Learn To Love The Nordic Hamstring Curl

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Hamstring strains can be frustrating for the athlete because they can take a long time to heal, and even after healing they have a tendency to happen over and over
  • From a preventive standpoint, the Nordic hamstring curl has been proven to reduce the number of hamstring strains in soccer players
  • I would recommend the Nordic hamstring curl for all athletes, in all movement based sports
  • Be sure to use correct form, and start off with a small number of repetitions and work up
  • The Nordic hamstring curl is part of the FIFA 11+ training program for soccer, as well as a standard component of hamstring strengthening in training programs in many other sports

A hamstring injury can take down athletes at any level of competition. In the springtime we commonly see elite athletes in soccer, baseball, and sprinting sports occupying the “injury report” on the newswires from recent hamstring injuries, often keeping them out of competition for many weeks or possibly months. Clearly, a way to reduce the risk of hamstring injuries would be very helpful, and the Nordic hamstring curl is an exercise that can do that.

A recent high-quality randomized study published in the American Journal of Sports Medicine showed that the Nordic hamstring curl used regularly and with proper form, can significantly reduce the number of hamstring injuries sustained by male soccer players. In my opinion, male and female athletes in all sports would benefit from the Nordic hamstring curl.

You need a partner to do the exercise. Players start in a kneeling position, with the torso Screen Shot 2016-05-17 at 8.05.25 AMfrom the knees upward held straight. The training partner ensures that the player’s feet are in contact with the ground throughout the exercise by applying pressure to the player’s heels/lower legs. The player then lowers his upper body to the ground, as slowly as possible. Hands and arms are used to break his forward fall and to push him back up after the chest has touched the ground.

This is a really great exercise but there are some cautions. First, make sure your form is perfect and use a partner. Check out any of several YouTube videos, or take a look at the handout in the FIFA 11+ for important notes on form. Second, I’ve had many patients actually strain a hamstring while doing hamstring exercises, so ramping up very slowly is critical. Be aware of any sharp pain during the exercise, and back off if necessary. The scientific paper used this protocol, increasing load very slowly:


Week Number Frequency, per week


No. of Sets per Training


Repetitions per Set


1 1 2 5
2 2 2 6
3 2 3 6
4 2 3 6, 7, 8
5 2 3 8, 9, 10
6- onward 2 3 10, 9, 8

These exercises can seem boring, especially to the young player but they definitely work. In my opinion, it would be well worth the effort if it means you’ll be a happier and more effective player in the game, rather than spending your time in rehabilitation.



Posted in Hamstring, Tips and Training | Leave a comment

Messing With Success

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Today’s post is purely my opinion, with some observations on parental influence in teenage athletics.

Towards the end of the school year, we gather with the Athletic Trainers and coaching staff natalie coughlin to see what worked and what didn’t in terms of the health and performance of our high school athletes. We do the same at the collegiate and professional levels with one major difference: we generally don’t have much direct influence from parents at the collegiate and professional levels. But we most certainly do in high school. For better or worse (almost always for the better) there will be parental influence in coaching and medical recommendations. It’s their right, and an involved parent is a very good thing.

Influence Done Right: Focus On Development and Enjoyment

Over the years I’ve noticed that some of the absolute best young athletes who go on to have sports success through college or beyond have quiet and somewhat laid-back parents. I remember in particular one set of parents accompanying their daughter for a discussion of issues with both of her shoulders. It was a complicated issue, requiring her to have surgery on both shoulders followed by a yearlong rehabilitation and no swimming. Through it all the parents took it in stride, insisting that they would take the long view. A few weeks in to her rehab the young lady showed me some photos of her with winning times at various meets. Not age group meets, but world class international meets with adult Olympic athletes. And she had three world records. I was astounded. I knew she was good but really really good? From her and her parents I never would have guessed.

Some of the most accomplished athletes I have seen have the least overbearing parents. I get the feeling that these folks have seen a good amount of success themselves and have a strong understanding of the long view to succeed. Early focus on skill development, encouraging sport experimentation, and handling ups and downs with equanimity. Parents who are former professional athletes are almost always this way.

Messing With Success

And on the other end of the spectrum we seem to be seeing more parents who are far too pushy of the coaching staff, the administration, and of their own children. Maybe there are not actually more of these parents but they sure are memorable.

There’s probably a psychological term for this but basically I see them living through their kids. Some admit to me that they have no personal experience with sports in their own childhood, or even basic adult fitness. In the exam room the parent often use phrases such as “we hurt the knee last weekend…”, or “we worked incredibly hard last summer on training, how could this happen to us…”

To be sure many of these kids achieve a high level of success when they’re very young. I’ll always believe the parents have the best interests of their child at heart, but an overbearing parental attitude seems like a sure fire way to mess with success. In my 23 years in orthopedic practice I’ve had a chance to see quite a few of these kids over their entire childhood and teenage development years. I’ve often had the feeling that the kids are participating in certain sports because their parents said they had to. Pleasing their parents is a powerful motivator for the youngest kids but it becomes quite a drag in the teenage years. Too many of these kids end up quitting their sport, after years of development, because it’s an easy way to rebel against a parent.

“Supportive but not overbearing” is a very tough path to choose especially when there are so many pressures around to conform to community norms. But who knows, maybe you too will end up with a daughter who becomes one of the most celebrated athletes in Olympic history, as the parents of my young patient did.




Posted in Parents, Psychology | Leave a comment

The Young Athlete Is Not A Small Professional

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Young athletes (and their parents) often try to emulate the rapid return to sport after injury that we see in adult professional athletes
  • Due to many factors associated with the unique needs of the young athlete it could be unwise or even dangerous to push the speed of recovery after injury
  • For sports medicine physicians, we will place the long-term health of the young athlete at the top of our priorities when determining a proper recovery process after injury

It’s totally understandable to want your injured son or daughter to be healed and back cwvDm9asA_Lw9YsGTQNy8vW7JoAplaying sports as soon as possible after injury. And since the progress of the professional athlete after injury is chronicled in great detail through social media there’s pressure on the young athlete to get back to play as rapidly as the pros. But the young athlete is not a small professional and in many instances the speed of return could be unrealistic or even harmful to the young athlete.

There are so many factors that make recovery from sports injury different for the young athlete compared to an adult professional. To list just a few: the young athlete may have an injury to a growth plate, thus creating possible problems with future growth with improper care; the psychology of the young athlete will typically be very different from a mature professional; and the adult professional often has access to 24/7 rehabilitative care specifically designed for rapid recovery.

For the young athlete: heavy emphasis on ensuring long-term health

Overall, sports medicine professionals will value the long-term health of the young player above all other factors. This means that sometimes it’s necessary to go a bit slower, to take a bit longer, and even to be a bit more cautious than we would be for an adult professional athlete. The end result is that the young player will occasionally feel ready to return to play before we recommend unrestricted play.

For the adult professional: emphasis on function

In contrast, for the adult professional athlete we will of course arrive at a proper diagnosis and provide detailed information to the athlete about the long-term risks and benefits of various treatment options but there is often a greater emphasis on function and acceptance of playing in some amount of pain. What this means is that as long as it’s reasonable and safe, we’ll work with the athlete and training staff at a pretty rapid clip to determine whether the player can do what’s required for their sport and position.

This also means that in some situations with professional athletes it’s necessary to push the envelope with accelerated treatments. Dr. Brian Cole, team physician for the Chicago Bulls and orthopedic surgeon at Midwest Orthopaedics at Rush put it this way in a recent interview in Wired:

“The decision to push the envelope can be really complex,” says Cole. The player might feel like he needs more time—but the organization, in a situation like the NBA playoffs, will want him back as soon as possible. Or maybe the player is anxious to get back before he is ready, feeling the weight of his or her team and even career. Amid all of this, a team’s physician has to be clear minded and focused on the best interest of the player. “It takes an enormous amount of humility,” says Cole. “You can never be a fan.”

For all players, of all ages, in any sport: physicians must put the player first

The interesting thing is that regardless of the situation, the sport, the player’s age, or whether they are male or female, the physician approaches sport injury the same way every time. By putting the player’s interests first. Dr. Bert Mandelbaum, the long time national team physician for US Soccer and Advisor to Sideline Sports Doc put it to me this way: “no matter the situation, whether it is a practice with very young players, a club team in a championship, or a professional in the World Cup there’s one thing we must do always: put the player first.”

This means that if you’re a parent or coach of a young player, putting their long-term interests first will give you the best possible chance of ensuring that athlete is good to go for the current season and for the long run.



Posted in Coaches, Midwest Orthopaedics at Rush, Parents, Performance, Psychology | Leave a comment

Pitchers: strengthen your legs and core to improve your pitching

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently presented study from orthopedic surgeons at Midwest Orthopaedics at Rush sheds further light on the risk factors for injury in elite adolescent pitchers
  • The study strongly supports the idea that fatigue is a contributing factor in poor pitching mechanics, which ultimately increases the risk for arm injury
  • The legs and core tend to fatigue and weaken before the shoulder and arm, suggesting that focus on core and leg strength would be helpful in reducing pitching injury risk

It’s that time of year- time to start thinking about baseball and young pitchers. Much has baseball pitcherbeen written about the effects of overpitching on the potential for shoulder and elbow injuries, but this week I want to highlight a unique study performed by the physicians at Midwest Orthopaedics at Rush, in Chicago, Illinois.

The researchers simulated a 90-pitch game for 28 elite, adolescent pitchers and then investigated how their shoulder and elbow motions affected pitching speed, accuracy, pain, and pitching mechanics. As expected, the boys became progressively more fatigued and painful with additional pitches. They also found that their pitching mechanics changed, which may ultimately contribute to injury.

The pitchers ranged in age from 13 to16 years of age, had been pitching for approximately 6 years and pitched an average of 94 pitches per week. Shoulder range of motion was assessed before and after the game. Speed and accuracy were measured for every pitch and every 15th pitch was videotaped. Perceived fatigue and pain were assessed after each inning.

The interesting thing the study authors noted was that core and leg strength may be a key component of fatigue and ultimately injury in pitchers. As pitchers became fatigued, trunk rotation timing began to falter and pain increased.

The key finding is that fatigue lead first to changes in the core and leg mechanics, and secondly to alterations in arm mechanics.

One of the study authors, Dr. Nikhil Verma, orthopaedic surgeon at Midwest Orthopaedics at Rush, said that “As adolescent pitchers became more fatigued, they lost the proper timing of sequential rotation of the hips and then the shoulders. The core musculature thus lost the ability to contribute to pitch velocity. We hypothesize that this change occurs because the core and leg musculature fatigues before the upper extremity and thus core kinematics change before upper extremity kinematics as adolescent pitchers fatigue. We thus hypothesize that core and leg strengthening may be key adjuvants to prevent fatigue and potentially prevent injury in youth pitchers.”

“The most surprising finding was that trunk/core kinematics change before upper extremity kinematics as pitchers become fatigued. This supports the concept of the “kinetic chain” meaning that the large lower extremity and core muscles are the true power generators for the baseball pitch. Many young players fail to appreciate the importance of trunk, core and lower extremity strength. Early fatigue in these areas may lead to increased stress in the arm and shoulder and potentially increased risk of injury.”

You can listen to a podcast of Dr. Anthony Romeo discussing the study key findings here.

Bottom line for young pitchers: to improve your pitching and decrease chances of injury, you must pay close attention to your leg and core strength.

Posted in Baseball, Elbow, Midwest Orthopaedics at Rush, Shoulder, Softball | Leave a comment

The Female Athlete Triad- Be On The Lookout

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The “female athlete triad” is a medical condition composed of eating disorder, irregular menstrual periods, and low bone density
  • Girls in sports in which there is pressure to conform to a certain body image are particularly at risk, such as gymnastics, figure skating, dance, and distance running
  • Treatment often involves many different types of healthcare providers
  • I will look for the female athlete triad for any girl who comes to the office with a stress fracture

Last weekend I was with a friend watching his daughter in a NorCal Premier State Cup soccer match on a beautiful spring afternoon. The girls were skilled players and the game was played at a high level. The players were fit and athletic, and yet I was reminded that female athletes in many sports have unique pressures that can predispose them to injuries only girls can get.

The female athlete triad is a combination of three conditions: eating disorder, irregular ahs_White-TEAM-xc_4476menstrual periods or no menstrual periods, and osteoporosis. A female athlete can have one, two, or all three parts of the triad. An emerging concept is that these conditions start off with low energy availability and from there a cascading series of changes take place that can end in serious problems.

“Body image” sports where a thin appearance is valued can also put a girl at risk for female athlete triad. Sports such as gymnastics, figure skating, distance running, diving, and dance are examples of sports that value a thin, lean body shape. Coaches or judges may even tell some athletes that losing weight would improve their scores.

Even in sports where body size and shape aren’t as important, such as many team sports, girls may be pressured by teammates, parents, and coaches who mistakenly believe that weight loss will improve performance.

Let’s briefly look at the components of the female athlete triad.

Eating Disorder

Most girls with female athlete triad try to lose weight as a way to improve their athletic performance or due to body image pressures. The disordered eating that accompanies female athlete triad can range from not eating enough calories to keep up with energy demands to avoiding certain types of food the athlete thinks are “bad” (such as foods containing fat) to serious eating disorders like anorexia nervosa or bulimia nervosa.

Irregular Menstrual Periods

Exercising intensely and not eating enough calories can lead to decreases in the hormones that help regulate the menstrual cycle. As a result, a girl’s periods may become irregular or stop altogether.

Some girls who participate intensively in sports may never even get their first period because they’ve been training so hard. Others may have had periods, but once they increase their training and change their eating habits, their periods may stop.


Estrogen is lower in girls with female athlete triad. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to osteoporosis, which means there is poor bone density. Poor bone density means the athlete is susceptible to stress fractures and other injuries.

I will start thinking about the female athlete triad if a girl sustains a stress fracture

As an orthopedic surgeon, I won’t be the one treating the different components of the female athlete triad but an orthopedic surgeon is often the doctor who treats the stress fracture. I make it a habit to ask some questions of the girl with a stress fracture to screen for possible problems with the female athlete triad. I’ll ask about their general diet and weight loss habits, energy level, and menstrual periods. If there’s even a hint that something may be amiss I’ll refer her to a primary care sports medicine specialist for proper evaluation and treatment.

This condition can be difficult to fully treat and often requires what we’d call a “multidisciplinary approach”, meaning that doctors, nutritionists, psychologists, physical therapist, and athletic trainers may all need to be involved. It’s important to acknowledge the problem and take the right steps to seek help and treatment.

Posted in Dance, Prevention, Running | Leave a comment

Simple Test For Return To Play After Ankle Sprains

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Ankle sprains can be surprisingly tricky to recover from; a number of these will have ongoing issues needing therapy
  • A simple way to test for readiness to return to play after an ankle injury is to have the athlete do a sideline functional test: jog, sprint, cut, pivot, jump. Successful completion of the test means they are comfortable, with normal speed and normal form. Pass the test= generally ok to return to play. Don’t pass the test= best to have physician evaluation, these ankles may need rehab.

The poor little ankle sprain just doesn’t seem to get its due as a significant injury. And to jump closeupbe sure, for most first-time sprains the ankle will heal and then allow the athlete to return successfully to play. But a surprisingly large number of these sprains will continue to bother the athlete even after a single sprain, more than a year after the original injury. What’s up with these? What do we do about them? And is there a way to predict who will have problems?

We often think of an ankle sprain as a fairly minor injury, one from which an injured athlete can return successfully to play in a matter of days or weeks. But a surprisingly large number of injured athletes will go on to have ongoing issues with the ankle months or even years after the original injury. The ligament injured in a sprain typically heals, but one underappreciated aspect associated with the injury is the loss of balance and loss of ability to do specific tasks such as jumping or cutting. There is a neurologic factor called “proprioception” which essentially refers to the joint’s ability to know where it is in space. This joint position sense can be lost with an ankle sprain and it often needs to be retrained. These are often the folks you’ll see wearing ankle braces months after their ankle sprain.

A recently published study in the American Journal of Sports Medicine studied athletes with first time ankle sprains and measured ankle instability and loss of function out to a year after the injury. They found that 40% of their patients had criteria that placed them in the chronic instability category- a number that I find remarkably high. The authors then correlated the tests they performed to see if any were predictive for the later development of ankle instability issues. They found that two types of jump tests were strongly predictive: a single-leg drop landing and a drop vertical jump. Inability to properly perform these tests at the 6-month time point predicted instability at 1 year.

Are there tests we can look at early after an injury that can assess readiness for return to play? Yes, I find that a simple sideline functional test is very helpful early in the injury recovery process. Let’s say that one of your players had an ankle sprain during competition and then rested for a week or two from training. I would then recommend that they try a simple functional progression consisting of:

  • Jog comfortably and with good form
  • Then sprint comfortably and with good form
  • Cut left and right with good speed and form
  • Pivot off the injured ankle successfully
  • And finally do a two leg jump with a stable landing

The entire test takes about a minute or two, max. You want to look for the athlete’s ability to progress the tasks and to do so without a limp, without pain, and with normal form. If they pass the test it’s generally ok to resume play. If not, it would be best to have physician evaluation, as these may be ankles in need of some rehab. Let’s give the ankle sprain some respect!

Posted in Ankle, Performance, Tips and Training | Leave a comment

Hiding From Concussions

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published article in the American Journal of Sports Medicine showed that a large number of college athletes indicated that they had not reported prior concussions to trainers or coaches
  • Reasons for non-reporting essentially fell into two categories: player did not want to be removed from competition, or the player did not think that their injury was a concussion
  • Men were more likely to resist disclosing a concussion than women
  • The study points to the need for continuing education of players and coaches about the need to recognize and disclose a possible concussion
  • My suspicion is that similar trends occur in the younger age groups. Peer pressure and desire to continue playing are powerful forces.

We’ve known for as long as people have played sports that athletes will either not disclose girls soccer headeran injury, or that they would play through an injury. For some injuries this probably isn’t a big deal, but for other injuries continued play would be a real risk for making the injury worse or possibly having a second injury resulting in permanent damage. For concussions, repeated injury can be disastrous. So it’s in our best interest as parents, coaches, and players to do everything we can to encourage players to disclose possible concussions and stop hiding from them.

This study is interesting as it looks at reasons for not disclosing concussions, and it attempts to get an estimate of how often athletes do not disclose possible concussions. It is a retrospective (meaning backward-looking) study of former collegiate athletes at a major D1 university, so its direct application to youth sports might be limited. Still, I know with certainty that young athletes will also try to hide from concussions so there are points we can take away from this study.

About one-third of the surveyed athletes indicated that they had not reported at least one concussion during their collegiate playing career. Two-thirds of the football players indicated that they had not disclosed at least one possible concussion. On the women’s side 85% indicated that they had disclosed all possible concussions, although interestingly in women’s soccer the full disclosure happened only 58% of the time (this university is a perennial nationally ranked powerhouse in women’s soccer).

The motivations for non-reporting are not surprising. The most commonly reported motivations included the following: did not want to leave the game/ practice (78.9%), did not want to let the team down (71.8%), did not know it was a concussion (70.4%), and did not think it was serious enough (70.4%).

In collegiate sports, the pressure to continue playing can be powerful. Some athletes could be in line for professional sports careers, many athletes could feel pressure from teammates, coaches, and fans. These athletes will want to stay in competition, a factor that sometimes will override their knowledge of concussion as a serious injury. As clinicians or parents we need to acknowledge these forces and work with athletes to reduce fears surrounding concussion disclosure.

For the younger athletes, psychological motivations can be equally powerful although they may be dictated more from peer pressure than other sources. What we can do is be their eyes and ears. Coaches are incredibly influential in this area. A coach properly trained in concussion recognition can be a huge help in reducing the chances for another concussion, and the coach can model effective behavior that’s in the best interest of the athlete. Parents and teammates are other major influences for young athletes. Let’s all be smarter about concussions and help the young athlete to do the right thing.

Posted in Coaches, Concussions, Parents | Leave a comment

Ivy League Bans Tackling At Football Practices: A Sign Of Things To Come?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The Ivy League took the extraordinary step to ban all player-to-player tacking at football practices. The news was reported this week by the New York Times
  • The ban is designed to reduce the risk of concussion, other head injury, and other contact related injury to the neck
  • On field performance at Dartmouth, whose coach Buddy Teevens instituted the ban himself in 2010, actually improved as in-game tackling improved and the team won the league last year
  • My opinion: if the Ivy League collects data going forward that conclusively proves a reduction in injury then this trend will spread

In medical epidemiology, the term “exposure” can be broadly applied to any factor that OLYMPUS DIGITAL CAMERAmay be associated with an outcome of interest. When we are discussing concussion risk, or risk of injuries to the neck and head, “exposure” essentially means how many times you could possibly be hit in the head. The thinking here is very simple: reduce the number of player-to-player tackles, and you reduce the risk of possible injury to the brain, head, and neck.

We’ve seen limitations in player contact during practices and games at the youth level, but this is the first time that it has really been undertaken at the collegiate level. If the Ivy League is able to prove over the next few years that they actually have a reduction in injuries with this new policy, I believe that policies like it could spread certainly to the high school level and possibly to other collegiate leagues as well.

There will be plenty of detractors for sure. The naysayers will state that tackling is an essential part of football and if you’re not teaching tackling during collegiate practices you’ll end up with poor tackling during games, and possibly even increase injury risk during games. There is some merit to this argument, but note that the Ivy League is not stopping tackling practice they are simply stopping player to player tackling during practice. In the New York Times article you’ll see that the Dartmouth football team uses a mobile tackling simulator to improve tackling technique for their players. (very cool video- have a look!)

For this policy to gain broader acceptance outside of the Ivy League, the league will need to do a few things over the next few years. First and foremost they will need to produce before and after data showing an actual reduction in injuries. Even though this policy makes inherent sense, that type of cause and effect data will be required if it is to gain broader acceptance. And secondly, the coaches of the teams themselves will need to be convinced that performance during games has not suffered as a result of this change in practice technique.

I have a strong feeling that these points will be proven correct. In the end fewer injuries means healthier players, and healthier players means that they stay in the game longer. And that can only be beneficial for all fans of the game.


Posted in Back, Coaches, Concussions, Football | Leave a comment

Reduce Parent-Coach Misunderstanding With The Preseason Talk

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • It???s very important to have a discussion with parents prior to the club season to establish a decision process for dealing with on-field injuries
  • A good preseason discussion will reduce in season misunderstandings and stress especially around return to play protocols

It???s impossible to get through medical school without using memory aids such as mnemonics or acronyms. One mnemonic I find especially useful is ??5 P???s?? which translates to ??proper preparation prevents poor performance??. It highlights the usefulness of preparation in preventing bad outcomes. Youth sport coaches prepare for practices and games every day, and I???d like to appeal to you to prepare your team???s parents for in-season injury management with a preseason talk.??coach and parent meeting

A preseason get-together between the parents and coaching staff is common in many sports and typically used to give the parents information about contact numbers, practice and game policies, equipment, etc. ??Back in the day?? this took place in person but is now frequently done with a lengthy email. Regardless of the delivery method, this is an excellent time to also educate the parents about the coach???s attitude and policy towards injury recognition and management. But in my experience few coaches actually discuss injuries. Discussing certain aspects of injury recognition and return to play in the preseason can go a very long way to reducing misunderstanding and stress during the season.

The single biggest area where differences occur is in return to play after concussion. Here???s a common scenario: a young athlete is suspected by the coach of having a possible concussion. She is removed from play, the parents are notified, and the parents take her to her local pediatrician for evaluation. The pediatrician does an exam, determines that the athlete has no current signs of a concussion, and clears her to return to immediate play. This might sound reasonable to most of you but there are a few problems.

The parents and the pediatrician were probably well intentioned, but poorly informed. In this case the player would have been better served by visiting a physician skilled in sport concussion management. Many pediatricians are skilled in sport concussion management but most are not. In this case the issue was that the pediatrician was unaware of gradual return to sport protocols and released the player to full activity too soon. If the parents insist that their daughter was cleared for immediate play, but the well-informed coach knew there should be a gradual return to play it can create a lot of friction between the parents, player, and coach.

If the coach lays the groundwork for this scenario during the preseason it will reduce the chance of misunderstanding later on.

As a coach, you can play a key role in safe return from injury, improving performance, and responding properly to injuries when they occur. Here are some steps you can take in the preseason to ensure the best outcome for your athletes and the team:

  • Educate athletes and parents about injury recovery, especially concussion, during the preseason. Talk with athletes and their parents about the dangers and potential long-term consequences of proper return to play.
  • Recommend to the parents that physicians with specific training in sport concussion are the best evaluators after a suspected concussion.
  • Insist that the player follow a gradual return to play (minimum 5 days) after concussion, and ask the parents to present a written clearance note from the doctor. Let the parents know in the preseason that you???ll require this.
  • Ask the parents to provide written notes from the doctor for any serious injuries in which there was an extended period of time away from play, such as recovery from fractures or surgery.

Injuries are going to happen. Let???s make sure we have the right education for the coaches and the processes in place to deal with the issues properly. Have the key discussions before the start of the season.

Posted in Coaches, Parents, Prevention | Leave a comment

Foot and Ankle Injuries in Ballet

By Adam Bitterman DO and Simon Lee, MD

Rush University Medical Center

Foot and Ankle Section

Department of Orthopaedic Surgery

Foot and ankle injuries are extremely common amongst those participating in dance activities. Those impacting the lower extremity account for roughly 65-80% of all dancer injuries.. Currently, it is estimated that organized ballet dancing begins when children are as young as 6 to 8 in age and its popularity is increasing. As the demands of the dancing community increase so too does the evolution of the field of dance medicine.??ballet

Ballet dancers are prone to a wide spectrum of injuries to the lower extremity including soft tissue irritation and inflammation, stress fractures, osteoarthritis, sprains, impingement syndrome and acute fractures. At the professional level, injuries are noted to vary based on rank, gender, role, and experience level. This is in contrast to the amateur class where inexperience and inappropriate training may play a greater role in injury prevalence. One must keep in mind that male dancers and female dancers perform different maneuvers and act in different roles during a performance. Therefore, each has an elevated risk of certain injuries. Additionally, in the published medical literature, conflict still persists regarding age and injury; no general consensus exists regarding those injury characteristics of the older participant versus the younger dancer.

Whether participating in a purely recreational or competitive environment, these injuries are generally a result of overuse impact on the hard floors as well as sudden changes and bursts of activity. Participants in dancing activities usually begin preparing for such competitions and recitals at an early age and over time their training may increase in frequency and amplitude leaving them prone to both acute and chronic injuries. Other contributing factors include the extreme positioning that these dancers must endure. A classic example is the ??en pointe?? position, which leads to additional stress of the dancer???s body weight on the tips of the toes as well as the ankle. Also playing a role in a dancer???s injury pattern is their shoewear, or lack thereof. The usual ballet en pointe slipper may be broken in easily and lose its supportive nature rather quickly, which can contribute to injury.

Acute injuries most commonly affecting the ballet dancer???s lower extremity are ankle sprains. These ligamentous injuries are a result of the ankle being positioned in such a way that there is less inherent stability of the boney articulation; thus leading to more stress being incurred by these structures. Whether a partial tear or complete rupture, ankle sprains may cause the athlete to have immediate pain and difficulty bearing weight on the affected leg. Supportive treatment for these injuries includes resting the leg but also a focused exercise program to increase the strength of the supporting musculature. Compressive adjuvants may assist in providing additional support. Other acute injuries include fractures of the ankle or metatarsal bones, particularly the fifth metatarsal. These injuries may require surgical intervention and a period of rest to allow for more predictable healing and earlier return to dance.

Chronic injuries in the ballet dancer generally involve boney changes over time and pathology within the tendons traversing the ankle and feet. These injuries will obviously become more prevalent in dancers who have histories of more intense and longer periods of participation during their careers. In these athletes, impingement between the bones of the ankle joint can occur in the front as well as in the back. In order for dancers to achieve the en pointe position, they must maintain a hyperplantarflexed position of their foot lending to the boney pathology and pain in the back of the ankle. The great toe is also an area for concern amongst dancing injuries. Participants may develop bunions over time or degenerative arthritis and a stiff first toe. Additionally, they may complain of pinpoint tenderness underneath the great toe where the sesamoid bones articulate with the longer foot bones. Metatarsalgia may result from altered mechanics of the joints of the ball of the foot or an abnormal landing, or simply chronic repetitive overuse, which results in additional stresses in the area, which manifests as pain along the ball of the foot. Other complaints to the undersurface (plantar aspect) of the foot may include plantar fasciitis, which is an inflammation of the supporting tissue traversing the bottom of the foot to the heel bone. Tendinitis, also known as inflammation of the tendon, may affect the many tendinous structures that exist within the lower extremity. In particular, the Achilles tendon, the largest tendon in the body, may become irritated over time and lead to calf pain or weakness while attempting to perform certain maneuvers. Another commonly affected tendon is the flexor tendon to the big toe. This may result from a slight tearing or a diseased tendon, which manifests clinically as pain, weakness, and possibly locking of the toe.

Treatment of these injuries is generally conservative as surgical treatment may lead to changes in overall performance, prolonged recovery time and even risk early retirement from dancing. When determining a return to performance protocol, it is imperative that the dancing athlete has a good understanding of the risk of recurrence. After all, these injuries place dancers at risk for altering their performance or even shortening one???s career.

When evaluating for injury prevention it is often helpful to differentiate risk factors as intrinsic versus extrinsic factors. Intrinsic factors would be those that are inherent to each individual such as their anatomy, any prior injuries, or contributing medical issues. Extrinsic factors would be those such as the dance surface, training regimen and schedule for example. Being able to compartmentalize injury causality into intrinsic and extrinsic factors allows for better risk identification, stratification and ultimately treatment. Unfortunately, it is less feasible to change the floor material as opposed to ensuring appropriate stretching, strengthening and transitioning from low amplitude work to high intensity training. Having a good understanding of the modifiable risk factors will ultimately lead to safer participation in ballet.

Overall, it is important to treat dancing injuries aggressively in order to maintain essential foot and ankle motion and limit future disability. Understanding the mechanics of dance will lead to better identification, treatment and outcomes of many ballet related injuries.


Posted in Ankle, Dance, Foot | 1 Comment