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

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

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

Start with 15-20 minute blocks.

How much can I spend on my phone?

Start with 15-20 minute blocks.

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

Enter the 15-20 minute block recommendation.

When to start?

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

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

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

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

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

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

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

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

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

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

Tips on Dealing with Post-Concussion Headaches

Given that headaches are the most common symptom after concussion and often the last to fully resolve,  I spend a good amount of time with my patients discussing headache triggers, anticipated healing course, and how to reduce intensity and duration. While this post is not intended to make a formal diagnosis or suggest specific treatments, I do hope to share some insights on post-concussion headaches that will help patients, families, and fellow medical providers.

• The location of the headache may be exactly at the point of impact, or perhaps on the different side of head, or even involve the entire head.

• Not uncommon to have all-day headaches right after a concussion. Waking up without a headache should be considered the first sign of improvement. Once that occurs, often headaches will still be daily, but will tend to occur later and later in the day. In the final stages of recovery, the headaches might not be daily, but rather may occur every few days.

• Look at a throbbing headache as a "pop-off valve" warning sign indicating overload of the healing brain.. While this type of headache might be frequently seen immediately after an injury, the evolution of a throbbing headache later in the recovery can indicate excessive activity, such as too much reading/schoolwork, noise exposure, or screen/media time or even a combination of all those factors at one time.  Reviewing and making adjustments in schedules and environments can turn down the cumulative overload and hopefully the throbbing headaches.

• Have found that using the 15-20 minute rule can be quite helpful for patients and families in determining if someone can read/text/play video games/watch TV after a concussion? The goal of course is to not trigger a headache or other symptoms. 
  • Pick one activity (let's say reading to start) and try to do it in a relatively quiet environment for 15-20 minutes. If that time limit is reached without a headache, cool- stop, take a break and maybe come back 30-60 minutes later for another 15-20 minute period of reading. If that second attempt also goes well, then can increase the activity period to 20-30 minutes 2-3 times a day. 
  • If headaches come about before the 15 minutes are up, then stop activity, note the time that passed before the headache began, and after the headache has resolved, try the activity again but stop 1-2 minutes before that past headache onset time.

• If a headache quickly worsens, such as the throbbing headache noted above, an immediate reduction in activity should cause some reduction in intensity. However, in any worsening headache or especially in the case of a "worst headache of my life", one should not hesitate to seek immediate emergency medical evaluation.

While the initial trauma to the head can be a primary cause of post-concussion headache, there can be several other contributors leading to more prolonged and intense symptoms:

• Commonly see a relative muscle imbalance in the suboccipital region where the skull connects to the cervical spine that can be the basis for one-sided or both sided headaches starting "in the back of the head" or with "neck pain". These types of headaches may be more noticed as the patient starts returning to reading, taking notes, and doing other activities that require holding or turning the head for longer periods of time.

• Headaches often associated with dizziness, blurring of words, or double vision that all may increase with reading, screen work, or note-taking could be a result of disordered vestibular-ocular function affecting the visual and balance centers of the brain. 

• Altered sleep patterns, commonly with difficulties either initiating or maintaining sleep, can lead to insufficient rest and an increased in headache duration and intensity. One particular trigger in the post-concussion patient is heightened sensitivity to light emitted from screen devices. Good general rules for all of us (not just post-concussion patients) include no screen devices at least one hour before bedtime and not having screen devices in the bedroom.

• Inadequate food and fluid intake can be a headache trigger for almost anyone, so just imagine how these issues can  be amplified after a concussion. Multiple small meals can be helpful as nausea or diminished appetites are common right after a head injury. Post-concussion dizziness may also be improved with adequate fluid intake, but please do check with your medical provider before increasing or adjusting any type of fluid intake after a concussion.

• Too much noise or too much light, often in combination with each other or with attempts to concentrate. May need to turn off or reduce background sounds, work individually in a quiet room, or use noise-cancelling devices. Reducing ambient lighting, turning down screen intensity, not sitting near windows with bright exterior light, or using regular or blue-light reducing sunglasses can also be helpful.

There are also over-the-counter and prescription medication, vitamin, and herbal supplements that can assist with headaches after a concussion, and I feel that a discussion of these options is best done in direct consultation with a medical provider who has examined the patient and reviewed all aspects of the medical history.

Please let me know of any other tips for dealing with post-concussion headaches.

Dr. Koutures Posts on Youth Soccer USA- Football.com

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

How to Protect the Knees of Young Athletes

What is going on with all these serious knee injuries in youth sports?   Why do young women seem to tear their Anterior Cruciate Ligaments more than young men?  

If your daughter (or son) lands with the knee caving in towards the other knee, then this article is a must read

The Anterior Cruciate Ligament (ACL) is a support ligament inside the knee that travels from the femur (thigh bone) to the tibia (shin bone), limits excessive forward motion of the tibia, and is crucial to overall knee stability.

Seemingly innocent, non-contact movements such as landing from a jump, twisting, cutting, or knee hyperextension are the most common mechanisms for ACL tears.

Studies involving several sports (basketball, volleyball, soccer) indicate that young women tear the ACL at a higher rate than young men. Several theories abound as to the reason, and a more popular thought is that abnormal landing mechanics can increase injury risk.

A preferred landing or turning occurs with the hip, kneecap and second toe lined up. Land or turn with a knee that "collapses" inside of the hip and second toe (much like the picture above) and the knee injury risk goes higher.

Tearing an ACL brings up some difficult decisions.  The athlete can select sports that do not involve cutting or jumping, or if they wish to continue higher-risk activity, surgical reconstruction with 6-9 month rehabilitation periods may be needed. Without activity modification, very few young, active athletes can return to high-level sports without frequent knee pain, instability and swelling.

Does the increased chance  of injury mean that young athletes should not play higher-risk sports?

Of course not.

I definitely think that the higher risk potential requires that certain precautions be taken to help protect the knees.

How can an athlete protect his/her knees?  

Sports-specific ACL injury reduction and knee neuromuscular training programs have been developed based on good studies that show significant reduction in ACL injuries.

Contact me for further details and specific drills/exercises particularly designed for use in weekly soccer practice warm-ups and can be applied to other jumping sports such as basketball and volleyball.

Other Knee Friendly Techniques include:

• Land from a jump on both legs as single-leg landing brings about a higher risk for ACL tear
• Land or cut with the knee slightly bent (not completely straight)
• Strengthen the hamstring muscles- these support the ACL in reducing forward tibia (shin bone) motion
• Controlled plyometric exercises (bounding and leaping) may strengthen the legs and reduce risk of ACL tears
• Make certain the athlete has good basic jumping and landing skills before starting full speed on-field play
• Knee braces have not been shown to prevent an ACL injury

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

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

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

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

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

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

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

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

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

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

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

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

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

5 Tips to Improve Recovery with Short Rest Periods Between Games or Practices

Dealing with double-day practice sessions, multi-event competitions over a weekend, or a quick turn-around from an evening event to the next morning practice? 

What are some sensible tips for young athletes to replenish energy, reduce post-exercise soreness, and be best prepared for that next practice or game?

1) Get that post work-out protein

Protein is the building block of muscle tissue, and the first 30 minutes after exercise is an ideal time for protein intake to allow muscle repair and growth. A good rough suggestion is 30 grams of protein mixed in with some carbohydrate to increase the protein absorption. Good tasting, easily accessible and rather inexpensive suggestions include a glass of chocolate milk, a container of Greek yogurt, or a large serving of peanut butter.

Click here for more info on the virtues of chocolate milk

2) Don't miss out on necessary fluids

Being under-hydrated after exercise can be a major set-up for poor performance in the next workout or game. Ideally, any fluid losses from exercise should be fully replaced, and one easy way to monitor is to do pre and post-exercise weights. Young athletes should return to their pre-practice weight before the next exercise session. 

For suggestions on fluid choice (water vs. sports drinks), click here.

3) Berries and Cherries can attack muscle soreness

Either immediate or delayed post-exercise soreness can put a damper on future sport activity. Good studies have shown that berries, cherries and even tart cherry juice have natural anti-inflammatory properties that can reduce muscle soreness with far fewer potential side-effects than both over-the-counter and prescription anti-inflammatory medications. Not only do those fruits taste much better than medications, they also provide important fluid and salt sources.

For more on tart cherry juice, click here

4) Best time to stretch is after activity

Many of us adult-types were taught that stretching before exercise was best. That though is definitely old-school and been replaced with recommendations for after exercise, when the muscles are warmed up and more able to benefit from stretching. Now, probably the last thing anyone wants to do after a hard game or practice is to take the time to stretch, but those valuable efforts that take only a few minutes can prepare muscles to better handle upcoming demands.

5) Ice Bath Challenge?

Many athletes seek out a cold water tub for their lower legs or even their entire body (below the head) to reduce soreness and help foster elimination of muscle waste products after exercise. The evidence in support of ice baths is mixed- so probably a situation where some athletes will find benefit, while others will not. 

Do you have any other recommendations for assisting in post-workout recovery to better prepare for the next practice or game?

Listen to Dr. Koutures Speak on Football Safety: High School Football America Radio Show

Thanks and appreciation to Jeff Fisher from High School Football America for the focus on football safety during his July 30, 2015 radio broadcast. A must listen for any high school football player, parent, coach, or fan who wants to learn more about:

• Contact practice limitations
• Concussion signs, symptoms, and return to school and football
• Helmets and limits to their protective abilities
• Heat Illness prevention tips
• Appropriate fluids before, during and after football activities
• Injury reduction techniques

To listen to the podcast, click here (my portion starts at 58:45)

Are there any other high school football sports medicine topics you would like to see covered during a future podcast? Email me (chris@dockoutures.com) or contact Jeff at jeff@highschoolfootballamerica.com

New Location: Orange County Return to Learn after Concussion Conference

New venue, same outstanding speaker and content!

Sign up now for the August 29th Return-to-Learn Concussion Training for OC Schools.

Designed for classroom educators, administrators, counselors, special education specialists, school nurses, speech/language pathologists, athletic trainers, and other parties who work with student-athletes after concussion.

Featuring renown speaker  Brenda Eagen Brown who will offer practical suggestions based on real-world situations supported by the latest evidence-based research.

I will join other local concussion specialists in a lunch period case-based discussion of return to learn challenges.

Wonderful PlayPositive Article on Coaches Helping Injured Players Stay Engaged

Wanted to share an excellent article by PlayPositive written for coaches to emphasize two basic tenets of Sports Medicine: focus on what one CAN do, rather than what one CAN'T do and always try to make positive learning experiences even out of the most difficult injury situations.

Very happy that our coaching colleagues can benefit from these recommendations, but the truth is that all of us involved in the recovery process (yes, that includes parents) need to read and heed this advice.

Injured athletes and performers who are unable to participate in usual training and competitive activities routinely report feeling strong senses of isolation and loss of self-identity. The formal diagnosis of an injury provides a particular set of challenges, but often the aftermath requires keeping the athlete "in the game" by continually communicating acceptable activities, cross training options, and criteria for safe advancement to advanced level of participation.

As emphasized in the PlayPositive piece, finding creative learning experiences will enable injured athletes to make important contributions not only to their long-term growth but also encourage team-based development.

An optimal response to any injury includes regular and open discussion that must be encouraged between athletes, families, sports medicine providers, coaches and other instructors. I often find that the time investment in exchanging messages, notes, and even cell phone numbers can make a huge impact and is greatly appreciated by all parties.

Do you have any particular recommendations to help keep injured athletes "stay in the game" during their recovery process? What are the most efficient ways to encourage communication between athletes, coaches, medical providers and families?

Return to Learn after Concussion Training: Coming to Orange County in August

Are you an educator, administrator, counselor, or a medical professional who works with student-athletes who are returning to the classroom environment after a concussion?

Do you have concerns, knowledge gaps, frustrations, or just plain wish to see how others manage these challenging situations?

Well, I wish to bring to your attention a  collaborative effort with the Orange County Concussion Consortium and the Orange County Department of Education to promote an important Return to Learn after Concussion Conference on August 29, 2015 featuring renown expert Brenda Eagan Brown.

Target Audience:

• School Principals, Vice Principals and other Administrators
• Classroom Teachers
• Curriculum Specialists
• School Nurses
• School Psychologists
• School Counselors
• Special Education Specialists
• Speech and Language Therapists
• Athletic Trainers
• Concussion medical experts
• Strongly recommend forming school-based teams to attend and maximize the learning experience

Please share this with colleagues and register early as seats are limited!

Getting Defensive about ACL Injuries in Soccer

Soccer players, coaches and families take notice:  two video analysis reviews of Anterior Cruciate Ligament (ACL) injuries confirmed long-time suspected vulnerability with off-balance single-leg landing, but also added a new twist: certain defensive movements may also be a previously unrecognized culprit.

Both the April 2015 British Journal of Sports Medicine (analyzed males only) and May/June 2015 Sports Health (analyzed both males/females) articles found that around 3/4 of all ACL tears occur when the opposing team had the ball and the injured athlete was defending. The Sports Health group found that females were more likely to be defending when they injured their ACL in comparison to male counterparts.

Now, while certain forwards who are reluctant (or lazy) to come back on defense may be silently rejoicing at this news, let's take a deeper look at the particular defensive situations that produced ACL injuries:

• Tackling to separate the ball from an opponent, which often requires last minute adjustments in body position and technique
• Cutting to track an opponent
• Pressing situations where the defending player typically made a sidestep cut in order to reach the ball or to tackle an opponent

Non-contact pressing mechanism (right knee). (A) At−160 ms, the defending player is running forward at high speed towards the opponent in possession of the ball. (B) At initial contact, he strikes the pitch with his right heel and makes a sidestep cut in an effort to reach the ball or to tackle the opponent, but no player contact. (C) At 80 ms, he rotates the trunk towards his left leg and puts the entire load on his right leg. (D) At 240 ms the right hip and knee joints are in abducted positions and the ankle joint is in eversion (dynamic valgus without collapse). From Walden, et al,BJSM, April,2015

In addition to defensive play, being out of balance with single-leg movements was also a more common culprits:

• Regaining balance after kicking
• Landing after heading

In both the defensive or out of balance situations, the injured knee was more apt to be in a valgus (bent inward towards the opposite knee) and straight position.

"Danger position": inward movement (valgus) and straighter right knee relative to right hip and ankle.

So, what teaching points can be made for younger soccer players?

No, we are not going to give any excuses justifying not playing defense (probably much to the chagrin to some players....).

The results of both studies indicate that ACL injury preventive interventions should place focus on keeping the knee in a flexed (bent) position and having the kneecap centered right under the hip and over the foot without any collapsing inward through:

• General postural and neuromuscular control of the core and lower extremities;

• Footwork and running technique during changes of direction in defensive playing actions, mimicking the pressing situation;

• Maintaining balance during shooting, passing and ball clearing;

• Jumping and landing technique during heading duels;

• Promoting fair play in order to avoid fierce tackling from behind

The findings of these two studies further underscore the importance of evidence based ACL injury prevention studies that can readily be found without charge on the web.

Players and parents, do you ask your coaches and trainers to include these training techniques? Coaches and trainers, are you adding value to your program by emphasizing injury prevention? Any other drills that you think would contribute to proper balance, defensive postures, landing and tackling techniques?

Turns, Jumping and Landing: Shin and Foot Injuries in Dancers

The following article is an edited version of a chapter on Adolescent Dance Medicine co-written by Dr. Koutures and Kathleen LInzmeier, MD in Adolescent Medicine: State of the Art Reviews, Vol 26 No 1 published by the American Academy of Pediatrics in April, 2015. This information is not designed to suggest or confirm any individual diagnosis. Any injury deserves complete evaluation by a dance medicine specialist.

         Advanced ballet dancers spend a great deal of time en pointe, which puts them at risk for foot injuries while in full en pointe and ankle injuries while in slight dorsiflexion (known as demi-pointe). While in full en pointe position, the ankle is relatively stable since the posterior lip of the tibia rests and locks on the calcaneus and the subtalar joint is locked with the heel in forefoot.

          A dancer is more likely to acquire a midfoot than ankle sprain while in en pointe.  Midfoot sprains result from a loss of balance while en pointe and performing spins.  Lisfranc injuries involve fractures or fracture-dislocations in the middle of the foot at the base of the long metatarsal bones.  Less common midfoot injuries include injuries to the dorsal ligaments between talus and navicular or the calcaneus and cuboid.

• GOAL: Seek immediate medical care with any twisting injury of the middle of the foot that results in  pain, swelling or feeling of limited stability

            The ankle is vulnerable to inversion injury when moving into slight dorsiflexion from en pointe position. As the ankle progressively inverts greater pressure is placed on the lateral ankle ligaments, particularly the anterior talofibular ligament. The talus is wider anteriorly and more narrow posteriorly. The inherent instability of the more narrow posterior talus combined with the vertical alignment of the anterior talofibular ligament make the ankle at risk for inversion while in plantarflexion but not fully in the more stable en point position.

         Underlying hypermobility and prior history of ankle sprains are strong predictive factor for ankle sprains. Hypermobility of the ankle joint causes forces at the foot to be transferred proximally in suboptimal fashion thus leading to injury. The incidence of recurrent injury after initial acute ankle sprain has been reported to be as high as 70%. Ankle sprains lead to reduced subtalar and ankle motion which can lead to resultant increased compensatory stresses on muscle tendon units contributing to repetitive injury. Impaired balance and proprioception can additionally follow ankle sprains and can last for up to 2 weeks following injury despite active rehabilitation.

• GOAL: Take appropriate time and get experienced guidance to allow maximal recovery from ankle sprains as an Increased risk for injury can occur if strength and coordination are not fully restored.

            Dancers are additionally susceptible to several unique fractures of the 5th metatarsal bone. Avulsion fracture of the styloid process of the 5th metatarsal, involving a fracture line perpendicular to the long axis of the bone, is associated with lateral ankle sprains as it is usually caused by sudden inversion of the foot. Acute metaphyseal-diaphyseal junction fractures, known as Jones fractures, occur with adduction of the 5th metatarsal often while the foot is plantarflexed and have a predilection for malunion due to the poor blood supply as the metaphyseal-diaphyseal junction is a vascular watershed zone. Oblique spiral fracture through the mid to distal portion of the 5th metatarsal are known as “Dancer’s fractures” and usually occur with twisting or inversion of the foot while on demi pointe.

Repetitive Landing and Jumping Resulting in Foot and Shin Injuries

            The repetitive nature of dance training can lead to many overuse injuries involving the feet and shins, especially if dancers have any underlying limiting anatomy, poor form, or insufficient rest. The spectrum of repetitive overload injury can range from soft tissue injury to bone stress reactions (increased bone resorption and production without frank fracture line) and eventually true stress fractures.

           Hallux rigidus (reduced motion of the big toe) is caused by repetitive flexion and hyperextension of the metatarsalphalangeal joint. It is usually the result of pronation of the great toe when attempting to force turnout leading to restriction of full dorsiflexion of the first metatarsalphalangeal joint with resultant prominent spur formation on the dorsal aspect of the first metatarsal head that prevents performing full relevé.  

• Many dancers with reduced first big toe motion accommodate for this limitation by putting more pressure on the outside of the foot, which can lead to ankle sprains and fractures of the fifth metatarsal. 
• GOAL: Increase first toe range of motion to reduce abnormal forces on the outside of the foot and also at the ankle, knee and hip

        Shin splints, or medial tibial stress syndrome, describe a traction periostitis that is associated with diffuse anteromedial or posteromedial tibial pain that typically involves the distal one third of the tibia.  While medial tibial stress syndrome occurs at the beginning of the season after a long period of activity, dancers are also prone to tibial stress fractures that usually occur in the middle to late season. Lower risk tibial stress fractures involve the proximal lateral or distal medial tibia. Dancers are also particularly at risk for traction fractures of the anterior tibial cortex that present with acute disability in male dancers after landing from a jump or more gradual onset in female dancers who might have poor bone health.

       The sesamoids are particularly at risk for stress injury given their vulnerable location beneath the base of the first metatarsal in the substance of the flexor hallucis brevis tendon. An exaggerated turned out position can also lead to sesamoid overload due to rolling out, which increases medial loading of the first metarsal-phalangeal joint.

• The medial (inside) sesamoid bears more stress both in releve and when dancers walk turned out. 
• GOAL: Correct turn out and plie positions so that the middle of the kneecap is over the 2nd toe can reduce stress on sesamoids and the inside of the foot.

        Another common site of stress fractures in dancers is the base of the second metatarsal, which is the longest metatarsal and therefore bears the bulk of weight while in demipointe position.  The distal aspect of the fibula, usually 10 cm above the lateral malleolus in the distal third of the shaft may also be prone to stress fractures which usually occur in the weight bearing leg and are frequently the result of poor balance and fatigue when initiating a turn.

• GOAL: Any midfoot pain, especially on the top of the arch of the inside of the foot, must be fully assessed for a navicular stress fracture which is a high risk traction injury due to repetitive jumping and landing on a plantarflexed foot.

        In the majority of stress fracture injuries plain films are typically negative and diagnosis instead requires Magnetic Resonance Imaging.  Rest from loading activities is usually necessary for healing for at least a minimum of 4 weeks, during which a dancer can utilize yoga, pilates, water based exercise and other non-impact forms of rehabilitation to correct biomechanical issues. Higher risk stress fractures, such as the anterior tibial cortex and tarsal navicular, require initial non-weight bearing on the injured limb, prolonged rest (several months) or surgical intervention and have a higher risk of adversely influencing the career of a dancer.

• GOAL: While no performer wants to be removed from dance for any period of time, knowing those situations that require prolonged rest and seeking appropriate specialty care can be the difference between ability to return to dance and the end of a career. 

Are there any other dance-related foot or shin injuries that should be mentioned? Do you have any practical tips or experience to help prevent or treat these common dance problems?

Should I Take Extra Iron to Increase My Athletic Performance?

Given an  important  role in hemoglobin, which is the part of the red cell that optimizes oxygen delivery to exercising muscles,  sufficient iron stores (best known as ferritin) are definitely essential to providing peak athletic environments.  There is little doubt that low red cell counts, also known as anemia, can torpedo both endurance and strength performance for many athletes.

Thus, should you seek out increased food and even supplement based sources of iron?

Well, the answer isn't so straight forward and depends on your current "group" of red cell counts and iron stores:

• Group 1: If you have low red cell counts with smaller red cell sizes and low iron stores, experience and science strongly suggest a need and benefit for supplemental iron intake
• Group 2: If you have normal red cell counts and normal iron stores, the prevailing thought is that supplemental iron intake is not needed and may actually have risks (organ damage, higher risk of liver cancer) that outweigh any benefits to your performance.
• Group 3: If you have normal or low normal red cell counts and low iron stores,  this is where things get real interesting as scientific studies and the sports medicine and performance communities do not have clear agreement.
  • Please click here for my thoughts on the growing trend towards medically supervised iron supplement programs in the non-anemic athlete with low iron stores. 

If that third category sounds a bit confusing, then let me add a bit more uncertainty to the picture.

• Athletic individuals have different oxygen transport and muscle function demands. Thus, what many of us consider as "normal" hemoglobin values for less active individuals may not be so acceptable for intense endurance or team sports athletes. Many athletes may strive for hemoglobin levels at least 2-3 points above the lowest range of normal.
• Hemoglobin or red cell counts can be lower in athletes due to increases in blood volume that allow for more efficient delivery of oxygen to working muscles. This is called pseudo-anemia where the red cell sizes and iron stores are both normal.
• Using ferritin to measure iron stores can be perplexing. Ferritin levels can be influenced by things like illness or even total body inflammation, so there are often cases where sick or over-trained and under-performing athletes mistakenly appear to be "doing better" with iron intake based solely on higher ferritin levels.
• If you "trust" ferritin, then deciding on acceptable levels is yet another concern. In many athletes, keeping levels in the 20-30 range is a challenge during period of heavier training or competition, with levels higher than that a true accomplishment.

So, how should you use this information to make sensible decisions for your health and athletic performance?

• Do not use any supplemental iron products (liquid iron, iron pills, ect) without appropriate medical evaluation and testing.
  • Those tests can include measurements of red cell counts (hemoglobin), total body iron, red cell iron saturation, ferritin, and possibly a test called soluble transferrin receptor which might be more accurate than ferritin in measure iron stores.
• If you are clearly in Group 1 or Group 2 from above, then your decision is probably more clearly defined.
• If like many people you are in Group 3, or even if you are in Group 1 or 2 and have questions, strong recommend scheduling a meeting with a sports medicine specialist who has additional experience, training and appreciation for the stresses and demands of higher level athletes to review your diet, training program and lab tests.  

Solid Tips on Preventing Swimmer's Ear

To water sport participants such as swimmers and water polo players, the pain of swimmer's ear can not just ruin good times in the water but also put a damper on regular life activities.

http://images.onset.freedom.com/ocvarsity/gallery/ndrbkf-wedpolo.jpg

Known in medical circles as Otitis Externa, swimmer's ear results from infection and inflammation of the external canal of the ear often due to prolonged exposure to moisture (such as in pools). Typical symptoms include pain and discharge from the outer ear along with difficulty chewing due to local swelling in front of the ear.

Once in full bloom, antibiotic and anti-inflammatory ear drops are often used for treatment, though in some instances oral pain medicines or antibiotics are needed for more severe cases. Many athletes will need a minimum of 2-3 days out of the water before being able to return.

To prevent the pain and disruption caused by swimmer's ear, follow these important tips:

• Regularly use of 2 drops of preventative ear drops in both ear canals after each and every water exposure. The combination of rubbing alcohol (isopropyl alcohol) and acetic acid (vinegar) can be purchased over-the-counter as premixed solutions or can be made at home with a 50:50 mixture of the rubbing alcohol and vinegar. 
• Don't be over-aggressive with cleaning out wax from the ear canals. Sufficient wax is the friend of a swimmer as a lack of wax in the ear canals increases the risk of infection, especially if small abrasions are left after vigorous attempts at wax removal.
• Dry out those ear canals after swimming. Tilt the head toward each shoulder to try and allow water drainage from the ear canals. Using a hair dryer at lowest settings can also help dry out the canals (just don't get too close for concerns over excessive heat or risk of hearing damage).
• Careful with metal earrings that could sensitize the ear to higher risk of infection. If possible, remove any piercings before swimming, especially in cases of recurrent swimmer's ear infections.

Can ear plugs or tighter swim caps help reduce swimmer's ear infections?

The use of hypoallergenic ear plugs with our without tight swim caps to reduce the risk of initial or recurrent infections is controversial. No substantial evidence exists to support strongly recommending plug or caps as absolute preventative devices.

Best to use the above prevention tips to reduce the risk of missing out on favorite water sport activities!

Resource: Pediatric Sports Medicine: Essentials for Office Evaluation (Koutures and Wong eds), SLACK Publishing, 2013

When Can Kids Throw a Curveball?

Want to ignite baseball passions perhaps even more than a Yankee-Red Sox or Dodger-Giant rivalry?

Ask the question “When should young pitchers throw a curveball?” and then stand back.

The basic concern is that the still developing bone and soft tissue structures in the shoulder and elbow may not be able to adequately handle the rotational forces needed to throw a curveball. A wicked curveball thrown early in a career could potentially lead to wicked damage and early termination of said pitching career.

Do scientific studies and articles offer any substantial help?

The USA Baseball Medical and Safety Advisory Committee has the recommendation that a curveball should not be thrown until age 14, with only fastballs and change-ups thrown before this age.

Why age 14? Most likely because most pitchers at this age have nearly full if not complete maturity of growth centers around the elbow and shoulder and thus these joints can better handle the forces of throwing a curveball.

• Now, not every child develops at the same point, and in pediatrics we are often trained not to use an absolute age to determine maturity, but rather to use certain milestone to better gauge individual development.
• A pretty solid (and simple) recommendation that maintain this spirit comes from a Major League team physician who states “Don’t throw breaking pitches until you nave shaved".
• The age or development-based recommendations are primarily based on baseball expert opinion and have no significant evidence-based supporting data.

On the other hand, a systemic review of published studies by Grantham et. al in Sports Health concluded that limited biomechanical and most epidemiologic data do not indicate an increased risk of injury when compared with the fastball in pitchers from Little League through professional ranks.

• The epidemiologic evidence to support limitations on the curveball is lacking rigor in study design
• The current biomechanical evidence (kinematic and kinetic analysis of the torso, shoulder, elbow and wrist) does not support limiting the use of curveballs at any level of baseball

         However, before one rushes off to the local diamond to teach the curveball to young throwers, I must share some other important conclusions:

• A young pitcher has a wicked curveball very likely will be perceived as a better pitcher and thus be asked to throw more often, leading to higher pitch counts which have been shown to contribute to  arm overuse injuries.

o   In my experience, anything that makes a young pitcher stand out (taller than peers, good control, stronger fastball) put more pressure on coaches and families to protect those talents and not let them be overused at too young an age.

• The “over the top” wrist snap motion routinely used to increase curveball spin may overload certain forearm supinator muscles, so training these muscle groups along with the shoulder rotator cuff muscles for the curveball.

o   Share this opinion, and would also recommend addressing any limitations in shoulder internal rotation range of motion that can also overload the elbow and wrist regions.

•  Do not underestimate the often unsung virtues of the change-up pitch. The authors found two studies found that throwing a changeup pitch reduced the incidence of elbow and/or shoulder pain and voiced support for USA Baseball’s recommendations to use the change-up to prevent arm injuries.

My bottom line: use stage of development, not simple a specific age, to help determine when a child is ready to throw the curveball. Realize that a good curveball sets a kid up for being asked to pitch more frequently, which can lead to overuse. Assessing shoulder, elbow, and arm strength and range of motion can reduce risk of injury when throwing a curveball.

Sorting out Causes of Elbow Pain in Young Throwers

Any type of elbow discomfort in a young thrower is not a good thing, and while the easiest kids to worry about are those who will openly report elbow pain or limited motion, other more subtle signs of a potential elbow issue might be:

• "shaking" of the arm between throws
•  less interest in throwing
•  throws going higher than usual
•  not being as accurate with the location of throws.

I get particularly concerned about kids who can use a fingertip to identify the exact location of pain and those throwers who have swelling around the elbow joint. I'm also particularly careful with any case of limited ability to straighten the elbow compared to the non-throwing arm; while this might be more acceptable in an adult thrower, it definitely is not normal in a child or early teenage thrower.

Likely culprits leading to elbow pain can include excessive throwing both in one game and over the course of season(s), poor shoulder internal rotation, lack of strength in the legs and back, and trying to snap the wrist or straighten the elbow with too  much force after releasing the ball.

I'll list several common causes  by organizing them according to location within the elbow. Of course, this post is not intended to diagnose or treat any form of pain and should not be considered formal medical advice, but rather should be used as a guide to seek care from a qualified pediatric sports medicine specialist.

A few definitions:  INSIDE OF THE ELBOW is above the pinky side of the hand, and the OUTSIDE OF THE ELBOW is above the thumb side of the hand.

Keeping in mind the following visual about the unique forces that throwing places on the elbow can greatly simplify thinking about potential elbow injuries:

source: http://radsource.us/ulnar-collateral-ligament-tears-of-the-elbow/

• Structures on the INSIDE OF THE ELBOW (BLUE ARROWS) are stretched when a ball is thrown
• Structures on the OUTSIDE OF THE ELBOW (RED ARROWS) are compressed or pushed together when a ball is thrown

Inside (Medial) Elbow Pain (again, most often caused by that stretching motion)

• Irritation of growth plate (aka: medial apophysitis or "throwers's elbow")
  • he medial apophysis is a growth center separate from the rest of the humerus bone (upper part of elbow). Both ligaments (connect bones together) and tendons (connect muscle to bone) have attachment sites to the medial apophysis, so any stretch of these attachments can pull on the growth center and cause a range of injury from more simple irritation to a frank fracture and increased separation of the growth plate
• Irritation or strain of flexor/pronator  muscles
  • These muscles start on the inside of the elbow and allow snapping and/or rolling over of the wrist. Often can be injured after learning new breaking pitches or throwing too many breaking pitches with improper form
• Stretching of Ulnar Nerve
  • The ulnar nerve runs along the inside of the elbow and repetitive stretching can lead to damage with numbness and tingling sensations that travel down into the ring and pinky fingers.
• Ulnar Collateral Ligament (UCL) Tears
  • opularly known as the "Tommy John ligament", the typical story of a UCL tear is immediate pain after one throw with inability to continue throwing. Less common in throwers who haven't completed growth- the apophysis tends to be the weaker link. In more mature throwers (high school and above), the UCL is at greater risk of injury. 

Outside of the Elbow Pain (caused by compression)

• Capitellum Injury
  • ocated at the end of the humerus bone, the capitellum can be damaged by repetitive compression leading to either damage of the entire bone (usually in throwers age 5-10) or more local areas of bone and overlying soft tissue cartilage injury (usually in thrower over the age of 13).
• adial Head Injury
  • Also caused by repetitive compression, injuries to the radial head can involve damage to the growth plate that could affect long-term growth
• xtensor-supinator muscle injury
  • These muscles control straightening and rolling of the wrist. requently known as "tennis elbow", injuries to these muscles are much more common in adults and if suspected in a younger thrower, damage to the capitellum or radial head must first be excluded before making diagnosis of extensor-supinator muscle injury.

Back of the Elbow Pain

• Olecrenon impaction syndrome
  • Repetitive straightening (extension) of elbow can cause irritation of triceps muscle insertion into the olecranon, or even bone spur formation in the olecranon region. Often caused by trying to whip the arm into the straightened position with too much force.

No matter the location of pain, any possible elbow injury in a young thrower deserve urgent and specialized evaluation to determine exact cause, review contributing factors, and provide appropriate recommendations for treatment and recovery. Trying to throw through pain may lead to more damage and ultimately reduce future ability to return to throwing activities.

What is the Best Fluid Choice for Young Athletes?

In one corner stands water, in the other stands sports drinks.

Just as young athletes go head to head on sporting fields, seems that these two heavyweightsare seemingly in competition for the designation of "best fluid choice".

Even good ol' Charlie Brown wants to know the answer, "Is there an outright winner in this battle?"

Is one better for pre-activity, during activity, or  for post-activity?

Could there actually be other fluid choices that can rise up and seize the coveted title?

Let the contest begin....

PRE-ACTIVITY

The Winner: Water just ahead of sports drinks

Why: Water provides an inexpensive, readily accessible and low-calorie option to maintain hydration. Cold water is better absorbed. For kids who for some reason won't drink water and prefer a flavored beverage, then sports drinks right before exercise are a sensible option. Keep in mind that the American Academy of Pediatrics counsels against routine consumption of sports drinks outside of sport activity due to concerns that include excessive sugar intake impacting dental health and body weight.

Guidelines for Use: The American College of Sports Medicine recommends these pre-exercise guidelines:

• Drink 16-20 fluid ounces of water or sports beverage at least four hours before exercise.
• Drink 8-12 fluid ounces of water 10-15 minutes before exercise.

Other Things to Consider: Dehydration can affect quality of exercise, ability to maintain appropriate body temperature, and lead to early fatigue and cramping.  Keep an eye on body weight, especially in hot or humid environments and when performing multiple exercise sessions with short recovery periods. More than 2% weight loss from regular weight suggests dehydration and requires adequate fluid intake (usually with water) to replenish losses and correct the reduction in body weight.

DURING ACTIVITY

The Winner: Kinda depends

Why: For most exercise activities that last under an hour, water is a very sensible choice that meets the needs of young athletes. If the exercise session lasts over an hour, water is still a solid selection, but there is an increased role for sports beverages to help replace sugar (carbohydrate) and electrolytes (salts). For those athletes who tend to be salty sweaters (white salt rings on headgear and uniforms, sweat has a distinct salt taste), sports beverages can help replace those sweat salt losses.

Guidelines for Use: Main Goal- use thirst as a guide rather than a forced schedule

Here are suggestions from our colleagues at the American College of Sports Medicine:

• Goal is to maintain fluid balance: 
• Drink 3-8 fluid ounces of water every 15- 20 minutes when exercising for less than 60 minutes depending on tolerance
• Drink 3-8 fluid ounces of a sports beverage (5-8 percent carbohydrate with electrolytes) every 15-20 minutes depending on tolerance when exercising greater than 60 minutes 
• Depending on tolerance: means use that thirst as a guide and realize that the above recommendations are a guide rather than a required mandate for most otherwise healthy athletes

Other Things to Consider: Drinking too much water can actually be dangerous, especially in ultra-endurance activities lasting several hours. Excessive water ingestion without adequate salt intake can lead to low sodium levels in the blood stream (hyponatremia) with risks of seizures, brain swelling and even death. Thus, many authorities recommend against rigid or forced consumption of water during ultra-endurance events such as marathons or triathlons.

POST-ACTIVITY

The Winner: Neither 

Why: Well, you actually cannot go wrong with water or measured amounts (again to reduce sugar/calorie burden) of sports drinks after  exercise, but if the ultimate goal is optimizing immediate (first 30 minutes after exercise) recovery including rehydration, then let me suggest some more favorable choices. 

• Chocolate milk: not only provides adequate fluids for rehydration, but also scientifically supported ratios of carbohydrate to protein that enhance muscle repair and recovery. Also delivers calcium and Vitamin D which are important for bone health (especially with indoor sport athletes that have reduced opportunity for  Vitamin D absorption due to limited sun exposure). Almond, rice or soy-based chocolate milk can be used for those who don't tolerate or are allergic to cow's milk. There usually isn't much objection to the sweet taste.
• Tart Cherry Juice: also provides necessary fluid intake with collateral benefits of anti-inflammatory properties that can reduce both immediate and delayed muscle soreness and stiffness. Might actually be able to reduce perceived need for non-steroidal anti-inflammatory medications after exercise.

Guidelines for Use: One 8-12 ounce serving of chocolate milk or tart cherry juice within 30 minutes of completing activity. Can use similar amount of sports beverage as well. Measure weight after activity- for every one pound of weight loss, recommend consumption of 16-24 ounces of fluid, of which water should be the primary component.

Other things to consider: In addition to chocolate milk, protein-rich foods such as peanut butter and Greek yogurt are helpful for muscle recovery. Berries and actual cherries are also good anti-inflammatory food sources. Limit sugar-filled sports drinks or chocolate milk to the immediate post-exercise period, and also watch high sugar content snacks after exercise.

More winning advice:  do not encourage sharing of containers (which can encourage sharing of illness) and do serve beverages cold for better absorption.

Dr. Koutures Quoted on Concussed College Athletes Choosing Early Retirement

Never easy for anyone to have to give up a sport and often the "athlete" sense of identity.

In a thoughtful and well-written article from Inside Higher Ed, Jake New weaves many perspectives on early retirement after concussion.

Highly recommend the read!

How to Keep Volleyball Knees Healthy

Kudos to accomplished writer and volleyball coach Eric Hammond for an insightful article on keeping knees healthy in volleyball players. I appreciated the opportunity to work with him and USA Women's National Team ATC Jill Wosmek on this important article.

The following table summarizes some key points, but I highly recommend you click here to read the entire piece originally published in VolleyballUSA.

Healthier knees: 5 tips
 - Avoid landing on straight knees. Always land and move "softly" 
 with hips, knees and ankles bent.
 - Try to land in good alignment, with the hips and knees lined up 
 with the second toe. Don't let your knees collapse in or rotate.
 - The best time to stretch is after practice or after a match when the 
 muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors 
 and calf muscles.
 - Don't hesitate to ice sore knees for 20 minutes after practices 
 or matches.
 - Knee pads help reduce bruises and pounding, especially 
 with repetitive diving drills. 

New California Football Contact Limits Provide Unique Opportunity to Study Effect on Concussions

According to the findings of a study published in the May 4th online edition of JAMA Pediatrics, practice periods are a major source of concussion for the high school football player. 

While the actual rate of concussion is higher in game play, just over half of the reported concussions took place during practice times.

The authors suggest that strategies should be implemented to evaluate technique, limit player-to-player contact and overall head impact exposures, and reduce other higher risk practice situations.

While the jury is still out on what constitutes proper technique, the mandates of California Assembly Bill 2127 will afford a vital opportunity to further study the influence of practice time limitations on concussion rates in high school football players.

The bill prohibits high schools from conducting more than 2 full-contact practices per week during the preseason and regular season, and prohibits this full-contact portion of the practice from exceeding 90 minutes in a single day.

To clarify, "full-contact practice" means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game.

Based on the findings of the above JAMA Pediatrics study, the hypothesis is that these new restrictions should reduce concussion rates in practice simply by limiting exposure time and cumulative risk.

Now, one might ask, why would there possibly not be a reduction in concussion rates?

• Is there a chance that limited practice times could lead to less comfort with tackling that could result in an actual higher game rate of concussion?
• Could football programs feel pressure to get in as much contact as possible during the 2 allocated 90 minutes practice periods, possibly leading to more cumulative exposure during that time?

A multi-location review of concussion rates (game and practice) is essential to confirm the effects of California AB 2127. 

In such a study, I would also suggest that concussion rates be broken down by academic grade of player, and even take into account years of experience of tackle football.

I wonder if neophytes (namely incoming freshman) who have never previously played tackle football could be at higher risk from contact practice time limits.  Would the contact time restrictions have less influence on upperclassman who have played tackle football for a longer period of time?

All stakeholders will be eager to see if indeed there is a documented reduction in overall concussion rates, and if such a reduction is seen across all levels of high school football.