Three Sports Medicine Articles Co-Edited by Dr Koutures in January, 2016 Pediatric Annals

Pleased to see publication of three outstanding articles on Reducing Cumulative Arm Overuse Injuries in Young Throwers, En Pointe Readiness, and EKG Screening in Athletes for the January, 2016 edition of Pediatric Annals. This Sports Medicine themed edition is the first of a 2 part series, with the second set of articles running in February, 2016.

Some of the following content may require a subscription to Pediatric Annals for full access.

Click here to access my Guest Editorial co-written by trusted friend and colleague Valarie Wong, MD

The discipline of pediatric sports medicine deals not just with musculoskeletal care, but rather encompasses a host of medical and orthopedic concerns to optimize safe and lifelong participation in sports and activities. Pediatric health care providers' well-known general medical and anticipatory guidance skills absolutely make them a natural and trusted part of the sports medicine team.

lick here to access the article: Reducing Cumulative Arm Overuse Injuries in Young Throwers by John Schlechter, DO

Overuse injuries are preventable when underlying contributors (GIRD, scapula dyskinesis) are addressed and enforced pitch counts are consistent with recommended limits. The single most important and modifiable risk factor in preventing injury in young throwers is activity modification and adequate rest periods prior to the onset of arm pain.

Click here to access the article: Assessing Readiness for En Pointe in Young Ballet Dancers by Jeffrey Lai, MD and David Kruse, MD

As with any medical evaluation, a proper history and physical examination are the first steps in assessing readiness for dancing en pointe. Age, years of dance training, and hours per week of training are important details to collect during the history, as are the ballerina's dance aspirations. Prior injuries, especially to the lumbar spine, hips, knees, feet, and ankles, should be recorded. The physical examination focuses on anatomy and flexibility, whereas functional assessments of technique, strength, and postural control also help determine pointe readiness

Click here to access the article: Use of Electrocardiogram as Part of the Preparticipation  Exam by Kelly Chain, MD and Andrew Gregory, MD

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. During preparticipation evaluation (PPE) visits, clinicians are receiving more questions about incorporating electrocardiogram (EKG) screening to detect potentially lethal heart conditions. Many families are aware that several countries in Europe routinely use EKG screening and wonder why the United States has not instituted this recommendation. What are the pros and cons of preparticipation EKG screening in the US, and how might athlete-specific criteria assist in reviewing EKGs conducted in young athletes?

Why a Sports Physical Should Take More than 10 Minutes

From medicalnewsinc.com 

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.”

RELATED LINK: 

AAP Council on Sports Medicine & Fitness:

https://www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Pages/default.aspx

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.

Overuse

“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.

Are Past Unreported Concussions Often Found in Pre-Season Assessments?

The use of baseline assessments to provide comparison data for future concussions provokes controversy about validity, cost, and time investment. If however, such testing routinely uncovered past unreported or even currently symptomatic concussions, would that influence opinions about the significance of such efforts?

Definitely curious if others have found significant numbers of previously unrecognized concussions in their preseason testing?

I met recently with administrators of a local contact/collision sport league who wanted to discuss their pre-season baseline testing program for concussion monitoring.

They have developed an amazing concussion program, complete with education, pre-season testing, surveillance, and return-to-play protocols.

Coaches or team administrators are required to report all suspected or confirmed concussions to league officials for follow-up monitoring of medical evaluation, treatment, recovery and return progression.

The leagues they supervise are growing, with now over 1000 athletes on multiple teams in several cities.

That means the potential of more pre-season evaluations, and whether the medium is computer or paper based, with or without functional testing such as vestibular or visual testing, we all know that this takes time, effort and tends to have a bunch of logistical issues.

So, not unacceptable to find ways to reduce the early season demands but still provide adequate data to analyze players after a concussion.

With the ability to compare post-injury results to solid age-matched normative data sets for many of the neurocognitive platforms, some have begun to question the utility of the time and expense for routine annual baseline testing.

Others have offered the opinion that every other year evaluations might suffice in the school-aged population and thus reduce some of the testing burden but not lose the value of the data.

These both sounded like workable options for this league to consider, until one eye-popping revelation was shared.

Realize, we're talking about a close-knit sport community where kids and families know each other well and administrators have designed a visible program that requires reports of all potential concussions, with penalties in place for failure to report.

You’d think that there wouldn’t be too many concussions that could sneak by so many watchful eyes.

Guess again.

A critical review of the pre-season data found a startling disconnect on many teams between the number of concussions officially reported to the league and the number of concussion the kids report in their baseline testing.

When asked to report either number of concussions or current possible post- concussion symptoms, the players admitted to a frankly startling number of concussions, including dates of injury, that were never officially entered into the league data base.

Now perhaps this shouldn’t have been so surprising to those of us having this conversation.

We always worry about under-reporting at the time of injury, not just by athletes, but also unfortunately by adult coaches and parents all eager to limit or eliminate any missed playing time.

Have also learned another thing when working with kids- when it comes to answering questions about symptoms or past concussions, kids just can’t seem to lie to a computer..

They might repeatedly deny past history or current problems to a medical provider in person, but when asked to report information to a computer, the flood gates tend to open.

I must give big-time credit to these league officials for underscoring the importance of their active, critical review of all baseline testing and not just passively collecting data for potential future use.

Their use of the computerized baseline testing information apparently allowed a better look at the true incidence of concussions, and unfortunately, a more realistic look at sandbagging or failing to report.

Now, I’m not entirely ready to endorse a punitive Orwellian “1984: Big Brother is Watching” approach to concussion management.

I still think trust and transparency between all parties is absolutely essential.

I’m also not totally on board with the absolute need for computer-based platforms for concussion evaluation or record keeping for that matter (often handwritten mediums provide sufficient information).

But if an annual computerized pre-season assessment  provides candid responses that reveal sufficiently high numbers of previously unreported or even worse, incompletely healed concussions, then maybe all that work, all that effort, and all those logistical efforts suddenly seem far more justified.

Very curious if other organizations performing large-scale pre-season baseline neurocognitive evaluations have seen a similar difference between “official” concussion reports and those self-reported on computerized assessments?

Is the above experience an isolated phenomenon, or is it worthy of further collaborative study?

Pre-season Preparation and Injury Prevention Tips for Soccer Coaches

Thanks to Canyon Football Club in Anaheim Hills, CA for inviting me to speak to coaches and managers on Soccer Pre-Season Preparation and Injury Prevention.

Below is a copy of the slide presentation:

Is My Daughter Ready for Pointe Work? A Dance Medicine Physician Perspective

The decision to initiate pre-pointe training is a sentinel event in the progression of a young dancer. Dancing en pointe which involves full-weight bearing on the toes, is fundamentally rigorous, can lead to a variety of lower body injuries, and signifies a high level of commitment to ballet that should not be taken lightly.

Relying on reaching a certain to start (ie: "we start pointe at age 11") is not sensible and supported by many dance medicine authorities. Rather, there is the concept of developmental age which takes into account dance experience, mechanics, strength, commitment, and nutrition/sleep for a more individualized assessment of readiness.

Many wonderful musculoskeletal screening recommendations have been made by respected authorities, and I will definitely reference them below and do use them in my clinical practice.

Before moving the focus on movement patterns, I like to take a step back with dancers and families to discuss fundamental concepts emphasizing sufficient sleep, dance-specific nutrition and balance of dance classes and adequate time off for recovery. If a young dancer is not ready to accept these key foundations for success, then I'm not certain she is ready for the rigors and "sacrifices" of point work.  Jeff Russell has an amazing review of how psychosocial traits of dancers, nutrition and fatigue all can contribute to injury and I highly recommend the read.

• Dancers must accept the unique physical and mental demands of point work leading to a need for increased sleep (minimum 8-9 hours a night)
• Adequate calcium (1000-1500 mg/day) and iron (15 mg/day) needs can be best addressed by 4-6 servings of dairy foods and 3-4 servings of meat/protein per day
• Minimum of 1-2 days off a week from organized activities to enhance recovery

Returning to the discussion of musculoskeletal readiness, The International Association for Dance Medicine and Science (IADMS) proposes the following guidelines:

• Not before age 12.
• If the student is not anatomically sound (e.g., insufficient ankle and foot plantar flexion range of motion; poor lower extremity alignment), do not allow pointe work.
• If she is not truly pre-professional, discourage pointe training.
• If she has weak trunk and pelvic ("core") muscles or weak legs, delay pointe work (and consider implementing a strengthening program).
• If the student is hypermobile in the feet and ankles, delay pointe work (and consider implementing a strengthening program).
• If ballet classes are only once a week, discourage pointe training.
• If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training.

Prospective point dancers can benefit from a focused musculoskeletal screening examination, and the great team at Childrens Hospital of Kings Daughters has a nice visual which illustrates some of the following:

• Measuring range of motion of the ankle, foot and especially the great toe. 
  • Limitations in great toe range of motion can lead to injuries not only in the foot, but at the ankle and knee
  • The Pencil Test can measure foot plantarflexion
  • Loose tissues on the outside of the ankle, often from past ankle sprains, may not be able to handle the stresses of pointe leading to fractures of the talus (lower ankle bone) or 5th metatarsal bone on the outside of the foot
• Assessing strength and endurance of the "proximal" structures (hip, buttock, quadricep and hamstring muscles) where weakness leads to abnormal stresses on the inside of the knee, shin, and foot/ankle
  • The Airplane Test has been associated with readiness for pointe work
  • Single leg squat alignment, where hips, kneecaps, and 2nd toe should all stay in line, is a great measure of that proximal strength
    • Collapse of the knee inward, excessive internal rotation of the shin, or significant collapse of the arch/rolling in of the foot are problem findings that should be addressed before starting pointe.
• I also like to put dancers perform plie in 2nd position- ideally inside of knee should be lined up over 2nd toe with minimal rolling in of foot. 
  • Inability to maintain this alignment is another problem area that should be addressed before starting pointe.
• If there is any history of past injury, the dancer should have completed a full rehabilitation program culminating in unrestricted return to dance before contemplating pointe work. 
  • The biggest risk to future injury is under-rehabilitated or lingering past injury

In any type of injury prevention and readiness assessment, communication is the name of the game. The results of a thoughtful medical and musculoskeletal assessment from a dance medicine specialist can be discussed with instructors and this collaboration is a wonderful medium to best prepare a young dancer when she is ready for pointe work.

Stronger Necks May Mean Healthier Heads

In the valiant effort to reduce the risks of concussion, must commend colleagues who developed a practical pilot study finding that measured increases in neck strength may reduce the risk of concussion in contact sport high school athletes.

The validation of a hand-held tension scale for neck strength is one important finding, but more readily applicable to athletes and medical personnel "in the trenches" are the following observations:

• Smaller mean neck circumference, smaller mean neck to head circumference ratio, and weaker mean overall neck strength were significantly associated with concussion.
• For every pound of neck strength increase, odds of a concussion decreased by 5%
• Identifying differences in overall neck strength may be useful in developing a screening tool to determine which high school athletes are at high risk of a concussion

Now we have a potential low cost easy to implement primary concussion prevention strategy, and that itself is very exciting news. Honestly, other than proper rule enforcement to reduce dangerous play, other primary prevention techniques including helmets, mouthguards, and teaching of "proper" technique haven't survived scientific scrutiny to be determined statistically valid. It is refreshing to find a strategy that not only has a good initial evidence base, but can readily be used by school/team-based athletic trainers, coaches, and strength and conditioning specialists in large-scale settings. Many football programs already incorporate some aspect of neck strengthening, and these findings should encourage possible expansion of more focused and monitored neck strengthening programs to all contact/collision sport athletes with appropriate on-going evaluation of strength gains and on-field concussion outcomes.

Does this appear to be a useful item to discuss in pre-participation exams? Would this possibly be useful to include in pre-season concussion baseline testing?

Concussion: No Attention Deficit to Ethical Care

Whether it be during a pre-participation exam, evaluation a patient with two previous concussions, or even while watching my kids at soccer practice, getting more and more inquiries that are based on the premise "should I let my child play their chosen sport and risk getting a future concussion?"

Bet most people who ask me don't anticipate the extent of what comes back at them....and often, my responses are formulated with even more questions.

In each case, I have found that there is no textbook or rote answer. Rather, each athlete brings an unique set of past medical concerns, life experiences, expectations,  and level of risk tolerance that deserves a personalized response that engages the athlete and family in that very decision-making process. In efforts to feel that I have adequately educated on individualized possible risks, I sometimes wonder if I overwhelm families with data and information, while in other cases I struggle with a lack of good science to help make evidence-based decisions about that risk.

The protection from future harm is a direct correlate of the principles of the Hippocratic Oath "First of all, do no harm" that does seem relatively basic in its premise, but in practice can be fraught with difficult dilemmas.

Case in point: how about the football player with Attention Deficit Disorder (ADD) who wants to play football? In practice, have had many patients with diagnosed or suspected pre-existing ADD have worsening of ADD symptoms after a head injury. Many have required re-starting or increasing medication doses as part of their treatment, and have had extended periods of recovery that have adversely affected grades for entire academic semesters or longer.

Looking at the medical literature, the studied relationship between pre-existing ADD and recovery from Concussion is inconclusive. My patient experiences more seem to mirror the findings that patients with pre-morbid ADD are more likely to have moderate disability after mild Traumatic Brain Injury (I do have some issues with this article, including definitions of brain injury, lack of comment on pre-injury treatment, and reporting of academic progress after injury).

So, if I have a professional regard that young athletes with ADD may have more complicated recoveries from concussion, how do I best convey this information to families?

Do I categorically discourage participation in all risky activities? If so, how do I define such activities, or do I leave that up to the family? Is it more proper to bring up this potential risk as a matter of appropriate patient education and let the athlete and family make the ultimate decision? Do the documented benefits of regular physical activity and structure of a team or individual sport outweigh the potential risks in this particular child? Do I have enough experience and data to make an evidence-based statement about ADD and concussion, and thus fulfill a primary duty to reduce future risk?

The legal and ethical implications in the evaluation and management of sport concussion published in Neurology , July 2014  provided an interesting review of how to frame approaches to these discussions. Important elements, which I hope I try to abide by in my practice, include:

• Staying current with state-based concussion legislation and prevailing standards of concussion practice
• Allowing patients and families to participate in making medical decisions, and to even refuse to comply with recommended treatment
• Providing appropriate education to allow informed decisions
• Respecting patient medical privacy by clarifying early in encounters whether health information can and will be shared with medical colleagues and school/team personnel
• Protect athlete as much as possible from future harm
• Acknowledge conflicts of interest that might cloud judgement 
• Provide equal access to concussion evaluation for all athletes

So, it is probably now readily apparent that an appropriate response for such as seemingly brief query ""should I let my child play their chosen sport and risk getting a future concussion?" is anything but brief. Just like each concussion is an individualized experience, assessing and counseling on risk stratification requires a personalized and methodical approach. 

In the particular case of ADD and contact sports, I find myself more apt to present my professional experience about those athletes with protracted recoveries to fulfill my duty as part of the informed decision making process that involves the athlete and his/her family. I also am more aggressive in reviewing and optimizing all aspects of their ADD management (school modifications, homework environment, tutoring, counseling, and medications) in hopes that in the case of a concussion, more comprehensive pre-injury ADD treatment may reduce post-injury complications.

What are your thoughts about counseling for concussion risk reduction? How would you best handle an athlete at higher risk?

Maximizing Good Memories from Summer Sports Camps and Intensives

As the old song goes, "Summertime, and the living is easy."

No school, no homework, no classroom tests or projects to worry about.

However, many young athletes and performers find ways to test themselves over the summer months by attending high level sports camps, showcases or intensives. They often take goals of getting stronger, learning new skills, getting noticed by college coaches and recruiters, and making new friends. 

Unfortunately, I have seen too many unhappy campers return home with injury or illness souvenirs after trying to play or perform at the higher levels of skill and intensity required at specialty camps and intensives for several consecutive days/weeks without sufficient support

What particular tips can I share to better put yourself in the position of writing the upbeat "How I Spend my Summer" essay upon returning to school?

• Don't rush right from a spring school or club season, or from a tough summer program right into a intense specialty sport camp or dance intensive
  • Specialty camps often teach higher level skills with higher number of repetitions against more talented competition. Plan schedules head of time to include taking a week for preparatory rest can increase enjoyment and the overall learning process.
• By the same token, don't leave camp and step right into full Fall sport/dance activitity
  • Insufficient recovery after a high level camp increases the risk of overuse injury and doesn't often allow full ability to utilize newly acquired skills. A bit of time off before and after intensive camps is the best recipe for success.
• Don't stop rehab or prehab routines just because you are going to camp
  • Many athletes and performers have individualized stretching and strengthening programs which must be continued while away from home.
• Observe those days of rest
  • Camp doesn't have to be all work, in fact, recent recommendations emphasize taking a minimum of one day off per week from organized activities to reduce risk of overuse injuries. 
• Don't forget medications
  • Many exercise-related or chronic medical conditions, such as asthma, can worsen when exercising at higher levels in foreign environments. Visit with your regular physician or sports medicine specialist ahead of time to optimize illness control and ensure you have adequate supply of medications.
• Know what medical resources are available
  • Ideally, a high level camp or intensive will have high level medical support such as athletic trainers, physical therapists, and other sports medicine specialists. In the real world, formal on-field or on-floor coverage is often sorely lacking. Highly recommend identifying local off-site resources and even making advanced maintenance and evaluation appointments especially for prolonged camp activities. Definitely recommend using quality and availability of medical support as key criteria for camp selection.
• Remember fluids are your friend
  • Summer camps often take place in unfamiliar hot and humid environments that require early and often access to fluids and salt sources. Water is a sensible first choice, with fluids containing salt and sugar more recommended for exercise lasting over a hour. While sport beverages can fit this requirement, using infant electrolyte replacement fluids can actually be more effective in overly humid environments
• Food is Recovery
  • If exercising for several hours a day isn't enough of a challenge, then add in dealing with being away from home for the first time, unappealing  or repetitive cafeteria food, or even worse, living in an apartment without access to prepared food. This often inadequate nutrition cannot properly sustain high level performance. Planning head and focusing on the following items can help correct these deficiencies:
    • Post-exercise protein intake- good sources include chocolate milk, Greek yogurt, and peanut butter
    • Fruits and vegetables- especially berries and cherries which act as natural anti-inflammatory agents to reduce post-exercise muscle soreness
    • Meat, poultry, fish, beans, eggs, and leafy green vegetables for additional protein along with iron source

Do you have any other recommendations or concerns about summer camps and intensives?

Cheering for Cheerleading to be Classified as a Sport

Add the American Medical Association to the growing list of prominent medical groups advocating for cheerleading to be formally classified as a sport.

This policy adoption at the annual AMA meeting this week in Chicago recognizes the rigors and risks of cheerleading to be as demanding as many other high school and collegiate level sports. The AMA statements reinforces the findings of a well-documented American Academy of Pediatrics Council on Sports Medicine and Fitness Policy Statement that describes the epidemiology of cheerleading injuries and provides sensible recommendations for injury prevention. (Full disclosure: I was on the committee that reviewed this paper and approved the findings and recommendations).

As a sports medicine professional who sees a fair number of bases, flyers, spotters, and tumblers, the designation of cheerleading as a sport would have a multitude of benefits:

• Cheerleaders would have better and essential access to certified athletic trainers (ATC) for injury prevention and evaluation along with assistance in return to activity progression. Deciding how to return any athlete or performer can be a difficult and individualized concern, but doing it without an on-site medical professional such as the school-based ATC is even more overwhelming.
• Requiring cheerleaders to have pre-participation athletic screening exams affords the opportunity to identify medical and orthopedic concerns and develop comprehensive management plans before these issues become major problems. A timely pre-participation exam could tag team with starting an appropriate strength and conditioning program focusing on common shoulder, back, wrist, knee, and ankle issues.
• A sport designation would hopefully lead to safer facilities including use of mats and not inappropriate types of flooring, higher ceilings, and institution of emergency action plans in the event of injury.
• Encouraging coaches to follow rules for execution of technical skills set forth by national cheerleading governing bodies
• Including cheerleading injuries in national injury monitoring programs to increase information on the type, frequency, and severity of cheerleading-specific injuries at the high school and collegiate levels.

Today's cheerleaders often start well before high school and participate on competitive cheer teams in addition (or in many cases, in place of) to cheering for particular schools and teams. The high level of skill and training asked of these performers places them at risk for both acute and overuse injuries often at similar levels to contadt or collision sport athletes. Denying cheerleaders the right to appropriate medical care and supervision only increases the chance for catastrophic outcomes.

That would be something no one would cheer about...

Click here for more information about cheerleading safety and injury prevention.