Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



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


August 27th is Date for 2016 OC Concussion Return to Learn Seminar


We are pleased to have the renown educator and speaker Brenda Eagen-Brown, MEd, CBIS return to the OC to review practical recommendations for post-concussion Return to Learn protocols and management.

We encourage school and district-based teams to bring Return to Learn protocols, success stories, and challenging cases to create an interactive opportunity for professional growth and collaboration.

Location: CHOC Childrens Hospital Wade Center (455 S. Main, Orange, CA 92868)

Date: Saturday, August 27th

Save the Date, Share with Colleagues and Stay Tuned for Cost, Times, and Registration Links

Objectives: Participants will have a firm understanding of:

1. Concussion impact on classroom performance

2. Strategies and accommodations to reduce student symptom severity

3. Collaborating with other interdisciplinary professionals (medical/rehab/athletic) for

optimum student concussion management

4. Why schools should identify professionals at the school building level to monitor

symptoms and academics through recovery

5. Identifying key barriers to treatment for minority or underrepresented populations.

(per American Academy of Pediatrics cultural diversity requirement)

Who would benefit from attending?

  • Classroom Educators
  • School Nurses
  • Special Education Instructors
  • School Psychologists
  • Principals and Assistant Principals
  • Guidance Counselors
  • Speech and Language Therapy Specialists
  • Athletic Trainers
  • Community Pediatric Health Care Professionals
  • Mental Health Specialists
  • Neuropsychologists
  • Physical Therapists
  • Neuro-Optometrists
  • Strongly recommend forming school-based teams to attend and maximize the learning experience

Click here for information on the 2015 OC Concussion Return to Learn Seminar


Should Soccer Goalkeepers Wear Helmets?

Received an email from a colleague asking my opinion on her 9 year-old son wearing a helmet when playing goalkeeper in soccer.

When it comes to soccer helmets and preventing concussions, my usual response is that there is inadequate science to support risk reduction. I am also concerned that some players wearing a helmet may be over aggressive, or that opponents may target a player wearing a helmet.

However, these thoughts are mostly for field players.

When it comes to goalkeepers, there are some similar and yet different thoughts.

Decent evidence that soft helmet use could reduce lacerations, bruising, and potentially skull fractures that may result from the diving actions or contact with the goalposts.

However, we do not have sufficient evidence documenting helmet use can lead to less rotational injury to the brain after close-range impact.

Would still be cautious about goalkeepers feeling a false sense of over-confidence using helmets and then putting their heads in risky positions.

Helmet or not, would strongly recommend the following head injury risk reduction techniques for goalkeepers:

  • Do recommend going feet first rather than head first into a challenged ground ball situation.
  • Raising elbows and knees to protect the head when in challenge situations can also be protective, as long as not done with intent to harm another player.
  • Keeping the hands up near the face while in the ready position to anticipate a shot allows quicker reaction of hands protecting the head.
  • 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 chance of feet being taken out from below leading to uncontrolled head impact with the ground.
  • 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.

If selecting a helmet, I do recommend finding one that doesn't adversely affect peripheral vision and also one that properly fits and continues to fit with use. A recent study indicated that improper football helmet fit may lead to more complicated concussion outcomes. Changes in liner, sweat pattern, and  hairstyle among other things were found to affect helmet fit. While study was done in football, do think it would apply to helmet use of all types.

Click here for more injury prevention tips for soccer goalkeepers



These Music Videos Create Great Percussion Ergonomics and Great Sounds

Much as a dynamic video can cause a performer's career to skyrocket, analyzing video of a musician's playing style can bolster long-term success by helping to create pain-free playing environments.

I was reminded of the multiple benefits of video analysis when I had the privilege of working with Storm Marquis, a talented percussionist from Chapman University Hall-Musco Conservatory of Music. 

Not only did I get to enjoy her wonderful musical pieces, but I also earned greater appreciation of the demands of a percussionist and how subtle adjustments in her positioning and instrument placement could reduce her concerns of pain in the neck, upper back, shoulders, and forearms.

Storm was kind enough to give permission to share videos, and I'll offer some insight on observations and adjustments that were made. Gives an unparalleled opportunity to offer more accurate and individualized recommendations.

As you watch and listen, keep in mind that each style of music calls for unique body movements and instrument set up sizes. A contemporary classical drumming piece has different demands than a jazz groove.

So, sit back, enjoy some outstanding music, and let's see how great ergonomics can translate to great sounds

Drumming 1 (Contemporary Classical):

  • Start with stool height/position- should adjust height so elbows are roughly at waist level and location is close enough to drum set to avoid over-reaching at upper and lower back areas. This will take pressure off the forearms and back of shoulders. 
  • Often, can't adjust height of percussion instrument, so must adjust height of stool or chair if available 
  • As Storm plays, notice how she keeps her neck and upper back in a good upright position with a relaxed and comfortable movement transition between drums.  This is another sign of proper seat height and position relative to the drum set.
  • She keeps a relatively looser grip that creates fluid movement without an overly tight grip that would place undue pressure on the forearms

Drumming 2 (Jazz Groove):

  • Notice foot pedal position- no need to over-extend knee to reach the pedal. Allows Storm to keep a relaxed, upright position
  • Wrists are kept just above lower drum level with easily controlled movement that doesn't overuse upper back, shoulders or elbows

Tympani Drums 1:

  • Sitting middle to forward position of chair to allow comfortable movement of arms while still maintaining good neck and upper back alignment. Avoids too much forward lean in the neck and upper back that could cause unnecessary nerve pinching and muscle overload.
  • Hand placement on drumsticks to allow the weight of the tips to initiate and maintain movement. Proper hand position and weighted drum stick selection not only enhances the quality of the sound, but also reduces cumulative burden on forearms. Drumsticks should be doing most of work, not wrists or hands.

Tympani Drums 2:

  • Wonderful cross-over technique where Storm uses her entire upper body to rotate while still keeping her shoulders in good alignment with her neck and lower back. Common errors are to either cross-over only with arms or to lean too far forward with shoulders.
  • Selection of a stool or chair that rotates can support the coordinated upper body rotation, with proper positioning to reduce over-reaching

Marimba 1:

  • Start with music stand placement.  Keeping music stand near eye-level reduces forward bending of neck and overload of front part of chest.  I understand and appreciate concern that this higher stand placement may limit audience ability to see performer faces and thus is not aesthetically desired for performances. A sensible compromise might be to have higher stand placements when first learning pieces and during rehearsals. When there is more comfort with the music piece, then can consider lowering the stand.
  • Wrists are just above the lower xylophone row and kept somewhat loose to allow free reach and rotation movements. Mallets are also held somewhat loose for more pain-free motion.

Marimba 2:

  • Hand and wrist position is comfortable with enough grip pressure to hold mallets but not too tight to increase tension of forearms. Hand placement on shaft of mallets to allow weight of mallet tips to initiate and maintain the mallet movements.
  • Body stand position to keep wrists right above lower xylophone row.
  • Strong, coordinated position of upper shoulders (comes from strength work for muscles that support the scapula bone in the back of the shoulder) that allows fluid movement of lower arms and rotation at elbows and wrists.

Marimba 3:

  • Follow leg movement and position- can start by watching in mirror behind Storm and then as camera moves to cover entire body position.
  • Knees and hips are slightly bent to allow more comfortable stance, not held in a locked or rigid position.
  • Notice this allows Storm to get more into the flow of the music- not only more enjoyable for her, but also better for joints and muscles.

Vibaphone 1:

  • May or not be able to adjust vibraphone height- ideal height allows wrist placement just above instrument without need to bend at waist or head/neck. 
  • Storm has a good, relaxed stance with slight bend to knees and appears comfortable throughout the entire piece.
  • Pedal position without need to over-extend or reach with the right knee and foot.
  • Music stand placement doesn't require excessive forward bend of neck.
  • Neck and upper back kept in good alignment, any reach or rotation is from a coordinated movement of the upper body without forward position of shoulders and front of chest.

Vibraphone 2:

  • Neck and head movement coordinated with arm movements and creates a good overall rhythm of performer and music.
  • Hand placement on mallet shaft to allow weight of mallet tips to do most of work.
  • Free and fluid movement of feet, due in part to selected standing position and also to location of pedal. Rotating pedals (not fixed position) are preferred for ease of entire body movement.

I can't thank Storm enough for these awesome contributions to both her health and the health of her fellow percussionists. I sincerely appreciate what these videos have taught both of us, and am eager to share this knowledge not just with other percussionists, but with all musicians. I definitely will use video analysis in the future to provide more accurate and personalized treatment recommendations.

Now, before closing out this blog, want to share a still picture as well.

As Storm was collecting all of mallets, folders and bags, couldn't help but notice the number of items and how she was carrying them:

Made both of us realize that optimal body position and ergonomics aren't topics limited just to the music room. Apparently there aren't reliable and durable rolling devices that can substitute for the multiple bags. I sense a potential opportunity here!


Best Football Helmet to Reduce Concussion Risk- The One that Fits!

Want to know the best type of football helmet to protect against concussions in high school football?

How about the helmet that fits properly?



The findings of a study in Sports Health identify "an important new potential intervention that may reduce concussion severity and even concussion incidence."

Using Athletic Trainers to evaluate helmet fit in high school players around the United States, the authors discovered that athletes with poorly fit helmets:

  • Averaged more symptoms with a concussion
  • Experienced symptoms lasting greater than a week 

The study also evaluated the type of internal helmet liner (air bladder, foam, or gel) and found that liner type was not associated with either number of symptoms or proportion of helmets with improper fit.

Neck muscle activation has been previously studied as a protective mechanism for reducing concussion, and a poorly fit helmet may limit this protective aspect:

  • If the helmet is not secured properly to the head, the neck muscles may not be able to reduce rotational forces transmitted from the helmet to the brain.
  • A loose helmet may also delay neck muscle contraction response to an impact 

Click here for more information on the role of neck muscle activation in reducing concussion

Particular challenges in maintaining proper fit include:

  • Varying fit with sweat or playing in wet conditions
  • Altering hair styles (including shaving of head after initial helmet fit)
  • Articles worn under helmet or liner (bandanas, hoods, google or glasses straps)
  • Potential leakage of air bladder resulting in insufficient inflation
  • Damage to internal liners from direct impact or improper care of helmet

Click here for an instructive PDF on a step-wise evaluation for proper helmet fit

Bottom line: Helmet fit is not just an early season exercise- players and team officials should ensure that helmets are checked weekly, including inflation of loose air bladders, to help reduce concussion severity and duration.


From a Pediatric Sports Medicine Expert- Eight Proven Ways to Reduce Youth Sport Injuries

Question: As a pediatric sports medicine specialist, when do you usually see injuries in sports?

1) When not wearing appropriate protective equipment.

Bike helmets do no good when they are strapped to the handlebars, just like shin guards can not work if they are left in the gym bag. Make sure the equipment is in good condition, fits well (especially with growing children), and is always properly used.

2) Within a month of a new season or activity

Good studies on Marine recruits show that foot stress fractures are most commonly seen three weeks into boot camp. My experience with young athletes is quite similar as about three weeks into a new sport, I will start to see overuse injuries. The body is unable to handle the stress of a new activity, and breakdown occurs. How can this be minimized? Have the athlete prepare for the new activity with some light conditioning. Going straight from X-box football to double days on the field can be a recipe for disaster. Also, start slow and increase intensity or length of workouts slowly to allow the body to adjust- and do not forget those rest days.                                                                                        

3 )When an athlete steps up to a higher level

This often includes playing with older, more mature (and bigger) athletes, attending an intense sport camp, or starting high school or college training. No matter what success the athlete has enjoyed in the past, these situations can overtax a young body. Limit situations where 9 year-olds play with 12 year-olds. Prepare well for camp or a new school, and gradually increase the training. Sports medicine physicians use the mantra TOO MUCH, TOO FAST, TOO SOON as a recipe for overuse injuries.  

4) Playing more than one sport at a time

Many athletes can handle playing club soccer and running cross country at the same time, while some cannot. Other athletes can handle summer football, baseball, and basketball camps without missing a beat while some cannot. I will often see athletes who are burned out from too much activity and once they take a brief rest period and then focus on one sport the majority return refreshed and are more successful.

 5) Playing too much of one sport

The more is better philosophy may work for some, but is has also caused the demise of many young bodies. Repetitive activity strengthens bones and joints, but too much repetitive activity can over stress bones and joints, leading to injury. Thus, swimming for two club teams, or playing on three baseball teams may be detrimental in the long run. Do not forget that private throwing lessons or personal training sessions also add to the cumulative stress placed on the body. Factor all activities into the equation when determining limits for your young athlete.      

6) Playing through pain or discomfort

No child should ever play through any significant pain. I use a 1-10 pain grading scale (1= no pain, 10= major pain). Any pain rating higher than 2-3/10 is significant pain. Schedule an appointment if there also is pain that causes a limp, changes technique, or forces a child to change position or not want to continue activity.

7) When an athlete is tired

Fatigue minimizes the ability to make quick decisions and movements that can help avoid injuries. Tired muscles and ligaments are less able to withstand forces on the field. Make certain the athlete is getting sufficient sleep (at least 8 1/2 hours a night, especially in high school ages) and enough rest between practices and games. Despite what many young athletes think, rest is your friend.  As a parent, it is your responsibility to help your child take appropriately placed rest days.

8) Too much running in cleats

Cleats are designed for a particular sport (soccer, baseball, football, etc) and not designed for prolonged running. In early season practices with lots of running and conditioning, have young athletes wear running shoes to run, and use cleats for the sport-specific drills. Will make a huge impact in reducing lower leg/heel pain and limit missed time.

What happens if an injury is not treated correctly?    

Children tend to heal quickly (that is why I chose pediatrics) so most injuries are not a long-term concern. However, in a worst-case scenario: the athlete has life-long pain or disability. Serious growth issues can develop if a minor injury is allowed to mature into a major injury. Injuries are a common reason why kids stop playing sports, and why athletes fail in the quest for a starting job, a varsity letter, or a scholarship. Certain injuries label the child as damaged goods, for example once a pitcher has a shoulder or elbow injury- it is common for coaches and scouts to automatically write off that athlete.

Have no regrets- call and get a qualified opinion on any childhood injury.

Complete Rest After Concussion May Not Be Best Prescription

This report from the 2016 Pediatric Academic Societies meeting adds to a growing body of evidence suggesting that children who get low risk exercise even while still having post-concussion symptoms may actually have shorter recovery periods.

One may rightfully wonder if there is some selection bias in these results- kids who may have felt less burdened by concussion symptoms naturally tried to return to exercise sooner. Further study will have to explore this potential phenomenon.

Overall, I think these findings and the outcomes of similar studies provide support for a more active post-concussion recovery monitored by qualified health care providers and not just predicated on rest and watchful waiting.

The proper time to start such active recovery is not certain and likely will be an individual matter as well.

This does also bring up the fact that many current concussion return to sport policies recommend or even require that athletes must be symptom-free before being allowed to return to any form of exercise.

If continued study indeed adds support to the role of appropriately monitored and prescribed exercise to enhance recovery, then these policies, such as the California Interscholastic Federation return protocol, will need to be amended.

Rather than a "one size fits all" uniform pathway, allowing some measure of flexibility may also provide beneficial when determining starting points and type/amount of exercise.

Otherwise medical experts and school officials are possibly restricted in utilizing exercise to aid in recovery and this limitation may actually be slowing the improvement of concussed athletes.



Waiting to Start Sports at Age Five, Better Chance Your Child Will Thrive

Formal introduction of organized sports should begin at age 5 at the earliest. 

Simple skills such as throwing or kicking a ball are part of normal toddler development. However, children this young are not ready for more complex tasks like proper throwing or kicking technique. All play at this age should be fun and spontaneous with minimal organization.

I highly recommend that all pre-school and early school--aged children learn basic movements skills such as balancing, tumbling, rolling, and jumping. No matter what activity is selected later in life, command of these fundamental tasks will enhance athletic ability and safety. 

Why wait until age five for organized sports?                                                                                                                                         

Most five year-old children have developed somewhat of an attention span to listen to adult teachers, work with other children, and follow simple multi-step commands.  They also can learn a task in one situation (school) and repeat it in a new situation (home). All these reasons explain why children start kindergarten at age five. These capabilities will also translate to a better learning experience with the main emphasis on fun and learning of the basic sport skills.

Start off with other healthy sport habits:

  • Allow a child to explore a variety of organized activities, and do not forget the importance of free play.
  • Even at this young of an age, remember that kids should who participate in more hours of organized sport per week than their age in years have a higher risk of injury.
  • Thus, five year olds should not exceed five hours per week of organized sport and better yet should have at least ten hours (twice that number) of unstructured free play.
  • In the early years of organized sport, there should be no competition (keeping score or standings) as competition is so complex it may interfere with learning skills.
  • Repeat as many times as necessary: there should be no competition. 

Contrary to the beliefs of many parents and coaches, an early start or early success in sports is not consistently correlated with success in later years. Thus, the key to five year-olds is to teach proper technique and focus on the basics.  At this young age, the winning percentage should not be based on any measure of wins and losses, but rather on how much fun the children have and how many want to play again the next season.

For more expert tips on starting your child in sports or for any pediatric sports medicine issues, call the office (714-974-2220) for an appointment with a pediatric sports medicine specialist.

Pediatric Sports Medicine Specialist Shares Key Tips on Preventing Arm Injuries in Young Pitchers

Thanks to St Joseph Hospital of Orange for selecting me to write the April, 2016 Physician Link on the key topic of Preventing Arm Injuries in Young Throwers

For more information on preventing arm injuries in young throwers, please check out the following links or call the office to schedule a complete evaluation

Cal AB 2182: Forgets Most Crucial Player in High School Concussion Management

I'm going to applaud the intent of California AB 2182 to help identify and protect high school athletes dealing with concussions.

I'm also going to applaud the sensible decision by legislatures to put the brakes on a state-wide implementation and rather request a smaller pilot program instead.

Now, I'm going to stop clapping and start getting upset.

Here's the crux of AB 2182:                                                                                                            The bill would require a school district, charter school, or private school that offers an athletic program to pay for neurocognitive testing or provide neurocognitive testing, as defined, for pupils who participate in interscholastic athletics in any of 12 designated sports. The bill would require this testing to take place at the beginning of an athletic season before any competitions have taken place, within 72 hours after any head injury and would require that this baseline testing be repeated at intervals not exceeding 24 months for as long as the athlete is enrolled at the school. The testing would be supervised by a licensed heath care provider who is trained in the management of concussions or other head injuries and is acting within the scope of his or her
practice. (emphasis mine)

Anyone associated with high school sports medicine knows full well that a Certified Athletic Trainer is absolutely the most qualified and appropriate health care provider to supervise any form of on-site injury monitoring program such as neurocognitive testing,

It is a embarrassing farce that California is the only US state not to recognize and license Certified Athletic Trainers, so in essence, the same governor that has twice vetoed professional license status now could be asked to support a bill that would potentially create unmitigated disasters without the expertise and contributions of Certified Athletic Trainers.

Who else would be best suited to organize pre-season testing, analyze those results and share with school officials and professional colleagues, deal with athletes who missed or sandbagged the initial testing, arrange for post-injury testing and help confidentially communicate those findings with concerned athletes, coaches, families and fellow medical treating professionals in often emotional and time-sensitive environments?

Anyone else going to line up for this job?

And let's not forget that neurocognitive testing is just one facet of concussion evaluation, and is not the definitive, "pass or fail concussion test" that many have been led to believe.

Appropriate concussion management takes into account many components (including symptoms, balance, vestibular/ocular function, academic performance, mental health) and the ultimate return to both the classroom and the athletic field requires an individualized multi-step process that often requires a team of health care providers.

Let's not also forget that concussions aren't the only issues frequently seen on the high school campus. Every other athletic-related injury requires professional evaluation, management, and coordination to determine severity, need for treatment and rehabilitation, and determine criteria and ability for return to play.

Again, who is the most qualified professional for this job?

You got it, the Certified Athletic Trainer.

Yet estimates show that only 40% of high schools have the most important components of concussion and all injury advocacy and management walking around campus on a daily basis.

So, I'm very frustrated with our California governor and his lawmakers.

Rather than address known, existing crucial deficiencies in providing licensure to Certified Athletic Trainers and funded employment opportunities, the decisions supporting AB 2182 would rather put time and money into testing that likely will not have the necessary foundation for success.

My professional experience has shown that if the allocation decisions were up to me and many of my fellow sports medicine specialty colleagues, we'd take that time and money to fund Certified Athletic Trainers and get our athletes a high return on that investment.

I certainly hope that some, if not all of the pilot schools are institutions that don't have Certified Athletic Trainers so those who analyze the results will get a practical impression of the true struggles raised by this bill.

Now, maybe in a somewhat backwards fashion AB 2182 will actually reveal the importance and expose the lack of Certified Athletic Trainer participation in the daily health and injury identification and monitoring, leading to state-based license recognition and unprecedented levels of placement in high school around the state.

If this happens, wow, then I will really be ready to applaud!






Best Warm-Up Programs for Young Soccer Players Reduce Injuries and Save Money

Adds to a growing list of studies supporting evidence-based neuromuscular training programs to reduce burden of both injuries and their associated economic costs.

Looking for neuromuscular training programs for young soccer players?

Check out these links:



Teens: 7 Essential Tips to get 8-9 Hours of Sleep and Decrease Injury Risk

Not quite able to get that elusive 8-9 hours of sleep per night?

Figure there will be catch up on the weekend, or once summer starts, or after the upcoming tournament ends?

Maybe you just don't think that sleep is that important in general safety, training and competition?

Well, if your goal is to optimize overall performance while limiting risk of injury, then wake up and take notice of the following studies on the importance of sleep:

  • Colleagues from Children's Hospital of Los Angeles found that adolescent athletes who slept more than 8 hours a night were 68% less apt to be injured than peers who did not get that much sleep per night. Athletes who reached higher grade levels in school actually had higher injury risks, so the additional sleep recommendations are even more important for older adolescents versus younger adolescents.


  • The USA Centers for Disease Control reports that teenagers who got 7 or fewer hours of sleep a night had a higher prevalence of risky behaviors such as not wearing bike helmets or seatbelts, driving a car after drinking or riding in a car with a driver who had been drinking, or texting while driving when compared with teenagers who got 9 hours of sleep a night.
  • Check out the wonderful infographic below from that compares a well rested athlete with a tired counterpart in a visual description of how poor sleep directly leads to poor performance. The graphic also illustrates the sleep habits of several well-known athletes and gives sensible tips on how to increase the quantity and quality of your sleep.


  • For those who must deal with frequent long-distance travel and the demise of regular sleep habits, there's an App for that. Researchers at the University of Michigan utilize smartphones to monitor circadian clocks and make recommendations on lighting and other tips to more rapidly adjust to new time zones with travel.

Now, even when young athletes try to get this adequate amount of sleep, It is very common to have struggles with falling asleep, especially in the junior high or early high school years. If this scenario sounds familiar, start with the following recommendations:

  1. Use bedrooms only for sleeping and changing clothes

  2. Eliminate or reduce electronic exposure (TV, DVD, smartphones, computers, etc) in the bedroom

  3. If must have electronic devices in bedroom, set to silent mode and turn upside down so screen is not visible
  4. Try to go to sleep within 1/2 hour of the same bedtime every night, even on weekends and other days without school

  5. Stop all electronic exposures at least one hour before bedtime

  6.  Limit caffeine use at or after dinner time

  7.  If having trouble falling asleep, turn your clock/timer around so you can't see the time

Many teenagers report awaking frequently during the night, or even more perplexing, getting the recommended 8+ hours a night, but still awakening tired or feeling fatigued during the day. In in these cases, highly recommend scheduling a medical evaluation to review sleep habits and hygiene, with focus on possible tonsil/adenoid enlargement, overtraining, uncontrolled asthma or allergies, depression/mood disorders and other illnesses that might contribute to interrupted sleep or poor sleep quality.

Identifying and Managing Anorexia Nervosa and Exercise Anorexia in Dancers

Was recently asked about my professional experience identifying and managing anorexia nervosa in the dance world, and will share thoughts below.

1.      Have you noticed any different approaches that you need to take throughout treatment of dancers who have or might have anorexia nervosa?

For all patients dealing with anorexia nervosa, one of the main initial issues is acknowledgingthat they suffer from the illness. Given that many dancers have a high sense of self-identity with their dance work, it can be even more challenging to come to this initial stage of acceptance. There is a fear not being able to dance, which then leads to a fear of not being identified as a dancer, and then ultimately a collapse of how they view themselves. In approaching treatment recommendations, one has to focus on the eventual performance enhancement goals, such as becoming a stronger, healthier, and more confident dancer.

Dancers often deal from a particular sub-type termed “exercise anorexia” where there is insufficient caloric intake to match often excessive exercise energy demands. This might occur in part due to ignorance of the nearly 4,000-5,000 calories that can be burned a day by intense dance, or the energy defiency could also be intentionally created by dancers who do additional exercise (treadmill, stair machines, elliptical above and beyond usual dance requirements. In working with dancers, I have learned to ask about the amount and frequency of exercise, both inside and outside the dance studio. This extra exercise may represent a compulsive behavior that is a direct part of the anorexia nervosa illness.

Many young dancers have limited financial resources which often means making compromises on the amount or type of food intake. I often see reduced intake diary and meat products, which are high calorie food sources that also have calcium and iron.

Female dancers often report higher levels of caffeine, nicotine or even illicit cocaine use both for stimulating energy levels and appetite suppression.

In dealing with dancers, one must address these more common dance world issues to provide individualized and comprehensive care.  Initially, a dancer may deny any problems with food intake, excessive exercise, or substance use, but as rapport and comfort are built with the medical team, such concerns may be more readily shared.

I also try to link the energy intake issues with the increased risk for bone stress injuries/fractures and irregular menstrual periods (in females) to educate the dancers and underscore the importance of appropriate medical care for the long-term health of a dancer’s career.

One helpfulthing about dancers is that they are used to working with multiple team members, from fellow dancers to multiple choreographers and instructors. Thus, once they understand that optimal treatment of anorexia nervosa requires an inter-disciplinary approach including physicians, nutritionists, and mental health providers, a dancer is more apt to accept this team-based treatment approach.

Dancers are used to tight, goal-oriented schedules, so I have found that setting short-term realistic goals definitely help in building confidence and compliance. Regular visits to modify goals and constant communication between providers (with appropriate privacy safeguards, of course) are also quite helpful. 

2.      In your experience, what affect does the dance world and its aesthetic standards have on dancers?

The aesthetic standards of the dance world favor lean physiques- from body revealing costumes and clothing to the demands of jumping, leaping, and partnering. Every day in the studio, a dancer is bombarded by direct comparisons with fellow performers in a competitive environment with occasional added subtle, or not so subtle comments (“you’d jump better if you were 5 pounds lighter”).

In some ways, the decisions behind anorexia give a dancera sense of control in an environment where there are constant uncertainties, such as being selected for a troupe, cast for a particular role, having to wear certain costumes, or being able to meet the demands of the choreographer.

With initial weight loss, many dancers gain a boost of confidence with increased jumping and turning abilities, and may hear approval and confirmation from colleagues and instructors.  This definitely makes acknowledging early issues with energy intake more difficult, and often medical care is sought only when there is a later significant decrease in performance.

3.      Have you seen more incidences in boys or girls and why do you think that is?

Studies definitely indicate a higher incidence of anorexia nervosa in females, which in the dance world is likely due to expectations such as costume choices, subjective ideals about form and technique with leaping and jumping, and ease of lifting lighter dancers when partnering.

However, one should not underestimate the incidence of anorexia in male dancers, who suffer similar demands on technique and form. While managing anorexia nervosa is a definite challenge in females, males actually have higher risk of more complicated outcomes, including death, from anorexia.

4.      How do you feel that a patient's receptiveness to treatment would be affected if the medical professional they were working with had a background/previous understanding of dance?

I think that dancers will definitely be more receptive to working with medical professionals that know the culture of the dance world and the expectations and demands placed on dancers. When a scared dancer hears that he/she is not the first dancer to seek treatment, and that a particular medical provider has indeed helped other dancers get healthy, they do not feel as isolated and are more likely to actively engage in a treatment plan. 

Dr. Koutures Writes on ConcussionConnection about Ivy League Eliminating In-Season Full Tackling

Dr. Koutures Speaks at ABT-Gillespie School at Segerstrom Center on Young Dancer Health

DocKoutures thoughts: Ivy League eliminating in-season tackling- would work in high schools?

How Little Limitations in Big Toe Motion Cause Big Problems in Dancers

In my evaluations of dancers with foot, ankle, knee or even hip pain, I tend to find that the root cause of these issues often starts with abnormal motion of the big toe joint (aka first metatarsalphalangeal joint or 1st MTP joint).

While some may question how such a small joint can cause such a great list of problems, a quick review of common dance positions provides reasons why optimal big toe function is so essential for healthy dance.

In demi-pointe, a dancer ideally should achieve full big toe dorsiflexion, which is where the big toe is able to be lifted up in the air and positioned closer to the rest of the foot.



Limitations in big toe dorsiflexion, known as hallux rigidus, lead to painful compensations or changes in function at several joints:

  • Sickling or putting more pressure on the outside of the foot which not only does not look appealing, but increases the risk of ankle sprains or even damage to the bones on the outside of the foot



  • Forcing the knees into a more forward position (can't see toes when in squatting position) which places abnormal stresses on the front of the knee joint
  • Increasing the need to flex or bend the hips, which also places an unusual demand on these joints

One cause of 1st MTP/big toe limited range of motion is osteophytes, which are deposits of extra bone growth in the joint.  Unfortunately, surgical removal is necessary and many a dancer's career has been shortened due to such destructive arthritis.

A more common cause of 1st MTP motion, especially in the school-age dancer, is dysfunction of the Flexor Hallicus Longus (FHL) tendon that follows a course along the inside of the foot and ends at the big toe. 

Restriction of the FHL routinely occurs in three spots and can significantly limit 1st MTP/big toe dorsiflexion:

  • Tarsal Tunnel at inside of ankle (STAR)
  • Intersection of FHL with neighboring Flexor Digitorum Longus tendon (TRIANGLE)
  • Attachment of FHL to the first bone (proximal phalange) of the big toe (SQUARE)

 A nice review of FHL dysfunction in dancers can be found here.

I have found that aggressive stretching of the FHL combined with intense friction massage at those three points of narrowing is needed to help dancers overcome this issue. While best results tend to come after working with a trained medical professional, self or home-based massage items include tennis balls, golf balls, and ice blocks (paper ice cups are a favorite).

How aggressive and intense does this treatment need to be?

Let's just say that the stretching and massage can be uncomfortable, bordering on painful, and it is not uncommon to have bruising of the foot if proper aggressive intensity has been found. Warning a dancer ahead of time about the potential pain and bruising helps prepare them and increases changes for favorable outcomes.

How have other dancers or medical professionals encountered issues with the Big Toe and what techniques have been learned to deal with the problems?

Six Common Indoor Volleyball Injuries

Working with Olympic level male and female volleyball players has allowed a unique appreciation for common injuries patterns seen in this wonderful yet demanding sport. Since there are six players on the court, I will identify six  frequently seen injuries and will also focus on key prevention tips for players at all ages.


1) Concussions

Most of the concussions I encounter are seen in liberos or defensive specialists, usually from direct impact either from attempted passes of hits at the net or collisions with other players or objects (poles, chairs on courtside) when diving for a ball. I have also seen a fair amount of concussions resulting from mis-matches on the court, namely defensive players trying to return serves or hits from much stronger and older players.

Any new sign of concern (such as dizziness, headache, blurred vision) or behavior change after head trauma should mandate removing the player from all activity and not returning until appropriate clearance from a sports medicine specialist who is familiar with concussion care. 

For more information about dealing with sports-related concussions, click here.

Prevention tips for the volleyball player include calling  for balls before starting a dive, ensuring defensive players are aware of incoming balls during hitting/serving drills, limiting older and stronger players from hitting into younger players, and protecting the boundaries of the court to limit impact with chairs or other objects.

2) Shoulder injuries

Between serving, setting, passing, hitting, blocking and diving, the shoulders receive an amazing array of demands, so it should be no surprise that shoulder injuries are among the most common volleyball-related concerns.

Most shoulder injuries are due to repetitive use and overload stress  leading to common abnormalities. Tightness in the front of the chest leading to a more forward position of the dominant shoulder can reduce normal function of the rotator cuff muscles, leading to pain and decreased hitting and serving accuracy and speed.  Tightness in the back of the shoulder glenohumeral joint can decrease the follow-through phase of hitting or serving and lead to problems with the labrum (soft tissue past between the ball and socket), the inside of the elbow, and even the lower back.

Appropriate stretching exercises combined with strengthening exercises of the scapula (wingbone) can reduce the risk of shoulder overuse injuries. Avoid hitting and serving with signs of fatigue (balls tend to go long with reduced speed) or any form of shoulder pain. Reducing the overall number of hits/serves can help, but more formal hit or serve count recommendations have not been studied at this time.

3) Finger/Hand Injuries

Tend to see finger joint sprains and dislocations mostly with blocking at the net. Rigid wrists with widespread  and relaxed fingers not only allow better ball placement down in the opponents court, but also reduce the chance for acute injuries.

The widespread finger position does place unique stress on the skin web spaces between the fingers that can lead to lacerations or breaks in the skin that are extremely difficult to heal, even with the placement of sutures. Better to prevent these lacerations in the first place by moisturizing the skin between the fingers on a daily basis. 

4) Low Back Pain

Volleyball-related back pain can come either from leaning forward such as with passing or following through on a serve/hit or more with leaning back such as in setting or initiating a serve or hit. Pain that is more with leaning forward could cause issues with the discs between the bones of the lower spine, while pain leaning back could lead to stress injuries of the posterior spine or joints.

It is amazing how much shoulder dysfunction (discussed above) can lead to back problems in volleyball players. If you haven't already, take the time to review post linking shoulder issues to back problems.

Learning how to initiate movements with the gluteal muscles in the buttock area can reduce stress on the lower back, especially with jumping. Single leg gluteal strengthening activities are particularly recommended. Certain technical errors, such as reaching too far for passing or hitting, can also increased forces on the lower back. Setters should attempt to make contact with balls right above their head- reaching too far forward for front sets or backwards on back sets is not the best for long-term back health.

5) Knee Pain

If you are a volleyball player who doesn't have knee pain, then either you are extremely fortunate or perhaps in a bit of denial. 

The repetitive jumping in volleyball often leads to pain in the front of the knee, especially in the patellar tendon connecting the kneecap to the shin bone. Throw in frequent knee contact with the hard wood court surface and you have a recipe for knee problems.

For healthier volleyball knees, pay attention to the following recommendations:

  • Avoid landing on straight knees. Always land and move "softly" with hips, knees and ankles in a bent position.

  • Try to land in good alignment, with the hips and kneecaps lined up with the second toe. Don't let your knees collapse in or rotate.

  • Initiate jumps with the gluteal muscles in the buttock region. This will improve knee and also lower back function.

  • The best time to stretch the muscles that support knee function is after practice or after a match when the muscles are warm. Focus on hamstrings, quadriceps, hip adductors/abductors and calf muscles.

  • Knee pads help reduce bruises and pounding, especially with repetitive diving drills. 

6) Ankle Sprains

Ankle sprains are the most common acute injury in indoor volleyball, and very few things spark intense debate in the volleyball community more than the question about using ankle braces to prevent these type of injuries. 

The majority of ankle sprains are when the ankle inverts (rolls in) and this most often occurs with play at the net where athletes make contact with another players foot when landing from a jump during hitting or blocking. More chaotic play such as with bad passes or plays out of system can also put ankles at risk.

The theory behind bracing is to reduce abnormal ankle motion, but some fear that depending on bracing might make lower leg supporting muscles weaker and maybe even increase the risk of knee injuries.

Click here to review the debate on ankle braces.

Once an ankle sprain has happened, little doubt that the combination of bracing and appropriate rehabilitation exercises can reduce the risk of future injuries.

Never hesitate to seek the opinion of a sports medicine specialist with any volleyball injury or to learn additional tips to prevent these problems.


Dr. Koutures Reviews New Mexico Concussion Return to Play Case

The mere fact that a return to play decision ended up in court is in itself a big shame.
And that shame is definitely rooted in a lack of preparation and breakdowns in communication leading to an oversimplified attempt to make a complex decision.