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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Dealing with Detours- Lessons Learned as a Sports Medicine Physician

I have become more comfortable dealing with detours

Detours are going to happen.

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

Then reality kicks in, and the detours begin.

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

My focus was on Dealing with Detours.

Let’s be real.

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

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

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

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

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

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

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

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

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

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

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

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

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

This takes building a relationship.

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

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

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

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

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

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

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

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

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

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

Some don't  miss their sport.

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

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

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

 Allow exit strategies.

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

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

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

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

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

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

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

Even if it's the Olympics. 

Develop rapport before dropping bombs

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

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

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

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























Boarding, Biking and Skiing- Tips to Reduce Injury Risk

Skateboarding, BMX biking, snowboarding, skiing, and mountain biking are all sports practiced by dedicated athletes who put time and attention into bettering their tricks, handling, and overall skill. These athletes deserve credit for their abilities- and also should follow some basic recommendations to prevent injury and spending unwanted time away from the skate park or trails.

Do helmets actually prevent injury? How can I tell that a helmet is properly fitted?

Personal experience backed by multiple studies proves that helmets do prevent injury. For example, helmeted cyclists are 88% less likely to suffer a brain injury during a crash.

Every time some one gets on a vehicle with wheels (skateboard, scooter, rollerblades, and bicycle) or a snowboard, there should be a helmet on the head. A helmet hanging off the handlebars or kept in the garage is doing absolutely no good. 

Helmets may not look cool, but a shaved head and scars from an accident look less cool.

Now, to be fully accurate, there are some limitations to helmets.

No helmet is 100% protective- they are designed more to reduce skull fractures than concussions.

Wearing a helmet does not give license to be more daring- make sure you read this a few times for emphasis.

A improperly fit helmet can reduce vision (which may increase, not decrease injury risk).

So, wear those helmets, understand limitations, and make sure they fit!

                                                    PROPER HELMET FITTING TIPS 

  • The helmet should sit level, covering the forehead in front with the strap adjusters fitting right under the ears and straps lying flat against the head; not hanging loose, curling out, or being twisted.
  • Test for proper tightness by being able to put only one finger between the straps and chin and if helmet can be rocked from side to side, tighten straps.
  • The helmet should rock slightly forward and backward, but tighten straps if it can be moved up off the forehead or down near the eyebrows.
  • Add-on stickers and paint can personalize the helmet, but often void helmet warranties. Buy only helmets with CPSC, ASTM, or Snell stickers certifying safety standards.
  • Multi-sport helmets should carry stickers certifying each sport- look for this sticker on the helmet, do not trust sales information or pictures on the box.

What is the scoop on wrist guards, elbow pads, knee pads and other protective pads and guards?

Many younger athletes do not like to wear pads, "they get in the way, get too hot, and they are not very attractive."

They do work, and work quite well in preventing broken bones, sprains, and road rash from falls or missed stunts. Experience has shown that wrist guards can greatly reduce the risk of forearm fractures due to falls from skateboards or snowboards.

Most people would prefer wearing protective pads and guards to wearing a plaster cast for 4-8 weeks.

A final statement: always know where you are going and be honest with your limits

  • A common recipe for disaster is to barrel down an unknown trail unaware of obstacles or drop-offs that lie ahead. Taking the time to preview the course or to ride the pipe a few times at slow speed before trying tricks at full throttle can increase confidence and lower the risk of an unanticipated fall.
  • Be aware of obstacles (rocks, trees, stairs, cars, and people) who might get in your away- always look forward 20-30 yards to anticipate any potential danger and to give time to make adjustments before an accidental impact.
  • Be aware of your own skills- your strengths and weaknesses- and take into account your limits before deciding to do a particular course or maneuver. Do not be pressured by friends or your ego, if you do not feel comfortable riding the black diamond snowboarding run, do not do it. Have fun and build your skills at a run better suited for your abilities.
  • Fatigue is also a major factor in injuries- many people decide to go out for one more run at the end of a long day, and that run ends up truly becoming the last one. Most authorities recommend stopping at the first signs of fatigue before judgment, endurance, and muscle strength become too low to prevent falls and serious injuries.

Wrestling: How to Keep Ideal Weight and Skin Health for Best Performance

How can I determine an appropriate wrestling weight?  Is it OK to cut weight, and if so, how much is too much?

While there are often no easy answers or simple formulas to determine an appropriate wrestling weight, some standards can help the decision-making process:

  • One can use a growth curve, which plots height and weight in comparison to age-matched individuals and also to past individual measures of height and weight. Can help determine if a desired weight "falls out" of the expected growth trajectory.
  • The body mass index (BMI), which measures weight in regards to height, may help determine an appropriate body weight for a particular individual at a given age. Be aware that more muscular individuals may have an artificially high BMI, so this might not be the most accurate measurement in certain athletic individuals
  • Another measure of body proportion called body fat percentage can help determine an appropriate wrestling weight though it historically has been used more to assess if an individual has cut too much weight. There are several methods for this measurement (calipers, bioelectric impedance, and water immersion) and a physician can help decide the most beneficial measurement, if needed, for a particular athlete.  The California Interscholastic Federation now requires bioelectric impedance monitoring to determine appropriate pre-season weight class selections for high school wrestlers.


Once a wrestler is in season, authorities do not advocate more than a 2-3 pound drop in body weight when cutting weight for a match or meet. Good evidence tells us that a reduction greater than 2-3 pounds brings about dehydration and depletion of body energy sources that place the individual at greater risk for fatigue and injury. Many wrestlers know too well that after cutting a large amount of weight, they were not able to wrestle as effectively and many also report difficulties with concentration and schoolwork. This is particularly important in younger athletes who are going through key phases in physical growth and development.  

When attempting to cut weight, use caution with any weight loss medication. Serious health issues can develop due to the use of these items, especially in growing athletes. If in doubt, consult with a sports medicine physician.

Frequent weight cycling (losing and gaining weight) can affect the immune system and make the athlete more at risk for respiratory illnesses and infections. This can be a major problem at the end of the winter season when many major meets take place.

How can we reduce common wrestling skin infections?

Due to close contact with mats and other athletes, wrestlers frequently contract skin diseases such as ring worm (aka tinea gladitorum), herpes, impetigo, and other infections. Not only are these a concern to the individual athlete, but they can easily spread to team members and opponents, thus officials routinely check the skin before large meets. To help prevent the disappointment of disqualification, the following recommendations may help:  

  • Wrestling mats should be cleansed with appropriate cleansing solution both before and after meets and practices.
  • Wrestlers should shower after meets or competition and use a good anti-bacterial soap.
  • Wrestlers should not share any personal care or grooming items (brushes, towels, razors, soaps, etc).
  • In the ideal world, the athlete should shower before leaving the gym or school and have wrestling clothing cleansed on a daily basis.
  • Coaches and parents should do frequent skin checks, and athletes should feel comfortable reporting any skin issues.
  • Any athlete with skin concerns should be immediately removed from participation and evaluated by qualified medical personnel. This is particularly important early in the season to prevent spread to the entire team and a resultant season-long struggle with skin issues. Once appropriate treatment has begun, cover any areas of skin concern when returning to participation by using tape or a bandage which can do the trick in most cases.

What other wrestling safety tips do you have?

Good neck strengthening and stretching exercises can help prevent spine injuries, ask a sports medicine speciaist for good recommendations. Shoulder strengthening is also important for many of the holds and techniques used on the mat. Mouth guards are essential to reduce dental/mouth trauma so demand that wrestlers wear mouth protection for all practices and meets.


How Much Rest Right After a Concussion?

A 16 year-old running back suffers a direct blow to the head in a Friday night game. He immediately has a headache and dizziness and is removed from the game. He is sent home in the care of his parents after a discussion of particular signs and symptoms that would require emergency evaluation, and follow-up on Monday has been arranged with the his pediatrician.

In the meantime, what should he be able to do over the weekend?

Traditional post-concussion recommendations have focused on strict limitations in both cognitive and physical activity until resolution of concussion-related symptoms. The “cocoon treatment” where absolute avoidance of all stimulation, often carried out in a dark bedroom for several days, was one such initial recommendation.

More recent data suggests that over-aggressive reduction of cognitive and physical stimulation may actually prolong post-concussion recovery. Thomas et al in Pediatrics  found that a strict 5 days of rest resulted in more daily reported symptom scores and slower symptom resolution versus 1-2 days of rest followed by stepwise return to activity. Zemek et al presented a paper at the 2016 Pediatric Academic Societies Meeting reporting that exercise within seven days of injury was associated with nearly half the rate of persistent post-concussive symptoms, or those that last beyond a month.

Striking a balance between overstimulation and understimulation is best done on an individual basis taking into account symptoms and patient preference. Allowing brief (initially 10-15 minute) intervals of activity such as light reading, listening to music, easy walking,  or even texting can reduce feelings of isolation and foster recovery. Patients should focus on one activity at a time (no “multitasking”) and should immediately stop activities that result in worsening of symptoms. Regular medical follow-up evaluation can help determine further at-home activity recommendations and also guide return to learn and ultimate return to sport progression.

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.

Three Key Questions that can Reduce Overuse Injuries in Young Dancers


1.  Am I going through a growth spurt?

Bottom Line: Longer arms and legs are harder to control without appropriate strength in the shoulder and hip areas. While many pre-teen and teenage dancers want to amp up dance commitments,  growth periods are not the best time for adding more technically demanding routines. Stick to basic movements, build central strength, and once in better control, then more ready to step up the skill requirements.

2. Am I still getting over a past injury?

Bottom Line: Trying to push through a past injury that hasn't fully healed is a recipe for future trouble. Better to take a step back, get proper medical care, and when more healthy, then push ahead with more classes and more intense routines.

3. How old am I?

Bottom Line: Absolutely the best evidence out there to reduce overuse injuries, and very easy to remember. If your age in years is lower than the number of hours of organized dance activities per week, your injury risk goes up in dramatic fashion. 

From a Pediatric Sports Medicine Expert- Eight Proven Ways to Reduce Youth Sport Injuries

Question: As a pediatric sports medicine specialist, when do you usually see injuries in sports?

1) When not wearing appropriate protective equipment.

Bike helmets do no good when they are strapped to the handlebars, just like shin guards can not work if they are left in the gym bag. Make sure the equipment is in good condition, fits well (especially with growing children), and is always properly used.

2) Within a month of a new season or activity

Good studies on Marine recruits show that foot stress fractures are most commonly seen three weeks into boot camp. My experience with young athletes is quite similar as about three weeks into a new sport, I will start to see overuse injuries. The body is unable to handle the stress of a new activity, and breakdown occurs. How can this be minimized? Have the athlete prepare for the new activity with some light conditioning. Going straight from X-box football to double days on the field can be a recipe for disaster. Also, start slow and increase intensity or length of workouts slowly to allow the body to adjust- and do not forget those rest days.                                                                                        

3 )When an athlete steps up to a higher level

This often includes playing with older, more mature (and bigger) athletes, attending an intense sport camp, or starting high school or college training. No matter what success the athlete has enjoyed in the past, these situations can overtax a young body. Limit situations where 9 year-olds play with 12 year-olds. Prepare well for camp or a new school, and gradually increase the training. Sports medicine physicians use the mantra TOO MUCH, TOO FAST, TOO SOON as a recipe for overuse injuries.  

4) Playing more than one sport at a time

Many athletes can handle playing club soccer and running cross country at the same time, while some cannot. Other athletes can handle summer football, baseball, and basketball camps without missing a beat while some cannot. I will often see athletes who are burned out from too much activity and once they take a brief rest period and then focus on one sport the majority return refreshed and are more successful.

 5) Playing too much of one sport

The more is better philosophy may work for some, but is has also caused the demise of many young bodies. Repetitive activity strengthens bones and joints, but too much repetitive activity can over stress bones and joints, leading to injury. Thus, swimming for two club teams, or playing on three baseball teams may be detrimental in the long run. Do not forget that private throwing lessons or personal training sessions also add to the cumulative stress placed on the body. Factor all activities into the equation when determining limits for your young athlete.      

6) Playing through pain or discomfort

No child should ever play through any significant pain. I use a 1-10 pain grading scale (1= no pain, 10= major pain). Any pain rating higher than 2-3/10 is significant pain. Schedule an appointment if there also is pain that causes a limp, changes technique, or forces a child to change position or not want to continue activity.

7) When an athlete is tired

Fatigue minimizes the ability to make quick decisions and movements that can help avoid injuries. Tired muscles and ligaments are less able to withstand forces on the field. Make certain the athlete is getting sufficient sleep (at least 8 1/2 hours a night, especially in high school ages) and enough rest between practices and games. Despite what many young athletes think, rest is your friend.  As a parent, it is your responsibility to help your child take appropriately placed rest days.

8) Too much running in cleats

Cleats are designed for a particular sport (soccer, baseball, football, etc) and not designed for prolonged running. In early season practices with lots of running and conditioning, have young athletes wear running shoes to run, and use cleats for the sport-specific drills. Will make a huge impact in reducing lower leg/heel pain and limit missed time.

What happens if an injury is not treated correctly?    

Children tend to heal quickly (that is why I chose pediatrics) so most injuries are not a long-term concern. However, in a worst-case scenario: the athlete has life-long pain or disability. Serious growth issues can develop if a minor injury is allowed to mature into a major injury. Injuries are a common reason why kids stop playing sports, and why athletes fail in the quest for a starting job, a varsity letter, or a scholarship. Certain injuries label the child as damaged goods, for example once a pitcher has a shoulder or elbow injury- it is common for coaches and scouts to automatically write off that athlete.

Have no regrets- call and get a qualified opinion on any childhood injury.

Waiting to Start Sports at Age Five, Better Chance Your Child Will Thrive

Formal introduction of organized sports should begin at age 5 at the earliest. 

Simple skills such as throwing or kicking a ball are part of normal toddler development. However, children this young are not ready for more complex tasks like proper throwing or kicking technique. All play at this age should be fun and spontaneous with minimal organization.

I highly recommend that all pre-school and early school--aged children learn basic movements skills such as balancing, tumbling, rolling, and jumping. No matter what activity is selected later in life, command of these fundamental tasks will enhance athletic ability and safety. 

Why wait until age five for organized sports?                                                                                                                                         

Most five year-old children have developed somewhat of an attention span to listen to adult teachers, work with other children, and follow simple multi-step commands.  They also can learn a task in one situation (school) and repeat it in a new situation (home). All these reasons explain why children start kindergarten at age five. These capabilities will also translate to a better learning experience with the main emphasis on fun and learning of the basic sport skills.

Start off with other healthy sport habits:

  • Allow a child to explore a variety of organized activities, and do not forget the importance of free play.
  • Even at this young of an age, remember that kids should who participate in more hours of organized sport per week than their age in years have a higher risk of injury.
  • Thus, five year olds should not exceed five hours per week of organized sport and better yet should have at least ten hours (twice that number) of unstructured free play.
  • In the early years of organized sport, there should be no competition (keeping score or standings) as competition is so complex it may interfere with learning skills.
  • Repeat as many times as necessary: there should be no competition. 

Contrary to the beliefs of many parents and coaches, an early start or early success in sports is not consistently correlated with success in later years. Thus, the key to five year-olds is to teach proper technique and focus on the basics.  At this young age, the winning percentage should not be based on any measure of wins and losses, but rather on how much fun the children have and how many want to play again the next season.

For more expert tips on starting your child in sports or for any pediatric sports medicine issues, call the office (714-974-2220) for an appointment with a pediatric sports medicine specialist.

DocKoutures thoughts: Ivy League eliminating in-season tackling- would work in high schools?

Practical Recommendations for dealing with a Sports Concussion


Listed below are informative blog posts with practical discussions of common sport-related concussion symptoms and concerns with helpful treatment recommendations.                             Please click on each bullet point below to access the particular article

Concussions do not necessarily require being hit in the head or getting knocked out.  The full definition of a concussion is any fall, blow, or trauma that causes physical, emotion, or mental changes with or without loss of consciousness. 
With formal names like Convergence Insufficiency and Saccadic Dysfunction you might indeed think that this stuff is far too technical to grasp,  but in reality, these issues strike at the very heart of some basic life functions.
Experts Debate: How Many Concussion are Too Many for an Athlete?
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.
Given that headaches are the most common symptom after concussion and often the last to fully resolve,  I spend a good amount of time with my patients discussing headache triggers, anticipated healing course, and how to reduce intensity and duration

How 2 Visual Problems after Concussion Affect Academics and Athletics

To convince you of the importance of healthy visual function after a concussion (and to get you to read this entire blog), let me ask those who have had a concussion to answer a few simple questions.

  • Does even reading a few pages lead to heavy feeling of the eyes or headaches?
  • Do you cringe at the prospect of hours of note-taking due to blurry vision, losing track of words, and again, onset of headaches?
  • Does trying to follow ball movement when you watch practice or a game lead to dizziness, double vision, and a strong sense of futile frustration and a desire to vomit?

Now, while there are other potential causes for all the above issues, one very common post-concussion denominator is indeed visual dysfunction, also known as oculomotor dysfunction.

With formal names like Convergence Insufficiency and Saccadic Dysfunction you might indeed think that this stuff is far too technical to grasp,  but in reality, these issues strike at the very heart of some basic life functions.

Now, without further delay, I will describe the two most common types of oculomotor dysfunction and how they can affect school and sports.


Convergence insufficiency occurs when your eyes don't work together while you're trying to focus on a nearby object. When you read or look at a close object, your eyes need to turn inward together (converge) to focus. This gives you binocular vision, enabling you to see a single image.  (courtesy of Mayo Clinic)

Real world consequences

  • Blurry vision, headaches, and dizziness when trying to change focus from more distant objects (screen, smart board, white board) to closer objects (note pad, lap top, worksheet)
  • Similar symptoms while trying to track and object coming closer to the face, such as catching a ball


Saccades – the ability to jump your eyes from one target to another accurately.Saccades are necessary for tracking skills while reading or copying information. In order to process visual information properly, the eyes must move smoothly and quickly from one object to another. Saccades are crucial to the ability of the visual system to perceive and interpret images. When smoothly tracking with the eyes, the eyes must also be able to cross the midline of the body without hesitation; (courtesy of NorthShore Pediatric Therapy)


There are 2 flavors of Saccadic Dysfunction- horizontal (side to side)  and vertical (up and down)


Real World Consequences


  • Fatigue, blurry vision  and headaches with reading (both screen and book/paper) as eyes loose track of words and lines due to inability to smoothly move from side to side
  • Double vision, headaches and even nausea when trying to follow back and forth ball movement, such as at a tennis match


  • Similar symptoms of distress when repeatedly looking up at a board or speaker, then looking down at a piece of paper or a computer screen
  • Worsening symptoms if trying to look up at a target (basketball hoop) or tracking a ball coming down from the sky

How can I get help with these problems?

Practical in-office testing strategies have been developed to better identify these issues, so do not hesitate to contact a sports medicine or concussion specialist for evaluation.

Depending on symptoms and evaluation findings, potential treatment strategies could include:

  • Classroom modifications
    • Assistance with note-taking
    • Listening to lectures or reading assignments rather in place of actual reading
    • Reduction in reading assignments
    • Oral testing
  • Oculomotor exercises
    • Options include home-based versus formal office-based programs
    • On-going research efforts are attempting to study ideal time frame after concussion to start visual exercises, and how to determine length of programs


Less Football Practice Contact Time May Mean Less Concussions

In the evolving discussion regarding the impact of limited high school contact football practice time on concussion risk, findings from the University of Wisconsin suggest that less contact practices may indeed result in less football-related concussions.

Photo courtesy:&nbsp;

Photo courtesy:

The state of Wisconsin was one year ahead of California in mandating contact practice time restrictions. Starting with the 2014 high school fall season, the Wisconsin Interscholastic Athletic Association (WIAA) prohibited contact in practice for the first week and limited full contact to 75 minutes per week for week 2, with 60 maximum minutes per week for week three and beyond. These limits are more restrictive than in California where two 90 minute contact practice sessions are allowed per week during the high school football season, thought the definitions of full contact are similar (game speed drills/situations where full tackles are made at competitive pace and players are taken to the ground).

Licensed Athletic Trainers at several Wisconsin high schools recorded incidence and severity for each sport-related concussion, and compared the two years previous to the rule change (2081 players) with data from the first year of the new limitations (945 players). 

Significant findings included

·        The rate of sport-related concussion sustained in practice was more than twice as high in the two seasons prior to the rule change

·        There was no change in the rate of concussion suffered in games pre and post-rule change

·        There was no difference in the severity of concussion (defined as average days lost from football activity) pre (13 days lost) and post-rule change (14 days lost)

·        Tackling was the primary mechanism of injury in 46% of sport-related concussions

·        Years of football playing experience did not affect the incidence of sport-related concussion in the first year of the new limitations

The authors concluded that limitations on contact during high school football practice may be one effective measure to reduce the incidence of sport-related concussion

How might this relate to California?

This is a well-constructed and much needed initial evaluation on the outcomes of contact practice reductions in high school football, with subsequent years of analysis now being anticipated to see if the above findings hold true over multiple seasons.

The maximum allowed football contact times in Wisconsin are about 42% of the maximal time currently allowed in California, so one may wonder if that increased contact time may make direct extrapolations between the states more difficult. This is where a similar study after the 2015 California high school season is vital to measure the outcomes here in this state.

I was greatly impressed with the finding that there was no change in game-based concussion rate and that the years of previous playing experience not affecting the incidence of new concussion as two potentially landmark outcomes for the future of football safety.  Coherent arguments have been voiced that lack of appropriate contact practice time might increase risk for inexperienced or under-prepared players, especially in game time situations. This was particularly voiced for freshman players with no previous tackle football experience. I eagerly await future studies to see if these outcomes are consistent and robust.

The lack of change in severity (again, measured in days lost) brings up a couple of thoughts. The initial reaction might be a bit of disappointment, in that reduction of cumulative head impacts in practice should perhaps lead to a lower burden of injury with a concussive blow and hopefully a quicker recovery. One may not want to try and read much into using number of days lost as a strong measure of severity, for standard return-to-play protocols often mandate a minimum of 8-10 days off from full activity which could influence the return time possibly more than symptoms and other measures of severity.

One important subject not analyzed in this study was the incidence of non-concussion injury rates before and after the practice contact limits were enacted. Concerns have been issued over under-prepared players not confident in tackling techniques or changes in technique (hitting opponent lower in body, for example) both possibly contributing to less concussions, but more shoulder, elbow, knee, leg and other musculoskeletal injuries. 

Curious if any groups in California are interested or have proposed a similar analysis of our first year with the high school football practice limitations?

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.

Dr. Koutures Posts on Youth Soccer USA-

Thanks to for the opportunity to share articles on soccer-specific sports medicine and nutrition topics. Check out their website for many interesting posts on youth soccer, and don't miss my first piece on Sports Drinks vs. Water: Which is the Best Choice for Young Athletes?

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



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

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

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

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

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

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

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

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

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

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

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

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

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