Stress Injuries to the Tibia: A Video Interview

Sincere thanks to Matt Swift, DPT from Change Sports Physical Therapy Institute for creating this video on Stress Injuries to the Tibia with focus on symptoms, treatment, and prevention. 

Exercise when Sick: Stop? Go? How to Reduce Risks?

Is it OK to exercise when sick? What symptoms should keep someone off the playing field?

When trying to decide if an athlete is too ill to participate in sports, I tend to ask the following questions:

• Is the athlete currently too ill to exercise?
• Will exercise make the athlete at-risk for more serious or longer-lasting illness?
• Is the athlete contagious to other members of the team or sport group?                                

Study and experience tells us that a fever over 100.4 degrees Fahrenheit may increase metabolic demands of the body, often making exercise more difficult. Thus, many authorities recommend starting with lighter levels of exercise with a fever, and using overall performance to advancing to higher intensity of exercise. Some athletes may perform quite adequately with a fever, while others will need complete rest from exercise until the fever is gone for at least 24 hours.

I have found that the neck rule can also assist athletes and parents in deciding on sport participation, with or without a fever:

• If symptoms are entirely above the neck (runny nose, sore throat, mild headache, etc) then there is less potential risk for more serious illness with exercise. Recommend light exercise at first, and if symptoms do not worsen, then gradually increasing the intensity of the exercise.
• If symptoms are below the neck (productive cough with mucous, chest pain/tightness, stomach ache, vomiting/diarrhea, rash, muscle/body aches) then there is a greater risk not only for worsening individual symptoms, but also for spread to teammates. Thus, recommend no activity until these symptoms are gone for 24 hours. If there is any concern contact your medical provider to receive further evaluation.

How can we limit spread of colds and other illnesses during the winter months?

Multiple factors contribute to healthy function of the immune system in preventing illness

No athlete wants to be sick during the season and no athlete wants to spread illness to other team members. Following some basic rules can help prevent the spread of infections: 

• Do not share water bottles, cups, towels, washcloths, or tissues.
• Shower immediately after exercise and change into clean clothes.
• Launder athletic equipment on a regular basis.
• If prescribed medications- take them as directed for the full length of the prescription.
• Use antibiotics only for the intended illness; never use them for a new illness or when they were not specifically prescribed. Incomplete or improper use of antibiotics can lead to bacterial resistance that may increase both the spread and severity of an illness.
• Get adequate sleep and nutrition as fatigue and poor diets can weaken the immune system.  Get no fewer than 8 hours of sleep a night, and schedule at least one rest day from exercise per week. Low-fat diets (less than 10-15% of daily calories as fat) and less than 4-5 fruits/vegetables per day can also reduce ability to fight infection.
• Consider the Influenza Vaccine (flu shot) in the fall months.  Influenza A/B viruses are common sources of illness and disability during the winter months and flu shots can reduce both individual and team risks from flu symptoms.

How does the amount of exercise influence risk of getting sick?

Moreira A et al. Br Med Bull 2009;90:111-131, © The Author 2009. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org

The above figure demonstrates that both intensity of exercise and fitness level can influence the risk of upper respiratory infection. More moderate levels of exercise can be protective against illness, while lower levels and higher levels of exercise may actually be related to an increased risk. This is often why athletes get sick right after higher level competitions or at the end of a particular sport season. Higher levels of fitness may also be protective against respiratory illnesses.

Is Weight Training Safe and Productive for Children?

There is no magic age at which a child can begin weight training. Readiness for weight training depends on the willingness of the child to lift weights, follow directions, and maintain the program for several months to see results. Remember, this is for the child, not for an adult or coach.  

Weight training should supplement regular sport activity. It is not acceptable to have weight training injuries keep an athlete away from his/her sport. I recommend qualified supervision by a performance or physical trainer who routinely works with children and adolescents. The focus should be on appropriate-sized equipment, meticulous weight lifting technique, starting with low weights/high repetitions, and working multiple body parts. In appropriate program, a child will often lift weights 2 or 3 days a week with at least 48 hours of rest between sessions. 

The physical results, such as muscle enlargement and weight gain, depend on the gender and developmental stage of the child. Routine weight training can make a child somewhat stronger by increasing nerve and muscle communication. However, if the child is looking for larger and more bulked muscles, then they must wait until after their growth spurt. Androgens are a particular hormone, produced more in boys than girls, which produce muscle and strength gains. Since androgens increase late in puberty right after the growth spurt (age 11-12 in girls, age 13-14 in boys) lifting before this time will not result in massive muscle bulking or extreme strength gains.

Does this mean one should not lift before the growth spurt? No, but just place the emphasis on good technique and reduce the expectations for big-time muscle gain. Remember, due to lower androgen production than boys, girls will have less increase in muscle mass.

Is weight training safe for children?    

Studies have shown that a properly designed and supervised resistance training program can be safe for children and young adults. Contrary to popular belief, weight training at a young age does not stunt growth as long as proper techniques are utilized.  There are reports of overuse injuries with back strains the most common but at no greater frequency than what is seen on the athletic field. Again, placing the emphasis on a properly designed and supervised resistance training program will help reduce injuries and maximize enjoyment.

Click here to learn about:Proper post-lifting recovery, focusing on nutrition and sleep, can greatly enhance the results and safety of a weight training program.

Does weight training work?  

Both published studies and personal experience have shown impressive strength, speed, and endurance gains with an appropriate weight training program. There is no good scientific data to show that this directly translates to better on-field performance, but it does contribute to overall athletic ability. The athlete needs to be aware that he/she must stay with the program or risk losing the gains. 

To produce optimal results, recommend starting a program during break periods between sport seasons and not initially scheduling weight training sessions on same days as practices or games. Once the athlete is more comfortable with the demands of weight training, can incorporate lifting sessions with regular training and competition activities.

Can weight training reduce injuries?    

High school-based studies indicate a resistance training program could decrease the number and severity of injuries, and also reduce the rehabilitation time once an injury has occurred. These benefits may be due to stronger supporting joint structures, muscle absorbing more energy before tiring out, and greater muscle balance around a specific joint.

Can weight training help with weight loss or weight control in children?

Weight training programs that feature higher repetitions, lower weights and limited rest between sets have been shown to contribute to both weight loss and weight control in children. Appropriate professional supervision in designing such a program can be of significant help.

Identifying and Preventing Arm Injuries in Youth Baseball Players Video

Thanks to colleagues at Intecore Physical Therapy for filming this video on Youth Arm Injury Prevention that has been distributed and shared with several local Little League groups.

5 Sensible Tips Guiding Nutrition and Recovery After Exercise

For centuries, athletes have searched for any substance or technique that could enhance exercise and allow for more effective weight gain/loss or increases in strength and endurance. Many available performance enhancing products may report claims of potential amazing efficacy but use of them can be clouded by concerns over true scientific support, side effects, and financial cost.

Here are 5 sensible tips to guide you on nutrition and recovery with your exercise program:

1.       The Importance of Sleep

Can’t begin to tell you how sleep deprivation can derail even the best constructed exercise program, as skeletal muscle needs adequate recovery time to rebuild damaged fibers and to increase the working capabilities of contractile units. Multiple studies support the efficacy of a minimum of 8-9 hours of sleep a day to foster such recovery. Insufficient sleep can also reduce mental alertness on the job or at school and has also been associated with statistically higher risk of illness or injury.  Establish a regular bedtime and not allow deviation of more than ½ hour and also encourage daytime naps of under one hour per day which have been shown to be restorative, add to the cumulative daily sleep amount, and not adversely affect nighttime sleep patterns.

·         TIP TO ASSIST WITH SLEEP: Stop any type of screen device use no later than one hour before bedtime, and do not have screen devices in the sleep area, as use right before bedtime or alerts/temptation to check during sleep have been associated with reduced amount and quality of sleep.

2.       The Timing and Amount of Protein

Protein is the building block of skeletal muscle and is needed to assist in that reparative and rebuilding process after exercise. Good data suggests that the best time for workout-related protein intake is within 30 minutes after completing exercise. A post workout protein amount of 25-30 grams along with a total daily intake of 0.5-0.7 mg protein/pound of body weight are both solid recommendations. I have always favored dairy or meat/bean/egg sources of protein as readily available products that confer well-absorbed collateral benefits of calcium, Vitamin D, and iron. Amino Acids are the building blocks of proteins, and intake of specific individual amino acids has been touted for both weight loss and strength building. However, there is a lack of rigorous support for high amounts of individual amino acids, so stick with whole food protein sources.

·         TIP TO ASSIST WITH PROTEIN INTAKE: 8-12 ounces of chocolate milk within 30 minutes of exercise is a sensible recovery drink that has a ratio of carbohydrate to protein that allows enhanced transport of protein to recovering muscles. Other good post workout food-based protein sources include Greek yogurt and peanut butter.

3.       What About Creatine?

Creatine is a natural substance that assists with regeneration of short-acting energy sources that fuel contraction in working skeletal muscle. Increased amounts of creatine in working muscles can potentially contribute to more intense workouts and also assist in muscle recovery after workouts. Powdered and liquid creatine supplement products have been studied, with trials that include higher loading doses for the first few days, followed by lower daily maintenance doses and other regimens that include medium daily doses without any higher loading amount. Positive results have included increased speed and ability to complete multiple short-burst activities such as 80-100 yard sprints. Possible side-effects include water retention, bloating, muscle cramping, and potential kidney injury (currently only reported with individuals that had pre-existing kidney concerns).  Anecdotally, many athletes using creatine have reported enhanced recovery with increased ability to work harder in subsequent workouts, and documented strength increases support increased muscle size not being simply due to water retention, but to increased contractile abilities.  Take note that many United States-based sports medicine advisory organizations do not endorse creatine supplementation in children under 18 years of age.

·         TIPS ON CREATINE USE: Creatine monohydrate in either liquid or powder format has been the best studied form of creatine. If using any supplement, ensure that you are getting exactly what is on the container and not any additional substances (see below). Reductions in creatine dose have been shown to assist with bloating, cramping or extreme water retention. Good food sources of creatine include wild game meats or wild-caught fish which also have those collateral benefits of protein, calcium and iron. Domestic meats and fish (especially free-range meats) still have reasonable amounts of creatine.

4.       Are Pre-Workout Supplements Safe and Efficacious?

Advertised preworkout supplements or “energy drinks” report to enhance athletic performance and routinely contain multiple components such as caffeine and taurine. While a few small studies support the performance enhancement of stand-alone agents, published data on combination products is scant, inconclusive, or confusing.  Safety concerns exist with use of products that have cross reactivity of multiple agents or larger than studied amounts of a certain product.

·         TIPS ON PREWORKOUT SUPPLEMENTS: Read labels! If using any preworkout supplement in addition to usual daily caffeinated beverage of choice, you might be getting an enormous caffeine load with possible dangers that outweigh possible benefits to your workout.

5.       What’s the Lowdown on other Supplements?

Use of a vast array of pre and post-workout supplement products has been touted to enhance athletic performance and exercise capabilities. Many of these products will work- no doubt about it, - however the gross majority of products do not have any rigorous practical scientific result to support clams and there is a tangible risk of adverse consequences from both known and potentially unreported elements in supplement products.  What is on the label of many products is not the same as what is in the actual container. Personal experience along with results found by national sport organizations have found a significant number of supplements that have additional, unreported elements that are potentially dangerous and might be banned for sporting competition. While most of you are not subject to drug testing for performance-enhancing agents, suffering real and possibly long-term health consequences is not worth the short-term gains in strength and endurance.

Sleep, Screen Device Use, and Concussion Recovery

Each concussion deserves individualized recommendations that seek to strike the delicate balance between a child's need for maintaining social contacts and attempt to continue with school work with a desire to not overwhelm the healing brain and increase post-concussion symptoms. An absolute restriction on screen use might reduce possibility of certain symptoms such as difficulty falling or staying asleep, but can also lead to social isolation contributing to higher symptom reports of anxiety, sadness, and outright depression. 

How can we best strike an appropriate balance between screen use and need for adequate sleep?

Ask most parents if they have worries about sleep issues and amount of electronics/screen device use in their school aged children, and you'll probably get ready nods and smiles of affirmation. 

Ask some of my sports medicine colleagues about why we are seeing more complicated and prolonged post-concussion recoveries, and you'll hear some suggest that the multi-tasking and multiple platforms of communication utilized by smart phones and other screen devices are potential contributing factors.

So since increasing sleep issues and attempts to pry screen-based devices from the hands of kids are common concerns to parents and medical professionals, it should be no surprise that difficulties initiating or maintaining sleep and regulating electronic use are often major challenges in children who have suffered a concussion.

Came across two recent studies on the subject of screen use and sleep that I think shed some interesting light on how we might make recommendations for all children, but particularly in the immediate post-concussion population.

One study from Proceedings of the National Academy of Sciences of the United States of America suggests the use of portable light-emitting devices immediately before bedtime has potential biological effects that may perpetuate sleep deficiency and disrupt circadian rhythms, both of which can have adverse impacts on performance, health, and safety. Such device use can:

•  increase alertness at bedtime, which may lead users to delay bedtime at home
•  suppress levels of the sleep-promoting hormone melatonin,
•  reduce the amount and delays the timing of REM sleep
• and reduce alertness the following morning

While this study used healthy young adults (mean age around 25 years of age), the findings are intriguing enough to be extrapolated to younger patients. Given the frequency where recommended oral melatonin clearly helps with falling and staying asleep, having another pathway to support internal melatonin production can be essential in the recovery process.

An additional study from the journal Pediatrics examined 4th through 7th graders and assessed associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. Particular interest was placed on smartphones which can emit notifications during sleep periods, and relevant findings included:

• Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations.
• Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep.

These findings found that small screens could have more adverse effects on sleep than television screens and thus caution against unrestricted screen access in children’s bedrooms for normal, healthy 4th through 7th graders, which again could be extrapolated to include concussed children.

Throwing this all together, a pragmatic approach to screen use after concussion that utilizes the findings of these studies may include the following clinical recommendations:

1) The preponderance of screen devices is an integral reality in the life of many school-aged children and significance of appropriate use cannot be underestimated in expediting post-concussion recovery.

2) Once appropriate, limit screen device time use initially to the middle of the day and not within one hour of any scheduled nap or evening sleep period.

3) All screen device use should be stopped at least one hour before bedtime,

4) Screen devices should be removed from the bedroom to reduce interruptions in sleep from notifications or temptation to check devices for updates during periods of awakening.

Once the child has recovered from the concussion, the child might find that continuing the above screen time recommendations may lead to continued enhanced amount and quality of sleep, which in itself may lead to an enhanced quality of life.

Concussionconnection.com: On-Campus Resources After Concussion

Thanks to colleagues from concussionconnection.com for publishing my blog post focusing on resources for disabled students on college and university campuses, particularly for student-athletes recovering from concussions.

Check out the blog post and a host of concussion-related resources at http://www.concussionconnection.com/knowing-resources/.

Are California Schools and Medical Providers Prepared for New Concussion Law?

California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) will take formal effect on January 1, 2015 and will provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

• Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
• Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
• Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
• Concussion education must now be part of required first aid training of every high school coach

For my initial reaction to this law, click here

In discussions with coaches, administrators, and fellow sports medicine providers, I'll throw out a few questions that have arose regarding several nuances of the law:

• When is the earliest that the 7-day return protocol begins?
  • Is it potentially at the time of formal diagnosis of a concussion by a licensed provider?
  • Is it when the athlete is fully cleared of post-concussion symptoms?
  • Can the period begin before a formal diagnosis is made?
• What is the formal definition of supervision?
  • Can an athletic trainer assume the role of supervision under the guidance of a physician?
• Given that the bill also limits contact football practices to two 90 minute periods per week, if the timing of those two practices is perhaps a day before a player's progression is ready for contact, can he have alternate contact to possibly play in a game if otherwise having an appropriate recovery?
• Are school and medical providers aware and sufficiently prepared for these new edicts?
  • Is there agreement or clarification on the above terms and concerns?
  • Have concussion management plans, if already in place, been modified or reviewed to address the new mandates?

Certain that there are other questions and thoughts out there- please use this as a forum to share with others.

Detective Work: 5 Culprits Causing Young Athlete's Bone Stress Injuries

As a sports medicine specialist, here 5 important factors that should be included in every evaluation of a bone stress injury:

1. Timing

• Early in a new activity (especially within the first 3 weeks), stepping up to a higher level (first weeks of high school or travel team), or increasing amount or intensity of workouts (double days or more difficult routines) all can lead to acute overload and bone stress injuries.
• Cumulative stresses from months of training are another frequent contributor to bone stress injury and can also reduce overall immunity. Tend to be very cautious with any local bone pain that comes up right after a major accomplishment (end of long season, finished lead role in major performance) and especially when a performer reports "I'm at the top of my game."
• Too much load, too fast of increasing load, or too long of sustained load 

2. Technique

• Inappropriate technique or attempts to modify mechanics can lead to bone overload. Examples include:
  • Longer stride with slower stride rate: evidence shows that a shorter stride and faster stride cadence may reduce overload on bones of the foot and lower leg in runners
  • Poor activation of gluteal muscles in the lower back/buttock region can place rotational forces on the thigh and shin regions
  • Gymnasts with poor stabilizing strength of upper back and shoulders may place undue forces and increase cumulative stress on the forearm bones
• Any under-rehabilitated past injury of any type can change technique and place abnormal forces on a particular bone or region of the body, increasing risk for stress injury. 
• Comprehensive review of technique and biomechanics, often involving coach insight, can be extremely helpful in addressing these issues.

3. Appropriate Energy Intake

• Insufficient caloric intake to meet training demands can lead to a decreased ability to repair/build bone structure. The International Olympic Committee published a recent paper outlining the concept of Relative Energy Deficiency in Sport that pertains to all athletes. 
• For female athletes, reviewing the elements of the Female Athlete Triad (includes absent/infrequent menstrual periods, disordered eating habits, and weaker bone structure) is absolutely essential to identify common and correctable causative factors for bone stress injury.
• A focused diet history combined with targeted physical and laboratory evaluation can be performed by a sports medicine specialist to provide greater insight.

4. Not enough rest

• Bone needs time to remodel after physical activity, thus insufficient rest can lead to a higher risk of stress injury. Acute (showcase events, tournaments, intense auditions) or chronic (playing on multiple teams, playing a single sport more than 8-9 months a year) cumulative stress is not ideal for allowing sufficient recovery time.
• The American Academy of Pediatrics Council on Sports Medicine and Fitness recommends taking at minimum one day off per week for acute recovery and limiting participation in a particular sport to no more than 8-9 months per year to allow longer-term recuperation.

5. Growth spurts

• A growing athlete often suffers from a lack of central upper back/shoulder and lower back/pelvic strength which causes the now longer arms and legs to have less control and coordination. Even with emerging increases in muscle strength, the immature developing bones are at an increased risk for injury.
• The entire body needs additional calories to foster growth, which might create a relative deficiency in caloric delivery to working bone and muscle, further increasing overload stress opportunities.

This blog post does not intend to diagnose or provide any management tips for a particular stress injury, or any other injury or illness. If you suspect a stress injury, please immediately contact a sports medicine specialist for appropriate evaluation and treatment recommendations. 

Overload injuries to bone are aptly called stress injuries as their often untimely presentation and unpredictable healing times can provoke high levels of emotional stress for patients and medical providers. While the actual diagnosis can require some detailed investigation, trying to identify root causes of stress injuries is a necessary detective game that can ultimately reduce the risk of future stress injuries and assess the overall bone health of the athlete.

Stress Fracture of the outer lining of tibia (shin bone) in a young dancer

A Simple Way to Understand the Types of Bone Stress Injuries in Athletes

Stress injuries to bones of athletes are often caused by relative overload, and in describing the spectrum of possible bone stress or overload injuries to patients, I often use the analogy of bending my pen while bored in class one day.

• If I just start trying to bend my pen, the pen doesn't bend much. This represents normal bone.
• As I continue to play with my pen, it does start to bend more. This represents a stress reaction where the bone is softer and less able to resist continued load. A stress reaction will create swelling (bone edema) on a Magnetic Resonance Imaging (MRI) study, but no true fracture line will be visible either on the MRI or plain x-ray study.
• If I'm really bored in class, or it's a longer class period, my continued attempts to bend the now even more weakened pen eventually may cause it to completely break on one side. This represents a stress fracture which is a progression of a stress reaction where a fracture line is seen on one cortex (outer lining of the bone) on either MRI or plain x-ray.
• Even more attempts to bend my pen may result in breaking it in half. This represents a complete fracture which is a progression of a stress fracture where the fracture line is now visible on both cortices (outer linings of the bone) on either MRI or plain x-ray.

Stress Fracture of Left Femoral Neck: This MRI picture shows a fracture line involving only one cortex (outer lining) of the femur (thigh bone) with bone swelling (edema) also present.

Look forward to an upcoming post on important things to consider after the diagnosis of a bone stress injury has been made.

Dr. Koutures Speaking at January 2015 CHOC Children's Sports Cardiology Conference

Early bird registration ends December 19, 2014.  Register today!

We have exciting news about our upcoming Sports Cardiology & Sudden Cardiac Arrest in the Young on Friday-Saturday, January 23-24, 2015.

Keynote Speaker, Michael J. Ackerman, MD, PhD, from Mayo Clinic in Rochester, Minnesota will be participating several times throughout our 2-day conference and giving his keynote address: State of the Molecular Autopsy Following SCD on Saturday morning. 

Dr. Koutures will speak on Heat Stroke: When Is It and When Is It Not? with emphasis on Prevention and Management of Exertional Heat Illness, Sickle Trait Collapse, Exertional Rhabdomyolysis and Exertional Hyponatremia.

The conference will create an opportunity for all those involved in the care of athletes and young individuals in general to gain up to date education relating to the cardiovascular effects of athletic
training as well as the diagnosis and management of individuals with inherited cardiac diseases, with the goal of preventing tragic young sudden deaths in the future.  

This biennial event attracts the world's leading experts on sports cardiology and sudden cardiac death in the young.
  
The aim of this conference is to draw together experts in the fields of sports cardiology, inherited cardiac diseases and sudden cardiac death in the young, who will discuss contemporary topics and developments in their respective fields.

One of the outcomes from this meeting will be to publish national guidelines on the "Prevention of Sudden Cardiac Arrest in the Young."  A special panel discussion on Friday afternoon will directly impact these guidelines. 

Three Causes to Consider with Chronic Knee Pain in Young Athletes

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

1) Osteochondral Lesions

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

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

Management of osteochondral lesions depends on several factors:

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

2) Anterior Fat Pad Impingement

Image courtesy of http://www.physiotherapy.co.uk/blog/wp-content/uploads/2011/09/hoffas_impingement1.gif

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

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

3) Placing Too Much Focus on the Knee

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

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

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

Be a Smart Coach- Use CoachSmart App to Make Athletes Safer

I have accessed CoachSmart while on the sidelines, and no longer have to guess or try to remember suggested adjustments for practice and games in hot or humid weather.  The information is concisely presented in the palm of my hand.

The iPhone app CoachSmart was developed by colleagues at Vanderbilt Sports Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt and is billed as the ultimate resource for coaches, offering real-time information on heat index and lightning strikes, frequently asked sports medicine and safety questions, and a group contact feature.

The The app is free to download in iTunes with an annual in-app subscription to live lightning data for $1.99.

• If lightning strikes nearby, the app sends an alert to the phone and the resource section provides information on what to do.
• The Home Screen gives current temperature, humidity, heat index and lightning strike information.
• The Map Screen is based on the user’s GPS location. One map shows lightning strikes within 25 miles, while another uses information from nearby weather stations to post current conditions, including heat index and wind chill.
• The Contacts function allows the user to compile team members’ contact info and send a message to the entire team with the touch of a button.
• The Resources section includes information that athletic trainers commonly dispense, such as hydration tips, injury prevention, concussion guidelines, and when to go to the emergency room. The resources will be updated as more information is needed or guidelines change.
• The app includes the Tennessee Secondary School Athletic Association (TSSAA) heat index guidelines.

Developed by Sports Medicine Physicians and Athletic Trainers with close guidance from coaches, the CoachSmart app brings many important topics into one easy location.

Recommending CoachSmart is now part of my pre-season safety talks to coaches, parents, and administrators, and will also be part of an upcoming lecture on Heat Illness.

The CoachSmart App was recently upgraded and returned to active status. I do not have any financial relationship with the CoachSmart App.

What is Role of Iron Supplementation in Non-Anemic Endurance Athletes?

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It is relatively common to have young endurance athletes come into my office requesting lab work to check for anemia (low red cell counts) and iron stores in hopes of finding a relatively straight-forward treatment for fatigue or low performance. While the prevailing trends in the sports medicine literature are more in favor of iron supplementation,  I must also bear caution that iron treatments alone are not a "magic bullet" and that more specific review of training regime, diet, and sleep patterns is absolutely essential.

There is no doubt that endurance athletes are at particular risk for anemia, Potential exercise-related causes include iron losses through sweat, stool and urine along with breakdown of red cells with foot impact against the ground in running. Concerns about the role of chronic training-related inflammation reducing general body iron absorption and recycling and a diet deficient in adequate iron intake may also compound the issue.

We may also hold a higher expectation for red cell count numbers in endurance athletes, and this bias creates more findings of relative anemia. Red cell levels that are in the low normal range may be fine for the less active or couch potatoes of the world, but may not be as acceptable for a higher level runner, swimmer or cyclist.

Over the past 5-10 years, I have definitely seen a movement among athletes, coaches and sports medicine experts to be more apt to recommend iron supplementation for endurance athletes who have low iron stores but who are not be anemic (have low red cell counts). Prior to that time, the prevailing thought was to favor iron treatments only for those athletes who were both anemic and having lower iron stores.  The results of a recent meta-analysis in the British Journal of Sports Medicine lend additional support that iron supplementation for low iron stores without frank anemia can improve iron status and aerobic capacity.

Interesting points discussed in the article that may further influence treatment recommendations include:

• Selecting appropriate markers to measure iron status-  serum ferritin (measure of body iron stores) can vary from day-to-day and in combination with iron saturation studies, both tests may not be adequate to reflect whole body iron status. Use of soluble transferrin receptor studies may be more accurate, though variations in lab techniques may limit comparisons of findings over time.
• Higher doses of iron supplementation over a shorter period of time were suggested to be more effective than smaller doses over longer periods with effect on iron stores to be diminished with a treatment period over 80 days. 
• Optimal dosing amounts, protocols, and routes (oral versus injected) require more study.
• Female endurance athletes may respond differently to treatment, most likely due to menstrual cycle variations on hormonal levels that may influence iron absorption.

While this information adds significant value to the measurement and treatment of iron issues in endurance athletes, it is crucial to recognize that focusing on iron alone is grossly simplistic and insufficient when evaluating performance issues in endurance athletes.

A comprehensive review of diet may reveal insufficient overall caloric intake as high level athletes often suffer from relative energy availability issues where training related caloric demands may not be met by food intake. I have often found that lower calorie diets often have low intake high protein foods such as meat. poultry, fish, and dairy sources that not only reduce intake of high level, easily absorbed iron sources (red meat, red fish, dark poultry, veal) but also essential calcium (dairy) and the protein stores needed for muscle growth and recovery (especially if ingested within 30 minutes after exercise).

Diet choices that help reduce inflammation can not only aid in absorption of essential nutritional elements, but also minimize joint stiffness, muscle soreness, and reduction in mental sharpness, Less processed foods, lower carbohydrate diets, and diets rich in items such as berries and cherries, fish and fish oils, and spices such as tumeric and ginger are recommended as part of an anti-inflammatory diet.

Inadequate sleep can also lead to inadequate performance. Emerging evidence suggests that a minimum of 8.5 hours a day (can include a short nap of no more than an hour) can reduce risk of injury, illness, and may also contribute to enhanced academic and athletic performance. Sleep is part of the overall recovery process that must be integrated into a thoughtful training program that feature adequate rest days and alternating periods of heavier and easier training that may have to be individualized for each athlete.

Fatigue and under-performance are common concerns in the endurance athletes and human nature often leads us to find convenient remedies. Findings that support iron supplementation in non-anemic athletes give some evidence-based measures of optimism, but must be tempered with the reality that more comprehensive evaluation is necessary to provide optimal outcomes. Seeking counsel from a sports medicine expert versed in training and performance concerns of endurance athletes is a sensible and often very productive step in enhancing overall health.

Vocal Cord Dysfunction: Making and Treating a Life-Changing Diagnosis

Pre-Concussion Mood Disorders May Lead to Prolonged Post-Concussion Recovery

In an effort to better identify young athletes who might be a greater risk of prolonged recoveries after suffering a sport-related concussion, the findings of a recent retrospective study indicate that a personal or family history of mood disorders maybe linked to a longer recovery period.

Researchers at Vanderbilt University compared athletes who had a three week post-concussion symptom resolution period versus those with a three month or longer symptom recovery period, and found that those with pre-concussion anxiety or depression had a 17-fold increased risk of having the prolonged recovery time.

The research team also found that a family history of mood disorders and delayed onset of symptoms were both also associated with an increased risk of prolonged symptoms after a sport-related concussion.

These findings definitely mirror my experiences in working with school-aged athletes who have suffered concussions during sport activities. 

I am more apt to ask about both personal and family history of mood disorders, often in the initial evaluation after a concussion. I will counsel families that any diagnosed or even suspected pre-existing emotional disorder, including Attention Deficit Disorder with/without Hyperactivity (not evaluated in the above study), depression and anxiety will have a tendency to worsen after concussion. 

In some cases, it is the concussion that makes pre-injury issues more clear and out in the open, and in those instances, we both have to manage the concussion issues but also give proper respect and attention to those underlying mood disorders. 

Early identification and aggressive psychological, medical, and school-based interventions are quite helpful in addressing emotional disorders. Key to have mental health colleagues available to assist in more difficult cases.

Failure to address the mood disorders leads to sub-optimal recovery.

I have also found that those pre-existing emotional disorders optimally managed with appropriate therapy and medication (when indicated) tend to have less consequences or flare-ups after an concussion. 

The findings of delayed onset of symptoms is also not a major surprise. I do tend to see namely depressive symptoms not fully present for up to 4-6 weeks after a concussion. Not sure why this occurs. Could be part of the anticipated physiologic healing response, but could possibly be a by-product of cumulative mental and physical  fatigue that accumulates by this time period and results in higher reported symptom presentations.

Baseball Safety Tips for Coaches and Parents

Important for parents to carefully monitor pitch counts, innings pitched, number of teams, and rest months.

Immediately contact your pediatric sports medicine specialist with any concerns with pain, fatigue, change in slot angle or overall performance.

Repetitive Ankle Sprains or Recurrent Ankle Swelling- Three Common Causes

When an athlete presents to me with concerns over multiple ankle sprains or on-going ankle swelling, what thoughts go through my mind?

• Inadequate Rehabilitation of Previous Ankle Injuries
  • The number one risk factor for future ankle injury is under-rehabilitation of a past ankle injury.
  • Ankle sprains are defined as stretching or partial/complete tears of the ligaments that connect bones on the outside and inside of the ankle joint. The majority of ankle injuries are caused by rolling in of the foot (called an inversion ankle injury) and cause damage to the anterior talofibular and calcaneofibular ligaments on the outside of the ankle. Injuries with rolling out of the foot are less common and cause injury to the deltoid ligament on the inside of the ankle.
  • The healing process with a damaged ligament leads to scar tissue formation at the site of the tear. Trying to come back too soon after an ankle sprain will limit the scar formation and predispose the ankle to future injury. 
  • Even with appropriate recovery time for scar formation, a sprained ligament is never completely as strong as prior to injury. Undertaking an appropriate rehabilitation program that builds up the strength and proper firing patterns of the peroneal muscles on the outside of the ankle can help compensate for the reduced ligament strength and reduce risk of later injury. Increasing strength of the muscle above the ankle, including the hip rotators, can also reduce the risk of future ankle problems.
• Underlying Structural Abnormalities such as Tarsal Coalition
  • The ankle joint is defined as the "upside-down U shaped mortise space" between the tibia (shin bone), fibula (thin bone on outside of lower leg) and the talus (first bone of foot). Below this mortise ankle joint are the sub-talar joints which include connections between the heel bone (calcaneous), talus, navicular (bone on top of inside foot arch) and cuboid (bone on outside of foot).
  • Abnormal bone or fibrous soft tissue bridges between these tarsal and sub-talar region bones can develop as part of on-going foot development or after an injury and can lead to restrictive motion of those sub-talar joints causing increased stress and higher risk of ankle sprains.
  • What are physical exam findings that suggest tarsal coalition?
    • Ask patient to walk with the feet turned in- they cannot turn feet in sufficiently to walk on the outside of the feet
    • Ask the patient to stand on toes with heels raised- when viewed from behind, the heel bone will not turn in (invert) suggesting reduced subtalar motion
    • Often these subtle physical exam findings are the best initial clues for discovering tarsal coalition
  • X-ray examination may show osteophytes (extra bone) on the front aspect of the talar neck (white arrow below), a prominent lateral process of the calcaneous, and narrowing of the joints below the talus (black arrow below). In many cases, Magnetic Resonance Imaging (MRI) or CT Scan might be needed to better define the anatomy

• Osteochondral Lesions of the Talar Dome
  • The top part of the talus bone (known as the dome) is covered by articular cartilage, and one or more ankle injuries can cause damage to the cartilage and underlying bone known as an osteochondral lesion.
  • Osteochondral lesions are notorious for not appearing on initial x-rays taken at the time of injury. Don't be fooled or lulled into complacency with normal early x-rays and an ankle that isn't getting better.
  • A classic presentation is the case of an ankle sprain which never fully recovers and results in chronic swelling of the ankle joint associated with clicking, catching, or locking sensations.
  • Often, repeat x-rays taken weeks to months after the injury may reveal signs of an osteochondral lesion (black arrow) with separation, fragmentation, and irregularity seen at the talar dome. MRI might be used to better categorize the nature of the injury.

This blog post is not intended to diagnose or treat any ankle or other injury.  If you have concerns over repetitive ankle injuries or recurrent ankle swelling, please contact me or your sports medicine specialist for a proper evaluation or treatment plan.

Comments on Recent Study Analyzing NCAA Concussion Policy

Thanks again to my wonderful colleagues at Concussion Connection for posting my comments and analysis on a recent American Journal of Sports Medicine study on NCAA Concussion Policy. 

To read my post, please click here

Do Colder Climates Foster More Sensible Development of Pitchers?

For years, I have heard claims that some Major League Teams favor drafting pitchers who grew up in colder climates.

The reason?

Fewer months able to be spent outside likely means fewer competitive pitches thrown, fewer innings pitched, and perhaps less risk of cumulative stress to shoulders and elbows. Practicing pediatric sports medicine in almost too sunny Southern California (yes indeed, we desperately need rain) I commonly encounter young throwers who pitch most if not almost all months of the year.

Now, thanks to the recent study Is Tommy John Surgery Performed More Frequently in Major League Baseball Pitchers From Warm Weather Areas?, there might actually be some scientific confirmation to these concerns.

Based on rates of elbow medial ulnar collateral ligament (UCL) reconstruction (commonly known as Tommy John Surgery) in Major League pitchers who played high school baseball in warmer vs. colder climates (defined by latitude on map and mean average temperatures), those who grew up in the warmth were found to have a more frequent and earlier UCL reconstructions than players who grew up in the colder environments.

I also found another interesting finding that almost 2/3 of the Major League pitchers in the study pool from 1974 to June 1, 2014 were from colder climates, while by the definitions utilized of warmer vs. colder climates, almost 2/3 of the 73 total studied areas were in colder climates while only 23 of 73 areas were defined as warmer. This correlation does make sense from a general statistical model, but when considering that the warmer areas contain purported baseball hotbeds such as California, Florida, Texas and countries in the Caribbean, Central and South America, the 2/3 proportion coming from colder climates again might support the higher risk cumulative stress and injury in warmer, more possible year-round baseball climates. Perhaps hibernating from too much pitching is ultimately a protective and positive thing and not just another reason to complain about bad weather in certain regions.

The published results on Major League pitchers should not be directly correlated with injury risk to pitchers at the pre-high school, high school and even collegiate or minor league levels. However, if similar studies were conducted at those levels with comparison of UCL reconstruction rates between  climates, I wouldn't be too surprised if the surgical frequencies were higher in warmer climates and possibly starting at younger ages as well.

The upshot of this post is not an endorsement or call for relocation to colder climates to foster a potential Major League Pitching career, but rather a cautionary tale that even in those fortunate and talented enough to pitch in the Major Leagues, the potential blessings to have year-round chances to competitively pitch must be tempered with the need for adequate rest and recovery. I think this need to not take undue advantage of virtually unlimited pitching opportunities does definitely correlate down to school-age and collegiate/minor league pitchers.

Once again, we are getting the message that more is not often better, especially in the long-term development of young athletes.