion, but some fear that depending on bracing might make lower leg supporting muscles weaker and maybe even increase the risk of knee injuries.

Click here to review the debate on ankle braces.

Once an ankle sprain has happened, little doubt that the combination of bracing and appropriate rehabilitation exercises can reduce the risk of future injuries.

Never hesitate to seek the opinion of a sports medicine specialist with any volleyball injury or to learn additional tips to prevent these problems.


Caring for Concussions: Orange Lutheran High School and Dr. Koutures

In the end, it all comes down to relationships.

“As the years have gone by, I’ve learned to appreciate the ability of the athletic trainers to have a relationship with each player,” said Dr. Chris Koutures.

Proud of being one part of the dedicated sports medicine team at Orange Lutheran High School that serves as a model for collaboration and communication.

Back Pain with Volleyball Serving or Hitting? Look at Shoulder Function for Possible Cause

Whether you are a junior level or even an Olympic caliber volleyball player dealing with back pain during serving or hitting, chances are that shoulder mechanics are part of the problem.

Starting the serving or hitting motion requires both extension (leaning backward) and rotating or turning of the lower back in the direction of ball contact. For a right handed hitter or server, that would mean having the trunk and lower back rotate toward the right.

Dave Smith (#20) in early hitting phase shoulder position

Dave Smith (#20) in early hitting phase shoulder position

Finishing a serve or hit requires rotation of the lower back away from the side of ball contact. Again, for that right handed hitter or server, that would mean having the trunk and lower back rotate towards the left after ball contact. 

Kim Hill (#15) with late hitting phase shoulder position

Kim Hill (#15) with late hitting phase shoulder position


This normal flow of movement puts localized stressors on the lumbar vertebrae bones that surround and protect the spinal cord in the lower back region between the rib cage and the pelvic bones.

Certain parts of these lumbar vertebrae, called the posterior elements which include the pars interarticularis,  pedicles, and articular process/facet joints that are at unique risk for overload injuries due to repetitive compression forces and somewhat limited blood supplies to these regions. 

Courtesy of

Courtesy of

In medical terms, we would call pain coming from these movements extension or rotational-based lower back pain, and it thus would seem very logical then to focus evaluation and treatment on the lumbar spine mechanics themselves.

However, my experience in working with higher level volleyball players has taught me that often the dominant shoulder can be a primary contributing culprit to this extension or rotational-based back problem, so now when I evaluate any such type of back pain in a volleyball player, I start by looking at the shoulder.

There are commonly two types of shoulder tightness patterns that can lead to both shoulder problems and pain at the lumber spine.


The pectoralis minor, coracobrachialis and biceps short head muscles all attach to the coracoid process, which is a bone prominent coming off of the scapula.

Courtesy of

Courtesy of


Tightness at this attachment site can create a hunched over posture that moms always like to warn about, but also can limit the ability to raise and reach back the shoulder which provides the power needed to hit a ball at the high end of a set or the toss before serve. 

If a player has limited flexibility in the front of the shoulder at the coracoid, one frequent way to compensate (or some would say, cheat) is to over-rotate at the lumbar spine in an effort to get the hitting hand far back enough to generate powerful hits or serves.

This over-rotation, while at first might allow the player to maintain high performance, may ultimately cause higher cumulative overload forces on those posterior elements of the lumbar vertebrae and those undesired stress injuries.

This condition causes pain EARLY (before ball contact) in the hitting or serving motions, and  proper identification and correction of tightness at the coracoid process can lead to healthier shoulder and back function.


The glenohumeral joint is the "ball and socket" joint that is surrounded by a soft tissue joint capsule.

Courtesy of

Courtesy of

Repetitive overhead motion such as hitting or serving can lead to tightness in the back of this capsule, leading to limitations in shoulder internal rotation or the follow-through phase after ball contact.

Called Glenohumeral Internal Rotation Deficit (GIRD), this tightness can lead to reduced accuracy and speed of hits/serves.

Many volleyball players will compensate (aka cheat) by increasing rotation of the lumber spine away from the side of ball after making contact, and eventually this too will place unwanted forces on those posterior elements of the lumbar vertebrae.

GIRD causes pain LATER (after ball contact) in the hitting or serving motions, and just like with anterior shoulder tightness, proper identification and correction can reduce both shoulder and back issues while allowing more high level function.


Volleyball players do not have to wait for the onset of back or shoulder pain to address potential problems. Fairly quick measurements of both anterior and posterior shoulder motion patterns can lead to suggestions for stretching programs, and I routinely incorporate these into pre-season or pre-participation evaluations as part of sensible injury prevention programs.

Athletes: Beware of "Spider Bites"

On a fairly frequent basis, I will see an athlete who says “I think I have a spider bite” and greets me with something like this raised “angry” appearing area with a raised central yellow component surrounded by a red, tense outer rim.

Image from:

Image from:

Immediately, I’m thinking of something far different than a spider bite.

In the athletic or performing arts worlds, when something looks like a spider bite, a first thought should actually be a potentially devestating infection known as Methicillin-Resistant Staph Aureus or MRSA for short.

Not trying to minimize being afraid of spiders and the potentially harmful impact of their bites, but overall, MRSA infections have become much, much more common and just as frightening.

We all have bacteria that grow on our skin, and most of them are fairly decent organisms that do little to interrupt daily activities.

However, certain bacteria that live on the skin surface are more ruthless and overtime have gained an ability to cause deeper infections by developing resistance to many antibiotics and thus not always responding to usual medical treatments.

MRSA infections are just those type of worrisome beasts.

And yes, they look “just like spider bites.”

Often starting with something as simple as a small scratch or other break in the skin, if left unchecked, MRSA infections can explode into limb-threatening and even life-threatening conditions that can be readily spread to other teammates and opponents.

Caught early in the course, ultimately less chance for more complicated outcomes.

Contact and collision activities (such as wrestling or football) tend to have higher outbreak rates, but any exposed skin can be at risk.

Some individuals or even families, for reasons not fully understood, are at risk for recurrent MRSA infections.

There is no doubt, however, that prevention is key:

  • Frequent self skin checks looking for open wounds, raised “angry”  areas, or other abnormal skin conditions that should receive immediate medical attention
  • Removal of any individual with skin problems (especially “spider bites”) from group activities and not allowing return until appropriate medical treatment and clearance
  • Wearing of protective devices such as gloves and eye/mouth shields when examiningor treating potential or known MRSA infection
  • Removing exercise gear and clothing right after exercise followed by an immediate shower
  • Daily washing of exercise clothing in hot water and/or using a new, clean set of clothing for each practice or game
  • Studies have shown that sharing of items can increase spreading MRSA or other skin infections
    • Require individual towels, washclothes, hairbrushes, nail clippers, soaps, deoderants and other personal grooming products without sharing any of the above items
    • Concern over possible spread from weight room, athletic training room, or activity related playing surfaces, equipment, tables and/ or benches emphasizes the importance of individualized towels and frequent cleaning with appropriate anti-bacterial products

When I see suspicious wound, if at all possible, I try to open it up to release that yellow “pus” material.

Called “incision and drainage”, this otherwise gross procedure actually serves two very important purposes:

  • The mere act of opening the wound and allowing drainage can get rid of the infection
  • The drained fluid can be sent for lab culture to truly identify the offending bacteria and what best choice of antibiotic(s) may be used if needed in treatment

We think that relative overuse of antibiotics in the past helped create these more resistant bacteria, so in certain cases, depending the drainage alone (without antibiotic use) is a sensible treatment option.

In other cases, such as deeper infections (into muscles, joints, or bones) or where drainage is either unable to be done or appears to be ineffective, antibiotics may be prescribed.

If antibiotics are used, sometimes combinations are selected due to culture/sensitivity patterns and also past trends in the local community.

Oral antibiotics are generally first-line for more skin-surface infections, while deeper or more complicated infections might require hospitalization for intra-venous antibiotics or more aggressive surgical care.

Once treatment for MRSA infection has been started, the following minimal conditions must be met before return to any type of activities with contact or collision with others

  • Any drainage must have ended for at least 24-48 hours
  • No new outbreaks or areas of infection
  • If antibiotics started, must have minimum of 72 hour coverage
  • Infected area must be able to be covered with appropriate “occlusive”dressings that reduce risk of spread

When ANY suspicion of MRSA infection is raised, immediate medical attention is absolutely essential.

So, be appropriately afraid of those "spider bites".....

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?






3 Whole Food Recommendations for Young Athletes

When making sports nutrition recommendations, I tend to favor the collateral benefits, lower costs, and the "knowing what you are getting", of whole food sources rather than individual vitamin or nutrient preparations. 

I was energized to  share the podium at the 2015 CHOC Children's RD's in Practice: Pediatric Sports Nutrition Conference with some truly amazing colleagues, and in reviewing their handouts, I found some new whole food thoughts that I felt needed to be shared.

I want to give full credit to both Shondra and Jessica Brown of CHOC Children's Sports Nutrition Program for organizing the conference, and to Becci Twombley, RD, CSSD who presented on the following important food sources for young athletes:

  • Importance of Whey Protein and Leucine
    • Whey protein is a quickly digested protein which can lead to more immediate muscle recovery
    • Whey protein is also high in the amino acid leucine, which can be decreased 30% after high intensity exercise
    • Good sources of whey protein (and thus leucine) include Greek Yogurt, eggs, steak and milk.
      • Yet another nod for Chocolate Milk as a post-exercise recovery beverage- not only do you get the whey protein and leucine, but the associated carbohydrates enhance the protein absorption and don't forget the calcium and Vitamin D!
  • Make a Beeline for Beets
    • High in betalines and beta-carotenes which include anti-oxidant and anti-inflammatory properties for boosting immunity 
    • Beets also have a high content of nitrates which increase nutrient delivery through augmented blood flow to working muscle, allowing for more efficient exercise
    • Best to eat either beet juice shots or 3-5 raw or juiced beets 2 1/2 hours before training (prolonged cooking of beets kill the betalines)
  • Probiotics for health of your digestive tract
    • Probiotics are live micro-organisms in the digestive tract that support absorption of nutrients and enhance immune function
    • Use of probiotics can reduce both the number of days and overall severity of respiratory illnesses
    • A solid probiotic source is none other than Greek yogurt....1/2 to 1 cup either daily or every other day will also give you that whey/leucine fix mentioned above and further stress the importance of whole food nutrition sources!



Dr. Koutures Thoughts on US Soccer Youth Heading Recommendations via MomsTEAM

On November 9, 2015, as part of a concussion-based lawsuit settlement agreement, the United States Soccer Federation (USSF) announced a series of recommendations directed at identification, management, and prevention of concussions in youth soccer.

In regards to youth players heading a soccer ball, the following recommendations were released:

  • Under age 11(U11) and younger
    •  U.S. Soccer recommends that players in U11 programs and younger shall not engage in heading, either in practices or in games
  • U12 and U13
    • U.S. Soccer further recommends for players in U12 and U13 programs, that heading training be limited to a maximum of 30 minutes per week with no more that 15-20 headers per player, per week.
  • All coaches should be instructed to teach and emphasize the importance of proper techniques for heading the ball.

As one of the co-authors of the 2010 American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness Policy Statements on Injuries in Youth Soccer, I responded to questions posed by Lindsey Barton Straus, JD of MomsTEAM  about certain aspects of these heading recommendations. Please click on the above link to read her entire article and my embedded comments which represent my opinions and may not be interpreted as official AAP policy.

Be on the lookout for a follow-up article from MomsTEAM that reviews return to play decision-making components of the settlement agreement 

Top Nutrition Concerns Seen in Adolescent Sports Medicine

Trying to figure if your young athlete needs iron to boost performance?

Uncertain if water or sports drinks would be be the best choice for the next practice or game?

Looking for healthy post-game snacks that will assist in muscle recovery?

Hearing a lot about protein and creatine supplements but not sure if adolescent athletes should use them?

You've come to the right place for practical answers to these and many other nutrition questions that I regularly hear in my sports medicine practice.

In appreciation of CHOC Children's Hospital inviting me to speak on Top Sports Nutrition Concerns Seen in Adolescent Sports Medicine first at their RDs in Practice – Pediatric Sports Nutrition conference and following up with a Pediatric Grand Rounds on the same subject,  figured I would compile a list of past blog posts that will form the backbone of those presentations.

Click on the above links to view the relevant post.

Eager to hear of any additional nutrition or other sports medicine based questions- will offer initial responses via email but always available for office consultations and more in-depth recommendations

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?

15-20 Minute Blocks of Activity: A Guideline for Post-Concussion Recovery

In the midst of the usual complexities of recovering from a sports-related concussion, I have found that one simple mantra of "re-start activity in 15-20 minutes blocks" can be an anxiety reducing guideline..

Looking to return to homework or other school-based activities?

Start with 15-20 minute blocks.

How much can I spend on my phone?

Start with 15-20 minute blocks.

As we discover that absolute rest and removal from usual duties might be counter-productive to recovery, the counter-concern over returning with too much activity, too quickly, or too soon is valid. 

Enter the 15-20 minute block recommendation.

When to start?

Usually within a few days after a concussion, and I will counsel patients that at a "good part" of the day where headaches or other symptoms are at a lower point, they should select one activity to start in a quiet room without other stimulation (loud music, bright outdoor light, texts on phone, etc). 

While most young people would immediately select their phone, the usual first choice is light reading from a book or magazine rather than a computer screen. 

Set a timer for 15-20 minutes, and once that period passes, stop all activity and take a break.

If successful, try another 15-20 minute block of similar activity again later in the day, and if that goes well, can increase to 20-30 minute blocks the next day.

Don't advise going past the "max" time recommendation. Better to finish "early" without symptoms than to muscle forward, develop a headache, and suffer a setback.

For those trying to decide when to return to school, have found that being able to complete 20-30 minute blocks of work 2-3 times a day is a minimum criteria for considering a partial (likely half-day) return to the classroom.

Once able to do at least 2 blocks of activity per day, can add a block of more "fun" which might include cell phone use, texting, appropriate surfing of internet, music, or even some relatively light video game play.

If unable to get through that initial 15-20 minute block of time due to headache or other symptoms showing up, don't despair.

Take the rest of that day off, and try the next day, again maximizing chances with success by ensuring a quiet distraction-free environment, good food and fluid intake, and hopefully after some restorative sleep.

If a few days of attempting the 15-20 minute activity blocks lead to more failure, then do not hesitate to contact your medical provider for more specific tips and further recommendations.