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Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School
Co-Author of Acclaimed Textbook
Pediatric Sports Medicine: Essentials for Office Evaluation
Orange County Physician Of Excellence, 2015 and 2016
In the end, it all comes down to relationships.
“As the years have gone by, I’ve learned to appreciate the ability of the athletic trainers to have a relationship with each player,” said Dr. Chris Koutures.
Proud of being one part of the dedicated sports medicine team at Orange Lutheran High School that serves as a model for collaboration and communication.
Whether you are a junior level or even an Olympic caliber volleyball player dealing with back pain during serving or hitting, chances are that shoulder mechanics are part of the problem.
Starting the serving or hitting motion requires both extension (leaning backward) and rotating or turning of the lower back in the direction of ball contact. For a right handed hitter or server, that would mean having the trunk and lower back rotate toward the right.
Dave Smith (#20) in early hitting phase shoulder position
Finishing a serve or hit requires rotation of the lower back away from the side of ball contact. Again, for that right handed hitter or server, that would mean having the trunk and lower back rotate towards the left after ball contact.
Kim Hill (#15) with late hitting phase shoulder position
This normal flow of movement puts localized stressors on the lumbar vertebrae bones that surround and protect the spinal cord in the lower back region between the rib cage and the pelvic bones.
Certain parts of these lumbar vertebrae, called the posterior elements which include the pars interarticularis, pedicles, and articular process/facet joints that are at unique risk for overload injuries due to repetitive compression forces and somewhat limited blood supplies to these regions.
Courtesy of www.studyblue.com
In medical terms, we would call pain coming from these movements extension or rotational-based lower back pain, and it thus would seem very logical then to focus evaluation and treatment on the lumbar spine mechanics themselves.
However, my experience in working with higher level volleyball players has taught me that often the dominant shoulder can be a primary contributing culprit to this extension or rotational-based back problem, so now when I evaluate any such type of back pain in a volleyball player, I start by looking at the shoulder.
There are commonly two types of shoulder tightness patterns that can lead to both shoulder problems and pain at the lumber spine.
The pectoralis minor, coracobrachialis and biceps short head muscles all attach to the coracoid process, which is a bone prominent coming off of the scapula.
Courtesy of fashions-cloud.com
Tightness at this attachment site can create a hunched over posture that moms always like to warn about, but also can limit the ability to raise and reach back the shoulder which provides the power needed to hit a ball at the high end of a set or the toss before serve.
If a player has limited flexibility in the front of the shoulder at the coracoid, one frequent way to compensate (or some would say, cheat) is to over-rotate at the lumbar spine in an effort to get the hitting hand far back enough to generate powerful hits or serves.
This over-rotation, while at first might allow the player to maintain high performance, may ultimately cause higher cumulative overload forces on those posterior elements of the lumbar vertebrae and those undesired stress injuries.
This condition causes pain EARLY (before ball contact) in the hitting or serving motions, and proper identification and correction of tightness at the coracoid process can lead to healthier shoulder and back function.
The glenohumeral joint is the "ball and socket" joint that is surrounded by a soft tissue joint capsule.
Courtesy of heyyoungbeliever.com
Repetitive overhead motion such as hitting or serving can lead to tightness in the back of this capsule, leading to limitations in shoulder internal rotation or the follow-through phase after ball contact.
Called Glenohumeral Internal Rotation Deficit (GIRD), this tightness can lead to reduced accuracy and speed of hits/serves.
Many volleyball players will compensate (aka cheat) by increasing rotation of the lumber spine away from the side of ball after making contact, and eventually this too will place unwanted forces on those posterior elements of the lumbar vertebrae.
GIRD causes pain LATER (after ball contact) in the hitting or serving motions, and just like with anterior shoulder tightness, proper identification and correction can reduce both shoulder and back issues while allowing more high level function.
PRE-EMPTIVE PREVENTION
Volleyball players do not have to wait for the onset of back or shoulder pain to address potential problems. Fairly quick measurements of both anterior and posterior shoulder motion patterns can lead to suggestions for stretching programs, and I routinely incorporate these into pre-season or pre-participation evaluations as part of sensible injury prevention programs.
Objective: Pediatric sports medicine is an evolving pediatric subspecialty. No workforce data currently exists describing the current state of pediatric sports medicine. The goal of this survey is to contribute information to the practicing pediatric sports medicine specialist, employers and other stakeholders regarding the current state of pediatric sports medicine.
Methods: The Workforce Survey was conducted by the American Academy of Pediatrics (AAP) Division of Workforce and Medical Education Policy (WMEP) and included a 44-item standard questionnaire online addressing training, clinical practice and demographic characteristics as well as the 24-item AAP Council on Sports Medicine and Fitness (COSMF) questionnaire. Descriptive statistics were used to summarize all survey responses. Bivariate relationships were tested for statistical significance using Chi square.
Results: 145 surveys were returned, which represented a 52.7% response rate for eligible COSMF members and board certified non-council responders. The most common site of employment among respondents was university-based clinics. The respondents board certified in sports medicine were significantly more likely to perform fracture management, casting and splinting, neuropsychological testing and injections compared to those not board certified in sports medicine. A large proportion of respondents held an academic/medical school appointment. Increases were noted in both patient volume and the complexity of the injuries the specialists were treating.
Conclusion: This pediatric sports medicine workforce study provides previously unappreciated insight into practice arrangements, weekly duties, procedures, number of patients seen, referral patterns, and potential future trends of the pediatric sports medicine specialist.
Thanks to CHOC Children's Hospital for filming my January, 2016 Grand Rounds presentation on Top Sports Nutritional Topics in Adolescent Athletes.
Topics include:
Pleased to see publication of three outstanding articles on Reducing Cumulative Arm Overuse Injuries in Young Throwers, En Pointe Readiness, and EKG Screening in Athletes for the January, 2016 edition of Pediatric Annals. This Sports Medicine themed edition is the first of a 2 part series, with the second set of articles running in February, 2016.
Some of the following content may require a subscription to Pediatric Annals for full access.
Overuse injuries are preventable when underlying contributors (GIRD, scapula dyskinesis) are addressed and enforced pitch counts are consistent with recommended limits. The single most important and modifiable risk factor in preventing injury in young throwers is activity modification and adequate rest periods prior to the onset of arm pain.
Listed below are informative blog posts with practical discussions of common sport-related concussion symptoms and concerns with helpful treatment recommendations. Please click on each bullet point below to access the particular article
Concussions do not necessarily require being hit in the head or getting knocked out. The full definition of a concussion is any fall, blow, or trauma that causes physical, emotion, or mental changes with or without loss of consciousness.
With formal names like Convergence Insufficiency and Saccadic Dysfunction you might indeed think that this stuff is far too technical to grasp, but in reality, these issues strike at the very heart of some basic life functions.
Experts Debate: How Many Concussion are Too Many for an Athlete?
In the midst of the usual complexities of recovering from a sports-related concussion, I have found that one simple mantra of "re-start activity in 15-20 minutes blocks" can be an anxiety reducing guideline.
Given that headaches are the most common symptom after concussion and often the last to fully resolve, I spend a good amount of time with my patients discussing headache triggers, anticipated healing course, and how to reduce intensity and duration
To convince you of the importance of healthy visual function after a concussion (and to get you to read this entire blog), let me ask those who have had a concussion to answer a few simple questions.
Now, while there are other potential causes for all the above issues, one very common post-concussion denominator is indeed visual dysfunction, also known as oculomotor dysfunction.
With formal names like Convergence Insufficiency and Saccadic Dysfunction you might indeed think that this stuff is far too technical to grasp, but in reality, these issues strike at the very heart of some basic life functions.
Now, without further delay, I will describe the two most common types of oculomotor dysfunction and how they can affect school and sports.
Convergence insufficiency occurs when your eyes don't work together while you're trying to focus on a nearby object. When you read or look at a close object, your eyes need to turn inward together (converge) to focus. This gives you binocular vision, enabling you to see a single image. (courtesy of Mayo Clinic)
Saccades – the ability to jump your eyes from one target to another accurately.Saccades are necessary for tracking skills while reading or copying information. In order to process visual information properly, the eyes must move smoothly and quickly from one object to another. Saccades are crucial to the ability of the visual system to perceive and interpret images. When smoothly tracking with the eyes, the eyes must also be able to cross the midline of the body without hesitation; (courtesy of NorthShore Pediatric Therapy)
There are 2 flavors of Saccadic Dysfunction- horizontal (side to side) and vertical (up and down)
HORIZONTAL
VERTICAL
Practical in-office testing strategies have been developed to better identify these issues, so do not hesitate to contact a sports medicine or concussion specialist for evaluation.
Depending on symptoms and evaluation findings, potential treatment strategies could include:
Click hear to read 3 opinions, include one from Dr. Koutures
Appreciate Patrick Skerrett and STATNews for the outreach.
Click on the following links for additional concussion information:
On a fairly frequent basis, I will see an athlete who says “I think I have a spider bite” and greets me with something like this raised “angry” appearing area with a raised central yellow component surrounded by a red, tense outer rim.
Image from: http://erinatc.blogspot.com/2013/05/staph-infections.html
Immediately, I’m thinking of something far different than a spider bite.
In the athletic or performing arts worlds, when something looks like a spider bite, a first thought should actually be a potentially devestating infection known as Methicillin-Resistant Staph Aureus or MRSA for short.
Not trying to minimize being afraid of spiders and the potentially harmful impact of their bites, but overall, MRSA infections have become much, much more common and just as frightening.
We all have bacteria that grow on our skin, and most of them are fairly decent organisms that do little to interrupt daily activities.
However, certain bacteria that live on the skin surface are more ruthless and overtime have gained an ability to cause deeper infections by developing resistance to many antibiotics and thus not always responding to usual medical treatments.
MRSA infections are just those type of worrisome beasts.
And yes, they look “just like spider bites.”
Often starting with something as simple as a small scratch or other break in the skin, if left unchecked, MRSA infections can explode into limb-threatening and even life-threatening conditions that can be readily spread to other teammates and opponents.
Caught early in the course, ultimately less chance for more complicated outcomes.
Contact and collision activities (such as wrestling or football) tend to have higher outbreak rates, but any exposed skin can be at risk.
Some individuals or even families, for reasons not fully understood, are at risk for recurrent MRSA infections.
There is no doubt, however, that prevention is key:
When I see suspicious wound, if at all possible, I try to open it up to release that yellow “pus” material.
Called “incision and drainage”, this otherwise gross procedure actually serves two very important purposes:
We think that relative overuse of antibiotics in the past helped create these more resistant bacteria, so in certain cases, depending the drainage alone (without antibiotic use) is a sensible treatment option.
In other cases, such as deeper infections (into muscles, joints, or bones) or where drainage is either unable to be done or appears to be ineffective, antibiotics may be prescribed.
If antibiotics are used, sometimes combinations are selected due to culture/sensitivity patterns and also past trends in the local community.
Oral antibiotics are generally first-line for more skin-surface infections, while deeper or more complicated infections might require hospitalization for intra-venous antibiotics or more aggressive surgical care.
Once treatment for MRSA infection has been started, the following minimal conditions must be met before return to any type of activities with contact or collision with others
When ANY suspicion of MRSA infection is raised, immediate medical attention is absolutely essential.
So, be appropriately afraid of those "spider bites".....
It seems that water bottles are virtual necessities in the sports world, right up there with the latest in athletic shoes, balls, and other key equipment. Reliance on forced drinking schedules and repeated admonitions to drink, drink, and oh yes, don't forget to drink seem to be just as commonplace.
While water or other sports fluid intake is generally considered a positive factor in sports, is there a chance that dependence, or namely over-dependence on drinking during exercise could actually cause more harm than good?
The answer is yes.
According to the Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015, over-indulgence of water and sports fluids can lead to a lowering of sodium levels in the blood stream, creating a situation called hyponatremia which can lead to fatigue, confusion, seizures, and ultimately death from brain swelling.
Related Topic:
My exposure to exercise-associated hyponatremia has been with marathons and Ironman triathlon distance events, and common teaching indicates that such endurance events indeed have the highest risk profiles.
What is particularly alarming and frightening is the growing series of reported symptomatic hyponatremia events in previously less suspected activities such as football (high school, college and professional levels), yoga, hiking and swimming. Probably several more cases that have never reached the medical literature.
All because sustained and excessive water or sports drink intake volume that became greater than sweat, urination and respiratory fluid losses leading to over-hydration and lower blood salt levels.
Yes, sports beverage do have some salt content, but often those sodium levels are too low to offset the large amount of fluid ingested. Thus, one cannot safely assume that ingesting sports beverages with their higher salt content than water will completely prevent the development of hyponatremia.
So then, should we just throw away all those sports drink bottles? Or how about do away with any forced recommendations to drink? What then are some sensible recommendations for amount of fluid intake during exercise?
I'll paraphrase from the Consensus Statement:
Bottom line- like many things in life, too much of a good thing can actually be a bad thing.
Focusing on finite amounts of fluids (bottles drank, ounces consumed) may not be the best guide, for according to the consensus statement, most healthy athletes should use thirst as a reputable guide in most exercise conditions and situations, and if there are any doubts, please do not hesitate to contact a trusted sports medicine professional for more individualized advice.
This blog post is not intended to provide specific diagnostic or treatment advice in the absence of a established professional evaluation. Individuals who read this should freely discuss information with their medical professional or sports medicine professional before changing any behaviors or practices.
The United States Soccer Federation decision to not have players under age 12 engage in heading activities and to limit heading exposure in players between age 12 to 13 has fueled many interesting exam room discussions about soccer-related concussions that have led me to develop particular thoughts on the topic, including a very unexpected and somewhat troubling take on the use of of soft helmets.
Many of my ideas have been incorporated in two thoughtful articles written by Lindsey Barton Straus, JD from Mom'sTEAM. Highly recommend taking the time to read both, as she very adeptly captures my experience and research with this important topic:
One of the main take-home points that underlies my philosophy and is echoed by several other interviewed authorities emphasized an individualized approach to determining readiness to initiate heading.
While certain categorical age-based decisions are far easier to implement, as we are continually taught in pediatric medicine, the focus should more often be placed on each child's developmental age rather than their chronologic age.
Another maxim in pediatrics- never hesitate to have a realistic discussion about a difficult topic- in this case, a dialogue between player, coach, family and medical professionals as needed to make the best decision for each athlete.
Having several such realistic discussions about preventing head injuries and making return to play decisions after concussion has also brought a unique, if not cynical insight into a related controversial topic, the use of soft helmets to reduce head injuries in soccer.
From a professional standpoint, I have always been somewhat unconvinced about the true protective value of soft helmets in soccer, and have never mandated that an athlete must wear one in order to continue playing the sport.
It didn't take long for me to learn that most of my young athletes shared my apprehension about helmet use.
However, their lack of interest wasn't due to their reading of the medical literature, or a more typical adolescent rebellion against parent/coach/medical professional authority.
Rather, they were afraid to wear them for fear of being a target.
"If I am the only one, or only one of a few that are on the field with a helmet, my opponents will come after me."
After hearing this concern several times over, I must admit that now when asked by a parent about my opinion on helmet use, I reflexively turn to the child and ask them to truthfully tell me their opinion.
Sure enough, I get reminded of the fear of being a target. Definitely makes the parents think a bit differently about helmet use, and given the lack of consistent evidence supporting their use, definitely influences my decision.
This may not be the most scientific way to form a response, and definitely is a sobering reflection on the competitive environment faced by many young players, but it does provide a practical and necessary real-world platform to best address each individual player's needs, concerns, and future expectations.
Curious if others have encountered hesitation to wear soft helmets based on perceived risk of being singled out on the playing field? Does this information change opinion on possible helmet use?
When making sports nutrition recommendations, I tend to favor the collateral benefits, lower costs, and the "knowing what you are getting", of whole food sources rather than individual vitamin or nutrient preparations.
I was energized to share the podium at the 2015 CHOC Children's RD's in Practice: Pediatric Sports Nutrition Conference with some truly amazing colleagues, and in reviewing their handouts, I found some new whole food thoughts that I felt needed to be shared.
I want to give full credit to both Shondra and Jessica Brown of CHOC Children's Sports Nutrition Program for organizing the conference, and to Becci Twombley, RD, CSSD who presented on the following important food sources for young athletes:
On November 9, 2015, as part of a concussion-based lawsuit settlement agreement, the United States Soccer Federation (USSF) announced a series of recommendations directed at identification, management, and prevention of concussions in youth soccer.
In regards to youth players heading a soccer ball, the following recommendations were released:
As one of the co-authors of the 2010 American Academy of Pediatrics (AAP) Council on Sports Medicine and Fitness Policy Statements on Injuries in Youth Soccer, I responded to questions posed by Lindsey Barton Straus, JD of MomsTEAM about certain aspects of these heading recommendations. Please click on the above link to read her entire article and my embedded comments which represent my opinions and may not be interpreted as official AAP policy.
Be on the lookout for a follow-up article from MomsTEAM that reviews return to play decision-making components of the settlement agreement
Appreciated the opportunity to speak with writer Samantha Costa on Handling Kids Sports Injuries
Topics discussed include:
In appreciation of CHOC Children's Hospital inviting me to speak on Top Sports Nutrition Concerns Seen in Adolescent Sports Medicine first at their RDs in Practice – Pediatric Sports Nutrition conference and following up with a Pediatric Grand Rounds on the same subject, figured I would compile a list of past blog posts that will form the backbone of those presentations.
In the evolving discussion regarding the impact of limited high school contact football practice time on concussion risk, findings from the University of Wisconsin suggest that less contact practices may indeed result in less football-related concussions.
Photo courtesy: http://www.ocregister.com/articles/orange-681360-park-last.html
The state of Wisconsin was one year ahead of California in mandating contact practice time restrictions. Starting with the 2014 high school fall season, the Wisconsin Interscholastic Athletic Association (WIAA) prohibited contact in practice for the first week and limited full contact to 75 minutes per week for week 2, with 60 maximum minutes per week for week three and beyond. These limits are more restrictive than in California where two 90 minute contact practice sessions are allowed per week during the high school football season, thought the definitions of full contact are similar (game speed drills/situations where full tackles are made at competitive pace and players are taken to the ground).
Licensed Athletic Trainers at several Wisconsin high schools recorded incidence and severity for each sport-related concussion, and compared the two years previous to the rule change (2081 players) with data from the first year of the new limitations (945 players).
Significant findings included
· The rate of sport-related concussion sustained in practice was more than twice as high in the two seasons prior to the rule change
· There was no change in the rate of concussion suffered in games pre and post-rule change
· There was no difference in the severity of concussion (defined as average days lost from football activity) pre (13 days lost) and post-rule change (14 days lost)
· Tackling was the primary mechanism of injury in 46% of sport-related concussions
· Years of football playing experience did not affect the incidence of sport-related concussion in the first year of the new limitations
The authors concluded that limitations on contact during high school football practice may be one effective measure to reduce the incidence of sport-related concussion
How might this relate to California?
This is a well-constructed and much needed initial evaluation on the outcomes of contact practice reductions in high school football, with subsequent years of analysis now being anticipated to see if the above findings hold true over multiple seasons.
The maximum allowed football contact times in Wisconsin are about 42% of the maximal time currently allowed in California, so one may wonder if that increased contact time may make direct extrapolations between the states more difficult. This is where a similar study after the 2015 California high school season is vital to measure the outcomes here in this state.
I was greatly impressed with the finding that there was no change in game-based concussion rate and that the years of previous playing experience not affecting the incidence of new concussion as two potentially landmark outcomes for the future of football safety. Coherent arguments have been voiced that lack of appropriate contact practice time might increase risk for inexperienced or under-prepared players, especially in game time situations. This was particularly voiced for freshman players with no previous tackle football experience. I eagerly await future studies to see if these outcomes are consistent and robust.
The lack of change in severity (again, measured in days lost) brings up a couple of thoughts. The initial reaction might be a bit of disappointment, in that reduction of cumulative head impacts in practice should perhaps lead to a lower burden of injury with a concussive blow and hopefully a quicker recovery. One may not want to try and read much into using number of days lost as a strong measure of severity, for standard return-to-play protocols often mandate a minimum of 8-10 days off from full activity which could influence the return time possibly more than symptoms and other measures of severity.
One important subject not analyzed in this study was the incidence of non-concussion injury rates before and after the practice contact limits were enacted. Concerns have been issued over under-prepared players not confident in tackling techniques or changes in technique (hitting opponent lower in body, for example) both possibly contributing to less concussions, but more shoulder, elbow, knee, leg and other musculoskeletal injuries.
Curious if any groups in California are interested or have proposed a similar analysis of our first year with the high school football practice limitations?
There is little doubt that goalkeepers are just a bit different than field players.
From being able to legally use their hands to the array of jumping and diving skills needed to keep the ball out of the net, goalkeepers develop a skill set that differs from their counterparts on the field.
Thus, it shouldn’t be surprising to learn that goalkeepers injuries can also be different in terms of causative factors and mechanisms that create risk.
The good news is that goalkeepers statistically don’t get hurt as often as field players, but when some of the goalkeeper-specific injuries do occur, they can significantly interfere with ability to play.
Here is a concise review of common soccer goalkeeper injuries and tips for reducing risks:
o Fractures to the radius bone are most commonly seen in child and adolescent goalkeepers who have their hands driven backwards towards the wrist when trying to make a save on a direct shot.
§ There is intriguing evidence that balls shot by adults or use of adult size balls (size 5 versus child-based size 3 or 4 balls) may contribute to an increased risk of radius fractures.
§ Risk Reduction Tips: Playing with age-appropriate balls and having adult/older players exercise caution when shooting on younger goalkeepers might reduce radius factures. There is no solid evidence that use of goalkeeper braces or gloves provide adequate reduction for wrist or forearm injuries.
o Side-diving can lead to abrasions (cuts) and bruises on the outside of the thigh region. Most of these are a nuisance, though open skin wounds can become infected and thus need to be watched and cleaned carefully.
§ Older, more professional level players may develop bursitis, which is inflammation of fluid-filled cavities that normally exist around the hip region
§ Risk Reduction Tips: Many goalkeepers used padded shorts for protection, though there is little evidence that both indicates that such padding reduces injury or helps guide selection of particular materials, sizes, or brands to reduce injury risk. Using a rolling motion with diving may reduce loading forces on the hip and thigh region.
o Some studies suggest that injuries to the adductor muscles on the inside of the thigh bone are more apt to occur in goalkeepers than field players, especially on the kicking leg. This might be due to the frequent rotational and leaping movements required in goalkeeping, and also might be worsened by repetitive oversue due to longer goal kicks or punting of the ball.
§ Risk Reduction Tips: Highly recommend the FIFA 11 Soccer Injury Prevention Program which has been developedfor all soccer players above age 14 (not just goalkeepers) to reduce not only hip/groin issues, but also injuries to the thigh,knee and ankle regions.
Limiting the number of longer goal kick repetitions, especially in early season practices with younger players, may reduce the cumulative burden on the hip adductor muscles. Allowing the player to gradually build strength and proper kicking technique may afford more repetitions later in the season.
o Goalkeepers also have the additional risks of having close-distance shots directed at them with little time to react or protect the head, or having other players kick them in the head when diving head-first to gain possession of a loose ball.
§ Risk Reduction Tips:
· Using a fist to punch the ball rather than attempt to make a catch in traffic may reduce the risk of either direct contact with other players or limit change of feet being taken out from below
· When going up in the air for a catch, raise elbows to protect the head (but not extending the elbows to impact or injury an opponent)
· Avoid going head-first into ball challenges, better to use feet first approach.
· Officials should enforce a reasonable protective halo distance around diving goalkeepers trying to collect balls to reduce risk of kicks or other direct blows to the head
· With potential close-range shots, teach goalkeepers to have hands up near the face for more immediate potential protection
· Soft protective helmets might reduce the risk of bruises, cuts, and even skull fractures, but they may not be able to limit rotational forces that are thought to contribute the most to concussions. There are also concerns that a player might play more aggressively when wearing a helmet and in theory actually increase rather than decrease the risk of head injury.
AUTHOR: Cindy Sanders
Often a perfunctory visit, the sports physical offers providers a golden opportunity to share information and listen to young patients.
Frequently viewed by parents and young athletes as more annoyance than necessity, it’s easy for the sports physical to devolve into automatic answers to a list of questions, a quick check of vital signs and then out the door with a signed permission slip for another year of organized activity.
But it doesn’t have to be … and really shouldn’t be … this way, stressed Chris Koutures, MD, FAAP, a board certified pediatrician and sports medicine specialist who sits on the American Academy of Pediatrics (AAP) Council on Sports Medicine & Fitness.
Instead, he continued, providers should look at the sports physical as a prime opportunity to address important issues with children, teens and parents. “There are a host of things we can look at … both sports specific and medically in general,” he said. “Every opportunity we get to sit down with a family is a chance to educate … whether with a sports physical or routine physical.”
Koutures, who is based in Anaheim Hills, Calif., is co-author of “Pediatric Sports Medicine: Essentials for Office Evaluation” and served as medical team physician for USA Volleyball and Table Tennis at the 2008 Beijing Summer Olympics. He pointed out providers have the opportunity to not only identify and fix current problems but to delve deeper to discover and address underlying issues that could prevent or reduce the impact of future injuries or illness. “One thing that pediatricians and primary care providers do so well is anticipatory guidance,” he said.
Koutures said there are a host of reasons families rely on retail clinics for a sports physical ranging from convenience to cost to the drop-in nature of such facilities. However, he pointed out, seeing your regular provider has a value-added proposition that shouldn’t be ignored. “If we do our job right, we are providing such a higher level of care,” he said. “If you have a relationship with that family, you can look at past history. We can see a history of asthma. We can look at a growth scale and see if there’s been a tremendous amount of growth. We can see immunization records,” Koutures enumerated.
He added the long checklist of issues, ailments and conditions on sports medicine forms makes it easy to simply answer ‘no, no, no’ to everything. However, those answers aren’t always accurate … whether by accident, oversight, or fear of being sidelined.
“You look at the sheet, and it says ‘no history of asthma.’ Really? There was an episode two years ago,” Koutures outlined an example of the benefit of going to a provider who knows a child’s history. “If you know the child has asthma, they can actually have a better sports experience because you are addressing and controlling the issue.”
He added, “Having that background knowledge is one more checkpoint to making sure we’re giving the best care we can.”
As important as it is to use the time to educate young athletes and their families about issues ranging from nutrition and hydration to concussion and overuse, Koutures said a sports physical is also a great time to listen. Particularly with older adolescents where part of the appointment is without the parent, Koutures said it’s a great time to open dialogue about alcohol, drugs and supplements and to allow kids to ask questions. “We need to take the time to educate ourselves,” he added of hearing a patient’s thoughts and concerns.
Listening, he continued, also plays an important role in an area where he believes providers could do a better job – assessing and addressing mental health issues. “It’s a silent epidemic,” Koutures noted of the number of adolescents feeling overwhelmed, anxious or depressed.
“If you get that one time a year to sit down with a family and address these things, you can make a big impact,” Koutures concluded of the sports physical. But, he added, “That’s not going to happen in 10 minutes.”
RELATED LINK:
AAP Council on Sports Medicine & Fitness:
Pediatric sports medicine specialist Chis Koutures, MD, FAAP, shared insights and advice on several common questions and concerns parents might have regarding their active offspring.
How Much is Too Much?
“The minimum the American Academy of Pediatrics recommends is one day off a week from organized activity,” Koutures said.
Furthermore, he continued, there are additional time limits on adult-directed activity that should be considered. “If you take the age of a child, that’s the number of hours of organized activity they should not exceed in a week,” he said of recommendations based on new data. Therefore, a 12-year-old shouldn’t participate in more than 12 hours of organized sports and practices in a week. However, Koutures stressed, this time limit doesn’t apply to additional free play with friends.
Overuse
“I think we’re seeing more overuse injuries,” Koutures said. In part, he thinks the increase is due to more children becoming one-sport athletes, which leads to repetitive motion. He added that when a child plays a number of sports, different muscle groups are engaged, and children mentally learn different movement patterns.
While physicians might not be able to change a child’s activity preferences, they can help mitigate overuse injuries through evaluation and education. “With my throwing athletes, I look at the shoulder range of motion. There are great studies that show if we can make sure they have appropriate follow through, we can reduce the risk of injury,” he pointed out.
Hydration & Nutrition
Koutures noted the AAP released a statement on sports drinks several years ago. “The belief is that for most times, water is sufficient,” he said. Koutures added that a sports drink might be appropriate when exercising for over an hour, particularly if it is hot and humid, or right after an activity to replace salt and sugar.
“We like to think of hydration as being a full time job,” he continued, noting proper hydration doesn’t occur during the small window of practice or playing. Instead, children should be drinking water regularly to prepare for … and recover from … activity.
He also tells young athletes to look at their urine to gauge their level of hydration. “If it’s really dark, that’s a sign of dehydration,” Koutures reminds them.
As for pre-activity nutrition, he said that somewhat depends on the child, time of day and personal preference or tolerance. Recognizing some kids really can’t eat much shortly before competition, he suggested trying fruit because of the liquids and quick energy it provides.
“The most important meal of the day isn’t breakfast, lunch or dinner,” he continued, “It’s what you eat right after you exercise. Getting some sort of protein mixed with carbohydrates in that first half hour after you exercise is essential for recovery.” Koutures added chocolate milk has a great protein-to-carb balance. Greek yogurt and peanut butter are also good options.
