Multiple Sports for Kids Translates into Multiple Benefits

Should my child play more than one sport? 

Most definitely.

Courtesy of the Franklin Institute (www.fi.edu)

Childhood is a time for challenge and exploration with a variety of sporting activity developing multiple skills and interests, usually leading to more overall sport enjoyment. 

Unfortunately, the concept of single-sport specialization is becoming more commonplace at increasing younger ages.

In fact, the American Academy of Pediatrics Committee on Sports Medicine and American Medical Society for Sports Medicine caution against early sport-specialization.

The concerns of physical injuries and emotional burnout often outweigh the benefits of concentrating on one particular sport.

Yes,there are the unique "early entry" sports such as gymnastics, figure skating, and swimming where early specialization is considered essential. 

However, those are considered more the exception rather than the rule.

More types of sport exposure often leads to more types of movement patterns and the development of a better athlete who ultimately may focus on baseball or soccer.

The cross-over potentials are endless.

Jumping skills developed in basketball can make for a more productive soccer goalkeeper.

Lower body control of wresting allows a football lineman to stay lower and be more productive with blocking technique.

Have seen the balance and body control learned in gymnastics translate into great success with diving or pole vaulting.

My ultimate example was a college baseball coach relating on how Greek Folk Dancing helped his middle fielders with their footwork when turning a double play (yes, he was Greek so bonus points there).

These more diverse athletes are less apt to get hurt or burned out, and they may have particular value for high school and college coaches. 

A multi-sport athletes can be perceived to have  more up-side potential versus the athlete who has focused on one sport for many years.

They are seen to be more receptive to higher level coaching, have less bad habits to break, and ultimately a higher ceiling.

Exposure to multiple sports may also identify previously under appreciated talents or passions.

In my work with the US Men's National Volleyball Team,  I routinely hear of how our athletes came into volleyball after first trying other sports.

As you would probably expect,  most of these taller individuals growing up in the United States were initially attracted to basketball. 

Others tried soccer or even water polo.

Now, while they might have made solid athletes in basketball or those other sports, they probably would not have achieved opportunities to play on an elite, international level and represent their country.

Had they not had the opportunity to branch out and try a new sport in middle or even high school, so much might have been lost.

Now, one more cautionary tale.

This multi-sport advice does not mean that children should participate in so many different sports that the parents feel like virtual taxicab drivers.

Make ample time for schoolwork, family time, friends, and just being a kid.      

And don't forget some simple guides to reducing injury:

• The hours per week of organized sport should not exceed the age of the child in years
• Children who less than twice as many hours per week of play compared to organized (adult driven sport) have more injury risk.

Can Vision Training Reduce Concussions?

While laudable efforts have been put into recognition, evaluation and treatment of a concussed athlete, those are all secondary prevention things done after the injury has already occurred.

Ideally, anything that can be done in the primary prevention world to stop concussions in the first place would be held in the highest of regard.

Helmets and other types of head gear unfortunately haven't served a sufficient protective role.

Now, there are efforts to look at the potential role of Visual Training to Reduce Concussion Incidence in Football, and pardon the pun, the results are eye-opening.

Over the course of 4 football seasons, researchers at a Division 1 Football institution used light board training,  strobe glasses, and tracking drills during pre-season summer camp and followed with weekly light board training during the season.

Findings indicated an association of a decreased incidence of concussion among football players during the competitive seasons where vision training was performed as part of the preseason training. The authors suggest that better field awareness gained from vision training may assist in preparatory awareness to avoid concussion-causing injuries.

The research team did caution  that this is an exploratory study and asked that future large scale clinical trials be performed to confirm the effects noted in this preliminary report.

What are my thoughts on this study?

1. I recall a discussion with a colleague regarding apparent increased in both number and complexity of concussed young athletes compared with 5-10 years ago. There is little doubt that increased concussion awareness accounts for higher patients numbers, but what about the complexity?  One offered answer surrounded the extent of visual stimulation required of students today- from tablets to smartphones, from more screen time and power point presentations- visual overload can lead to lower threshold for  head  injury. While this hasn't been strictly proven, the findings of the above study could lend support to more effective visual processing and perhaps less overall eye strain may be protective against concussions.
2. The study does compare head injury rates in the four years prior to the study and those found in the four years with the visual training intervention. There were coaching changes  and thus possibly differences in contact exposures between the before and after groups. Trying to compare the reported rates of concussion between this institution and other Division 1 school can be difficult- many programs are very guarded with injury rates, especially when it comes to concussion.  All reported concussion numbers (pre/post) seem somewhat low, but again, hard to make an exact statement due to lack of comparison data.
3. If these results are validated, I have to wonder if teams will invest the time and energy to adopt such a program. Knee injury reduction programs have been  developed with solid supporting evidence, but use by teams lags sorely lags. Concussions are obviously a big deal, so I'd like to think that credible prevention programs would be readily put into place, but part of me has doubts from this past experience.
4. Agree with the study authors that this is a preliminary study that merits further investigation with more schools and players of different ages.  Not ready to run out and ask schools to invest in the visual training equipment and protocols just yet, but quite eager to see if others can reproduce these results.

I think all of us in the sports medicine world are looking for evidence-based techniques to reduce/prevent concussions. Do the results of the above study seem reasonable to you?  Would your team or group be willing to put in the time investment if such a program proved able to limit concussions?

Dr. Koutures Named 2015 Orange County Physician of Excellence

Thanks to the Orange County Medical Association, Orange County Register, and Coast Magazine for recognizing me as a 2015 Physician of Excellence for Pediatric Sports Medicine.

Recommendations for Children and Distance Running

The risks of injury and illness in distance running may be related to the total mileage and number of hours training per week. There is no agreement amongst sports medicine professionals about distance limitations for children. Until further data are available concerning the relative risk of endurance running at different ages, the American Academy of Pediatrics recommends that if children who enjoy distance running and make the individual choice to train free of injury or ailments, there is no reason to preclude them from training for and participating in such events.

Let me re-emphasize that bold point.

Children should be the ones selecting to run, free of any pressure from peers, parents, coaches or other influences.

Most running injuries include overload injuries to muscles and bones of the legs and feet, and there is the real emotional "burnout" injury from excessive exposure to running.

Concerns have been raised over possible damage to bone growth plates from high amounts of running, but examples of this type of injury have not been consistently found in medical studies.

Looking at running injury patterns and statistics, it is fair to say that when the young athlete is generating the interest and eagerly participating in a sensible training progression, there is a fairly low risk of physical or emotional injury.

To help develop an appropriate program, many recommend using the 10 percent rule is an appropriate guide and considering certain variables:

• Weekly running distance
• Intensity (range includes long slow runs to hill training to speed work)
• Number of training days per week

An athlete should only increase one of those three variables, and no more than a 10 percent increase from the previous week.

Not having number of training hours per week exceed the number of years in the child's age has also been shown to reduce the risk of overload injury.

A comprehensive program should also ensure adequate sleep and nutritional support that can assist with recovery from training.

Studies have shown that sleeping less than 8 hours per night may lead to an increased risk of injury or illness.

Consuming protein right after exercise (one gram of protein for roughly every 2 pound of body weight) can assist with muscle repair and recovery. Chocolate milk is a particularly good choice along with Greek yogurt or peanut butter.

Finally, putting more focus on developing the running experience and less on competitive outcomes (medals won, finish times) very likely will reduce the risk of injury and foster a more productive healthy outlook on running for the young athlete. 

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?

Lower Rib Pain in Athletes

Have recently seen an interesting group of patients with significant lower rib area pain.

The pain is most often found either on the right or left side, and is particularly noted at the lowest of the twelve ribs. There might be a mass or finger-tip area of discomfort, while in others there is the pain is more spread out and may even move toward the flank or shoulder blade region.  Sometimes, the lowest few ribs actually "pop' or have excessive mobility on physical examination.

Don't tend to hear of any changes in appetite or bowel function, and if there is any evaluation of the organs or function of the abdominal cavity (liver, intestines, etc), this tends to be fairly unremarkable.

I definitely do hear about how certain body movements that can trigger issues. For some it is bending forward at the waist, while others are limited with turning/rotating or leaning back.

Here is another important commonality- they all are overhead athletes.

One is a swimmer, the next is a softball pitcher, and a third is a volleyball middle blocker, and yet another is a dancer.

As I have worked with each of them and recreate particular positions that bring about discomfort, it becomes glaringly apparent that shoulder region dysfunction is a strong contributor to the rib pain.

Now if you realize that there are three joints that make up the shoulder region, and one of them involves the scapula (wingbone) interaction with the rib cage, then the association between rib pain and shoulder function should become more clear.

Courtesy of: conornordengren.com/2011/10/14/the-shoulder-girdle-part-1-bones-and-joints-2/

• Lower rib pain on the same side as the dominant arm, such as in a softball thrower or the volleyball hitter, often is due to tightness in the front of the shoulder that limits external rotation and eventually strength and power to hit or throw an object. To compensate for this lack of shoulder external rotation, the entire trunk may over-rotate in the direction of the dominant arm, placing abnormal traction forces on the abdominal muscles that attach to the lower rib area
• Lower rib pain on the opposite side of the dominant arm often is due to tightness in the back of the shoulder glenohumeral joint that limits the follow through phase after hitting or throwing. To compensate, the entire trunk may over rotate to the side opposite the dominant arm and place abnormal traction forces on the abdominal muscles that attach to that opposite side lower rib area.
• Swimmers and dancers tend to equally use both arms and thus might have pain on either side. Looking at the scapula position on the rib cage along with tightness in the front and back of the shoulder is essential to identifying causes of abnormal forces on the lower rib region.

Once these functional issues have been identified, have found that the combination of several management concepts can contribute to resolution of the lower rib pain:

• Appropriate activity modification (limited hitting, throwing, or other provocative positions that trigger the lower rib pain)
• Focus on increasing flexibility of the front/back of the shoulder along with addressing muscle firing patterns around the scapula
• Evaluation of movement patterns in thoracic and lumbar spine that may be contributing to abnormalities at shoulder and lower rib area
• Topical pain relief to lower rib area
  • This may include topical or injected anti-inflammatory medications, hot/cold, local friction massage, and acupuncture

These type of cases illustrate the importance of considering dysfunction in regions above or below the area of pain, and how the interaction of different joints continues to be a fascinating challenge for sports medicine specialists.

The above information is meant to illustrate past experience and is not meant to diagnose or act as a substitute for proper, individualized evaluation by a medical professional. It also does not guarantee the accuracy or outcomes of any diagnosis. Please do not hesitate to contact your sports medicine specialist for more information.

Why University Athletes May Hide Concussion Symptoms

I often encounter athletes who continue to practice or play in a game despite suffering concussion signs and symptoms and since hiding this information is not considered advisable and potentially quite dangerous,  have to admit that my initial response is along the lines of "what were you thinking?"

We as medical professionals have a pretty set initial response to a concussion- any suspicion of concussion, immediately remove from activity.

Pretty certain that athletes may view the initial response to concussion in a different light than us medical types.

As I find myself more often hearing of athletes hiding symptoms, my response still is a "what were you thinking?" but rather than asked in a frustrated or ready for a lecture tone, it is asked more in a sense of wanting to appreciate their mindset.

Is it lack of appreciation for the risks of concussion? How about denial? What about worry about losing a role on the team or not wanting to "bother" anyone?

Thus, it was interesting to see that Delaney and colleagues addressed this issues with their study Why University Athletes Choose Not to Reveal Their Concussion Symptoms During a Practice or Game.

The objectives of this paper were to  better understand why athletes who believe they have suffered a concussion while playing their sport “hide,” or decide not to volunteer, their symptoms to medical staff by identifying:

• specific reasons why athletes who believed they had suffered a concussion during a game or practice decided not to seek attention from medical staff at that time, how often these reasons occurred, and how important these reasons were in the decision process
• whether there were individual variables that may have made an athlete more likely to not volunteer his or her symptoms to a therapist/trainer or physician during a game or practice.

Findings of anonymous questionnaires that asked only about "self-diagnosed" concussions revealed that almost 20% of the 469 males and female athlete respondents believed they had suffered a sport-related concussion within the past 12 months. Of great interest was the fact that 78.3% of those athletes reporting a concussion did not seek medical attention either during the practice or game.

Why not?

Main reasons for "keeping quiet" were:

• “Did not feel the concussion was serious/severe and felt could still continue to play with little danger" 
• "Had similar symptoms of a concussion in the past and felt that there was little or no danger as had no problems with previous concussions or similar symptoms in the past"
• "Fear that being diagnosed with a concussion would affect standing with the current team or future teams”
• “Fear that being diagnosed with a concussion would result in negative of repercussions from the coach or coaching staff”
• "Felt that would be removed from the game by the medical staff and did not wish this to happen”
• “Fear that being diagnosed with a concussion would result in missing future games"

So, it appears that common human emotions- denial, minimalization and fear- are playing a big role.

All are understandable and none aren't surprising.

Not saying that they legitimize hiding symptoms or make it acceptable practice.

But rather they give unique insight into the psyche of university athletes and perhaps open particular in-roads to improving the culture of reporting concussion symptoms.

We need to recognize the fear of being removed, and attempt to address this fear by underscoring importance of early admission and treatment hopefully leading to a less complicated recovery and potentially an appropriately quicker return.

We need to have teams and coaches limit any negative responses to concussion diagnoses and provide essential support to any concussed or any injured athlete for that matter.

We need to acknowledge the competitive drive of our athletes and channel this into a competitive drive to protect their brains by offering such comprehensive diagnostic and management programs that athletes wouldn't think of missing out on getting such essential care.

Thoughts on California Interscholastic Federation Concussion Return Protocol

Right before California Assembly Bill 2127 became law on January 1, 2015, I wrote on this blog many questions remained unanswered about certain provisions, namely clarifying what is meant by "no less than a seven day" return progression, when does this seven day period begin, and a better definition of appropriate supervision during this period.

Today, after reviewing the recently released California Interscholastic Federation (CIF) Concussion Return to Play Protocol, it is now readily apparent that the intent of the law was to ensure that if an athlete was concussed let's say on a Friday night, that they will not be able to return to play the following Friday night.

This comes as no great surprise to many of us in the sports medicine community and serves to bring uniformity to something that we had suspected since the bill was signed into law.

There are several other provisions of the Return to Play progression that should be of unique interest, and I will list them below along with my professional comments:

• Return to play cannot be sooner than 7 days AFTER the diagnosis of a concussion by an physician MD/DO
  • Now we know when the "clock can start" and what concerns me is not so much the sports with one game a week, but those with multiple games a week.
  • If a football player is concussed on Friday night, having the physician evaluation the following Monday or even Thursday doesn't have a real time sensitivity since that athlete is out for that next week's game and still has the seven day period potentially available to play in the following weeks game.
  • However, let's take the case of a basketball player with a tournament that involves key games possibly 8-9 days after a concussion. There might be pressure placed on the physician to see that athlete ASAP to get the clock started for a potential return in that 8-9 day period
• No physical activity for at least 2 full symptom-free days AFTER you have seen a physician 
  • Given the emphasis on the no return within a full week after a concussion, can certainly see why this element was put into place.
  • Does limit the judgement of medical teams to allow light, low-risk activities that might be well-tolerated in the initial post-concussion period and may also actually assist in that recovery.
• A certified athletic trainer (ATC), physician, or identified concussion monitor (e.g., coach, athletic director), must initial each stage successfully passed
  • Leads to an increase in the paper trail but also makes each school responsible for monitoring a step-wise return to play and not just allowing a full immediate return to sport. 
  • Hopefully this provision will further underscore the important role of a certified athlete trainer on a school campus. For those schools that don't have one, this might serve as a strong motivator to find necessary resources to support the hire of an ATC to help maintain compliance with this new law.
•  Minimum of 6 days to pass (non-contact) Stages I and II. Prior to beginning (contact) State III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor. 
  • That 6 day minimum again written with a direct eye on football and not having an athlete return for that next game after a concussion
  • Here's another spot where having an ATC can make the process easier- as a physician, if I have a strong working relationship with an ATC, I might not need to see the athlete back in my office before allowing return to contact if the ATC is comfortable with the return protocol and progress of the individual athlete.
  • Now, if there is no ATC on campus, stronger chance that I will require an office visit between non-contact and contact return.
• MANDATORY: You must complete at least ONE contact practice before return to competition. (Highly recommend that Stage III be divided into 2 contact practice days as outlined above.) 
  • Remember that AB 2127 also limits full contact  practices to only 2 ninety minute sessions per week. 
  • Curious to see how a return to play that recommends 2 contact sessions works out with these new contact practice limitations

I will close out this post with a  passionate request to CIF and the sports and school communities: despite any concerns or disagreements, this protocol is now in place and thus must be publicized, discussed and shared through multiple mediums to get the word out to all coaches, athletes, parents, administrators, and medical providers. . I can honestly say that with past state or CIF concussion policy updates, I was shocked at how often reasonable, involved, and usually well-informed colleagues were unaware or ignorant of these changes. If all schools are following the same protocol, there will be more universal acceptance of this new policy, so CIF cannot passively oversee dissemination, it must take a very active and vocal role to increase the appropriate use and eventual greater acceptance of this new protocol.

Heart and Aorta Issues in Elite Volleyball Players

My role as a team physician for the United States National Volleyball Teams allows the fortune to work with not only with elite athletes and coaches, but also with an amazing group of medical colleagues.

Davis CK, Dyar DA, Vargas LA, Grossfeld PD. Cardiovascular and Musculoskeletal Assessment of US Elite Volleyball Players. Clinical Journal of Sports Medicine, 2015

Our goals are to provide our athletes the highest quality of injury and illness prevention and treatment with efforts to continually increase our awareness of volleyball-specific medical concerns.

Figure courtesy of www.columbiasurgery.org

Elite level volleyball tends to attract taller players who happen to have longer arms and fingers more conducive to blocking and hitting. Those same characteristics that provide a competitive advantage on the court may also unfortunately be a marker for a condition called Marfan Syndrome which has abnormalities in the connective tissue of the body leading to dilation (widening) of the aorta.

The aorta is the tube-like vessel that transports blood flow from the left side of the heart to the rest of the body. Widening of the initial segment of the aorta (known as the root and ascending aorta) can take place by itself and can also be found in cases of connective tissue disorders (like Marfan syndrome). A wider aorta may lead to higher risk of rupture (dissection) leading to sudden collapse and most often death. 

So when working with a group where everyone is tall and thin, is there sufficient information to help us determine individual player risk and proper modes of evaluation?

While it might be logical to think that taller people should have wider aortic measurements, there has been a lack of data determining normal versus potentially abnormal and even dangerous measurements in tall athletes. One study of Italian Olympic Athletes proposed aortic root measurements greater than 4 centimeters in males and 3.4 centimeters in women might be worrisome, but only a few volleyball players were included in this study.

Thus, I am so very proud to share the article Cardiovascular and Musculoskeletal Assessment of Elite US Volleyball Players that was published by trusted USA Volleyball cardiology specialty colleague Paul Grossfeld and his associates at Rady Children's Hospital in San Diego.

Paul's study attempted to fill a knowledge void by evaluating elite US Volleyball players using:

• medical and family histories
• targeted physical examinations specifically focusing on abnormalities present in Marfan syndrome
• transthoracic echocardiograms.

What was found in the 37 male and 33 female US National Team members?

• Three male athletes (8%) had an aortic sinus diameter greater than or equal to 4 cm, one of whom also had an ascending aorta greater than 4 cm.
• Two female athletes (6%) had aortic sinus diameter greater than or equal to 3.4 cm, and another had an ascending aorta of 3.4 cm.
• There were no other intracardiac or arterial abnormalities. 
• Individual musculoskeletal characteristics of Marfan Syndrome were common among the athletes but not more frequent or numerous in those with aortic dilation.

Paul and his colleagues concluded that the prevalence of aortic root dilation in this population of athletes was higher than what has previously been reported in other similar populations. He also recommended long-term follow-up of these athletes as essential to better determine the potential contribution of high-level volleyball training versus individual aorta characteristics as the cause of the aortic dilation to better identify the risk of further dilation and dissection.

These findings and recommendations apply most directly to adult, elite volleyball players, but should be of interest to a wider population that includes younger volleyball players, non-elite adult volleyball players, and other taller, thinner elite athlete groups such as basketball players, crew rowers, and track and field jumpers.

Perhaps future efforts will provide more specific screening and evaluation recommendations for a wider group of volleyball players, namely junior level/collegiate athletes and non-elite level adults.

Very grateful to Paul and his group for his diligence and insight, and eager to have the opportunity to share our expanding volleyball medicine knowledge with the entire volleyball community.

Protecting Adolescent Pitchers

If you happen to know an adolescent pitcher who has the fortune of being taller or throwing harder than his peers, chances are that he is perceived as a valuable asset on the diamond.  Often this attention and demand may lead to requests to play on  multiple teams at the same time.

Unfortunately, these unique characteristics may also lead to an increased risk of shoulder and elbow injuries that could derail the promise of future enjoyment of  baseball. 

A video analysis of 420 adolescent baseball players along with review of pitching and injury histories found that for each 10-inch increase in a pitcher's height, 10 mile-per-hour increase in pitch velocity, or play for more than one team all significantly increased the risk of arm or shoulder injuries.

Does this mean that having a gun for an arm is a bad thing? Is being tall a negative in the injury world?

I think the reality is that anything that makes a young thrower stand out from peers leads to the temptation of overload and the resultant overuse arm and shoulder injuries. 

If proper perspective and patience is exercised, then less chance for badness down the road. However, if combination of all those talents mean requests for more appearances on the mound, playing for more than one team, and thus less overall rest periods, then that is when  the problems begin.

It is a natural to want to showcase talents, but for those who are blessed with certain gifts, ensuring appropriate rest during key developmental years can ward off those unwanted outcomes and lead to more enjoyment down the road.

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Chocolate Milk: A Solid Post-Game Snack Choice

Looking for an inexpensive post-exercise or post-game snack that aids in muscle recovery, delivers several key nutritional components, tastes pretty good, and will make both young athletes and their parents happy with your choice?

Look no further than chocolate milk.

Now, some might say that I have an inherent bias towards chocolate milk due to my medical school and residency years in the dairy state of Wisconsin followed by work in California (another prime milk producing region).

However, when one looks at the science, chocolate milk carries a fair amount of support.

• Chocolate milk has about 26 grams of carbohydrate and 8 grams of protein for a carbo:protein ratio that is fairly close to the 4:1 figure touted by experts to provide necessary substrates for glycogen replenishment and muscle/tissue repair after exercise.
• Reviews comparing chocolate milk to other recovery drinks including water or sports beverages found that chocolate milk may be as effective if not superior in promoting post-exercise recovery specifically by increasing post-exercise muscle protein building with an increased time to exhaustion with exercise. 
• Chocolate milk can be viewed as a more accessible and more affordable recovery beverage for many athletes, taking the place of more expensive commercially available recovery beverages.

What's even more exciting is that not only does one get the benefits of post-exercise carbohydrate (this is one form of carbohydrate  intake that can be endorsed even by a low carb diet advocate such as me) and protein, but let's not fail to mention other essential nutrients found in chocolate milk:

• With about 150 milligrams of sodium and 425 milligrams of potassium in a typical 8 ounce serving. chocolate milk can replace sweat losses of these key elements.
• Chocolate milk also contains about 300 milligrams of calcium that is more easily absorbed that other forms of calcium in food or supplements. Given the importance of adequate calcium intake especially for teenage females (about 1500 milligrams/day), chocolate milk can provide a significant daily contribution.
• Vitamin D fortified chocolate milk can provide 100 international units of Vitamin D/8 ounce serving to acts as a  key component for bone health.

So when it comes time for your post-game snack duty, or if looking for a favorable post-exercise recovery beverage, again, look no further than chocolate milk and don't forget to take in a few final key thoughts:

• Best to drink chocolate milk within 30 minutes of finishing exercise.
• Low fat chocolate milk has been studied the most, though overall fat content should not affect carbo:protein ratio or amount of other nutrients.
• If cannot tolerate or allergic to cow-based milk, can try alternatives such as almond, soy, or rice milk products.
• Best if served cold to enhance enjoyment.

Studying Role of High School Principals in Return to Learn after Concussion

If there isn't enough frustration and feeling of being overwhelmed after suffering a concussion, the process of returning a student back to academic work can only seem to magnify those concerns.

While return-to-play progression protocols have been established to assist in getting athletes back to sport, similar return-to-learn programs have lagged behind.  The sheer complexity of  meeting particular needs and schedule demands of each student requires an individualized plan created with appropriate understanding of expectations and optimal communication between medical professionals, families and educators.

Often, recommendations include  designating a point person who can advocate for the student and family by communication with fellow educators and monitor of student progress.  This same person might also provide on-going dialogue with outside medical providers. However, finding a person with appropriate knowledge and desire to accept and carry out these roles can be difficult. 

A school-based concussion management and response plan can provide further framework to delineate expectations, potential adjustments, and roles, though the actual implementation and utility of such plans has not received much study.

Given the common findings of frustration and lack of apparent coordination in the return to learn process, I was excited to review the article HIgh School Principals' Resources, Knowledge, and Practices regarding the Returning Student with Concussion  in an effort to gain unique and previously unreported insight into school-based resources and management strategies.

Using a cross-sectional computer-based survey of 465 urban, suburban, and rural public high school principals in the state of Ohio, key findings of this study included:

• Just over 1/3 of the principals had completed some form of concussion training in the past year, with those who completed such training have higher self-reported concussion knowledge scores and were more likely to have provided or supported concussion training for school faculty who were not directly involved with youth sports
• When identifying a point person, athletic trainers were most often reported, but about 1/5 of respondents did not know or designate a point person at their school. Schools that identified  more than one point person tended to  have more students, a principal with higher self-reported concussion knowledge, and to have a full or part-time athletic trainer.
• Athletic trainers were reported as the main agents of communication with medical professionals for concussed student-athletes, while school nurses and counselors assumed this role for concussed students who were not athletes. Principals, assistant principals, and guidance counselors assumed the primary role of communication with parents for all students  (regardless of athlete status).
•  When asked to respond to a list of short-term classroom adjustments commonly recommended for concussed students, over 90% of principals agreed with all or most of them, with just over 30% requiring a health care provider note to initiate the adjustments.
• Several principals reported a school response-to-intervention (RTI) team to assess student needs and to develop an intervention plan in terms of academic adjustments and accommodations.
• About 1/3 of the schools had a written concussion plan, with 75% of those plans addressing academic adjustments and accommodations.

How can we use these findings to better assist our concussed students in their effort to return to the classroom?

• A principal with concussion knowledge is essential- thus ensure more (and hopefully higher quality) concussion training for principals, which could then translate to more training for school personnel, the identification of point persons to assist concussed students, and better communication between principals and the parents of a concussed athlete.
  • Potential avenues include Internet modules from the National Federation of State High School Associations and the Centers for Disease Control and Prevention.
• An athletic trainer is essential- thus ensure that every high school campus has a  certified athletic trainer acting as an advocate for concussed students and being on campus for part/all of the academic day (not just for after-school activities) to foster relationships with teachers and help monitor student developments.
• An intervention team is essential to initiate academic adjustments early after a concussion, preferably without the absolute need of a medical provider note to reduce any obstacles.
• Providing a concussion management plan that delineates roles and expectations and is shared with all key parties (students, school personnel, families and medical providers) to provide education and on-going assessment of the utility of the plan.

What other recommendations do you have to assist concussed students return to learn? Do these recommendations seem reasonable and practical?

Three Cheers for Cheerleading Safety Tips

Cheerleaders such as bases, flyers, backspots and tumblers need agility, strength, and frequent practice to fine-tune routines and prevent injury. Unfortunately, the frequency of cheerleading injuries is rising with the increasing complexity of stunts. 

How can cheerleaders, advisors, parents and coaches reduce these injury risks?

• Practice should take place in proper environments: use mats to practice landings and dismounts, and have high ceilings for jumping and throwing routines.
• Experienced and knowledgeable instructors should be consulted to teach the basics of cheerleading in an individualized and step-wise fashion for all participants.
• Coaches should be trained in first aid, CPR, and not hesitate to collaborate with sports medicine personnel such as certified athletic trainers to prevent, evaluate, and properly manage cheer-related injuries.
• A base must know how to support a flyer without hurting him/herself, while the flyer must know how to land safely.
• Teach flyers rolling and landing techniques over and over again.
• Bases need to work on using their legs, buttock and posterior hip regions for proper lifting and holding techniques that reduce cumulative trauma to shoulders and the back.
• Tumblers should develop appropriate strength in the back of the shoulders and hip regions to take pressure off elbows, wrists, and knees.
• Pre-season conditioning is essential with focus on shoulder, hip and back strengthening exercises. An athletic trainer, physical therapist, or sports medicine physician can demonstrate and recommend appropriate conditioning programs.
• Encourage necessary recovery by regularly scheduling rest periods (at least one off day a week during season and at least 2-3 months a year off of cheerleading activities).
• Avoid multi-level pyramids or throwing of cheerleaders unless all participants are comfortable and well-trained in these skills. One weak link can ruin the routine for all others.
• If there is pain or discomfort with any portion of a routine, do not compromise personal safety or the safety of teammates. Work with a coach or obtain medical evaluation before returning to practice or competition.
• Once returning from a injury, a cheerleader should go through a progressive step-wise return by first working on individual skills such as tumbling, kicks, and tucks before moving to group activities and finally stunting.

Click here for more cheerleading safety tips.

Do you have any more suggestions for cheerleading safety tips? 

Injury Prevention Tips for Adolescent Dancers

The following Injury Prevention Guidelines summarize findings from the article The Adolescent Dancer: Common Medical Conditions and Relevant Anticipatory Guidance by Kathleen Linzmeier, MD and Dr. Koutures which is published in Adolescent Medicine State of the Art Reviews, April 2015 and is copyright from the American Academy of Pediatrics.

1)      The American Academy of Pediatrics recommends a rest period from organized physical activity that includes a minimum of 1 full day off per week and 2 to 3 months off per year.

2)      Emerging evidence suggests that the risk of injury increases when the number of hours of organized sport/dance activity per week exceeds the age of the child in number of years (eg, a 14-year-old girl should not exceed 14 hours per week of organized dance activities).

3)       Single sport or activity specialization at young ages can increase the risk of physical and emotional overuse, frequently leading to burnout and complete cessation of activity. Particular warning signs may include decreased interest in dance activities, lower school grades and attendance, less social interaction, changes in appetite or sleep, and mood alterations such as irritability, anger, or lack of fun or new activities.

4)      Incorporating recommended weekly and annual rest intervals along with varying the types of organized activities can reduce the potential for burnout.

5)      Medical practitioners may be asked for their opinion on the readiness of young dancers to begin dancing en pointe, which is an advanced ballet skill that places extreme stress on the lower leg, ankle, and foot

6)     Readiness recommendations focus not on chronologic age but on the presence of adequate whole body strength and balance (especially of the foot and ankle), lack of current restricting injuries, sufficient “pre-pointe” dance class exposure (minimum 3-4 years), and the future goals of the dancer.

6)     Screening tests that can assess appropriate proximal strength, proprioception, and placement of extremities not only for pointe but for higher-level leaping

7)      Medical professionals should maintain an open dialogue about adequate intake of calories and essential vitamins and minerals, and maintenance of healthy weight to best support ongoing dance activities.

8)      Physicians should respect the anatomic and emotional changes that occur during puberty without hesitating to modify or change focus to more basic skills to allow compensation for changes in movement patterns and coordination.

Great Advice on Preventing Teeth Damage in Sports

Thanks to Miller Orthodontics in Orange, CA for providing some key information on teeth health during sports participation.

Article one summarizes key points about the use of mouth guards and retainers during sports. it also describes in depth what to do if a tooth is knocked out on the field:

1. Find the tooth
2. Hold the tooth by the crown (the surface farthest from the gumline), not the root
3. If it is an adult tooth, try to put the tooth back in the socket right away
4. If the tooth can not be put back in the socket, store it in cold milk (do not store in tap water)
5. Bite down on a gauze pad to relieve bleeding and pain
6. Call your dentist immediately

Article two focuses on how teeth may be damaged by sugars found in juices or other sports beverages, with the following key tips:

Even one drink a day is potentially harmful, but if you are absolutely unable to give up that sports- or energy-drink habit, we encourage you to minimize your consumption, use a drinking straw or rinse with water after drinking. As odd as it may sound coming from us, do not brush immediately after drinking sports and energy drinks; softened enamel due to acid is easier to damage, even when brushing. Remember, it takes your mouth approximately 30 minutes to bring its pH level back to normal. The best thing to do is to wait an hour, then brush to remove sugar that lingers on your teeth and gums. 

An Intensive Effort to Reduce and Prevent Dance Injuries

Always a leader in cutting edge dance, Backhaus Dance is also front and center with promoting health dancer practices. Proud to be part of their Summer 2016 Intensive faculty and proud to share tips below with all dancers and dance educators.

Thrilled to have DR. CHRIS KOUTURES, MD, FAAP @dockoutures joining us! #healthy #dancers #BDSI2016 #faculty #support pic.twitter.com/30zipRd20w

— backhausdance (@backhausdance) July 12, 2016

Click on each slide to advance.

 

Taking Control of Your Concussion Recovery

Check out my February post and other great advice at Concussion Connection.

Key excerpt:

“In certain situations, less might be more by building in easier days, rest days, or even off weeks.”

Past shared posts include:

• Sleep, Screen Device Use, and Concussion Recovery
• Knowing Your Resources

10 Interesting Facts About Lower Body Injuries in Youth Soccer

1.       In youth soccer, most lower body injuries come from non-body contact and occur more in competition than training or practice sessions.  While training injury incidence rates usually do not change with increased player age, match injury incidence tends to increase with age through all age groups

2.       The time of the adolescent growth spurt (girls usually age 12-14 and boys usually age 13-16) seems to have an increased vulnerability for traumatic injuries.  Afterwards athletes seem to be susceptible to cumulative overuse injuries.

3.       Knee injuries occur in 7% to 36% of injured players and are seen more frequently in females  Middle school soccer playing females have a higher rate of anterior knee pain issues than volleyball or basketball players. Any single-sport adolescent female has a higher risk of anterior knee pain issues.

4.       Adolescent female soccer players suffer a roughly 3-6 times increased risk of ACL rupture compared to boys playing the same sport. Several factors have been proposed for the increased risk, such as anatomic differences, hormonal contributions with menstrual cycles, and higher-risk single-leg landing, turning, and jumping positions.

5.       Female adolescent players who completed certain Neuromuscular Training Programs intended to reduce knee injuries have been shown enjoy significantly reduced ACL injury rate compared with players with low compliance.

6.       Ankle injuries account for 16% to 29% of injuries and are more frequent in male and older players   Ankle contusions more common in younger players due to the more ground-oriented game, while in older players ankle sprain tend to occur due to the more aggressive and faster game.

7.       Taller players are more likely report more overall injuries than shorter players, and more apt to suffer knee injuries often by playing more physically demanding positions with jumping and abrupt turning.

8.       Shorter players are often recipients of intense and often violent direct contact to the foot and ankle regions.

9.       Greater exposure to training and competition leads to a greater risk of injury due to the high intensity of the activities.

10.   The higher incidence of injury during matches than training highlights the need for education and prevention programs in youth soccer. These programs should focus on coach education aimed at improving skills, techniques, and fair play during competitions with the goal of reducing injuries.

What ideas do I have to help reduce these risks?

• Find ways to make evidence-based injury prevention programs standard practice for all young players
• Ensure proper Certified Athletic Trainer or other medical coverage
• Place large emphasis on fair play and rule enforcement
• Caution with players tending  toward year-round or single-sport emphasis at/near their peak growth periods

What ideas would you add to help young soccer players reduce lower body injuries?

Use Young Athletes Age "2" Prevent Overuse Injuries

Do you know your child's age in years?

Can you remember the number "2"?

Good.

Those basic pieces of information allow you to make key decisions that can reduce the risk of overuse injuries in your young athlete.

If the number of hours of organized sport activity per week exceed the number of years of the age of a young athlete, then there is a statistically higher chance of suffering a serious overuse injury.

If the ratio of organized sports to free play is greater than 2:1, then there is a statistically higher chance of suffering a serious overuse injury.

That's it.

Pretty simple. Pretty easy to remember.  Pretty easy to put into practice.

Thanks to  Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes: A Clinical Case-Control Study by trusted colleagues Neeru Jayanthi, Cynthia LaBella and their co-authors in Chicago, these simple decision rules can now provide evidence-based guidance to an area where concrete recommendations were sorely lacking. Over 800 injured 7-18 year-old athletes who were treated at two sports medicine clinics were compared to similar aged healthy children who came to the same clinics for pre-participation sports physicals.

Now, what are organized sports?

Any sport activity which is organized and supervised by an adult.

This does include games, practices, conditioning, speed training, weight training, and individual skills training sessions. Probably fair to extrapolate to technique courses, choreography courses, rehearsals, and individual skills sessions for dancers and other performers.

Not only do we get those two helpful decision rules from these findings, but also an emphatic reminder of the value of free play in the safe development of young athletes.

That's another simple thing to remember and put into regular practice.

Dr. Koutures New Video Presentation Page

Check out new webpage with Video Presentations: 

https://chris-koutures.squarespace.com/dr-koutures-videos/

Current Video Presentations  include:

More to come- suggestions for future Video Presentation ideas eagerly accepted for consideration.