Safety Rules Changes Needed To Grow Youth Sports

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • US Soccer recently recommended several changes to rules about heading the ball for younger age groups, designed to decrease the risk of concussion
  • US Soccer’s moves follow the changes implemented by other organizations such as USA Hockey and USA Football to minimize injury risk amongst the younger players
  • The theory overall is that minimizing injury risk in the youngest age groups through rules changes will keep kids playing the sport longer
  • USA Hockey is one of the few US youth sports seeing substantial enrollment increases between 2009 and 2015, with the changes in safety rules for the youngest players often cited by parents as a factor in promoting the sport for their kids
  • My opinion is that rules changes like these are necessary to grow each sport, or at the least to stem the tide of declining participation

Today’s post contains a lot of personal opinion, backed by science, data, and what I think Screen Shot 2015-11-24 at 9.03.52 AMis common sense. My guess is that my opinions will be totally dismissed by some or found to be controversial by many.

My fundamental beliefs are that lifelong exercise is critically important to the health of increasingly obese adults, and that proper sport participation as kids can lead to great habits as adults. I also believe that team and individual sports can be great for many, many kids, and that those kids who are especially gifted or motivated should be given opportunities to advance to the elite or professional levels.

The facts, however, reveal declining sport participation in almost all US team sports, as shown in the graphic. Several excellent studies have been conducted by independent organizations as well as internal data collected by sports governing groups. Parents across many sports typically cite the same negative influences in deciding which activities to cut back on:

  • Time commitments
  • Cost, especially travel teams
  • “Professionalization” of youth sports
  • Injury risk, especially in collision or contact sports

Rules changes designed to reduce injury risk are amongst the most effective ways to decrease traumatic injuries (such as concussion) and overuse injuries. When combined with changes addressing some of the other common concerns the result can be dramatic growth of participation. This has been proven by one of the organizations to first implement broad changes in the youngest age groups, USA Hockey.

Some of the changes included in USA Hockey’s American Development Model (ADM) include elimination of its 12 and under national championship (reducing interstate travel), ban body checking in the under 14 age groups (reducing traumatic injury risk), and even encouraging players to play multiple sports.

Five years in to the ADM we see that youth hockey participation in the US is up by 44%.

Changes such as rules on heading the ball for young soccer players are sure to create an emotionally negative response from game traditionalists- at least initially. But over time my prediction is that sports such as football and soccer will be able to use these changes to effectively stem the tide of declining participation in the same way hockey has done.

So you get to choose. Do you want to take steps to grow your sport and ensure its survival or do you want to ignore the trends and see it slowly disappear?






Posted in Coaches, In the News, Parents | Leave a comment

After Concussion: Don’t Just See A Doctor, Be Sure To See The Right Doctor

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • It’s important to see a doctor trained in sport concussion management after a concussion. Not all doctors know about return to play protocols.
  • Appropriate doctors are typically trained in sports medicine or neurology, and web searches will usually indicate whether they have training in sport concussion. See also the link I provide in the text below for the American Medical Society for Sports Medicine.
  • You (or your child) have only one brain: treat it well and don’t take chances with returning to play before properly going through a return to play protocol

Much has been written about concussion in young athletes but today I want to devote a few words to an area not often discussed: who should the young athlete see after a suspected concussion? concussionbasketball

Most of you are likely familiar with leagues such as the NFL and NBA where athletes with a suspected concussion are required to go through a “concussion protocol”. The protocol typically involves a clinical evaluation by a physician skilled in sport concussion management. This would include the physician evaluation, possible sophisticated diagnostics such as neuropsychiatric testing, and a gradual return to play protocol. The gradual return to play protocol exists because sometimes concussion symptoms might not be present at rest but might return with physical exertion. The protocols are designed to give the athlete the best possible chance of safe return to play.

Many of you might not be aware that most state interscholastic (meaning: high school) federations, and several national governing bodies for youth club and recreational sports also have gradual return to play protocols after a concussion. The protocols call for an initial evaluation by a physician knowledgeable in sport concussion, and then a return to play protocol that takes 5 to 7 days for an uncomplicated concussion. This is pretty much the same type of protocol followed by professional sports leagues.

The key part of the equation is seeing the right doctor after a sport concussion. Let’s start off with examples of who not to see. First off, I’m an orthopedic surgeon and team physician, and most of my orthopedic colleagues would not be the right person to see after a concussion because we will usually not be skilled in doing the neurologic testing. We are very knowledgeable in remove from play on the field, and can monitor the return to play protocol, but not good for the detailed evaluation. Next, seeing doctors who have zero knowledge of sports medicine is just a bad idea. We have seen parents who get a clearance note from their next-door neighbor who happens to be a dermatologist. Really? You’d mess with your child’s brain that way? Shame on you parents, and shame on you Dr. Dermatologist. And finally, this may come as a surprise to you but your local pediatrician or family doctor might not be the best choice either, as many of them have no idea of the gradual return to play protocols.

The types of doctors that would be good choices are usually non-surgeons who are specifically trained in sports medicine. These doctors with special qualifications in sports medicine come from a variety of medical specialties such as family practice, internal medicine, emergency medicine, or physical medicine + rehabilitation. An excellent resource to find these sports medicine trained physicians is the American Medical Society for Sports Medicine. On the lower right corner of their home page is a “Find A Sports Doc” search tool. Put in your zip code and a wide enough search radius and you’ll likely find an excellent choice.

In some cases such as multiple concussions, post-concussion syndromes, or other serious conditions it would be best to see neurologists or other concussion specialists at a concussion center. You’ll find these at most major universities that have medical schools.

If you’ve had a concussion I urge you not to cut corners in the return to play process. The cost of a bad decision is simply too high. See the right doctor, make sure to follow his/her instructions closely and give yourself the best chance of a successful recovery from concussion. You only get one brain. Use it wisely.











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Yes, Sometimes You Really Should See A Doctor

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Very broadly speaking, see a physician if you have a nagging physical ailment that you’re just not sure about
  • For acute injuries on the field of play there are some “red flag” situations that I outline below that often need immediate evaluation
  • And finally, for ongoing problems you’ll need to be on the lookout for decreases in sport performance or chronic painful movements. These may indicate an underlying physical problem. Proper evaluation and treatment can often shorten the recovery time and improve performance while still allowing modified play during healing.

One of the most common questions I’m asked by friends or by parents of players at events girlsbasketballconcussionis “do we need to go see a doctor”? This isn’t always easy to answer, as some simple injuries don’t need to be seen by a professional, and in other instances waiting too long to see a doctor can result in making a simple injury a potentially permanent problem. So let’s look at a few scenarios.

First: See A Physician If You Have Something You’re Just Not Sure About

I’ll start off with a very broad statement: go see a physician if you’re just not sure about something. This could literally be anything from a headache that doesn’t go away, a lingering cough, or even vague nagging joint pain. Many things are treatable, and it all starts with a diagnosis from a skilled clinician.

Second: Some On-Field Injuries Will Need Immediate Evaluation

Sideline Sports Doc is in the business of teaching coaches how to perform basic on-field evaluation of injuries. We teach about what we call The SAFE Method, which involves an assessment of the Story, Appearance, Feel, and Effort. In each of these categories are some red flags that would signal the need for immediate attention. For example, in Story, if there are complaints of significant pain, you’d be wise to see a physician immediately. Under the Appearance category you’d look for things such as immediate bruising or swelling. If either of those happens in the first minute or two, you’ll likely need to go to the local emergency room. With Feel we are asking you to press lightly on the injured area, and if this produces considerable pain with light touch that warrants immediate evaluation. And finally with Effort you’ll check for the ability of the injured athlete to move the injured area on their own. If this effort is painful or if they are unable to move the area at all then get to a physician urgently.

Third: Ongoing Pain, Discomfort, or Poor Sport Performance Could Benefit From Proper Evaluation And Treatment

This is sometimes a tricky decision. The young athlete often hides ongoing or nagging injuries from their parents or coaches out of fear that something will be discovered that keeps them out of play for an extended time. And they might be right. But more often than not, proper diagnosis will allow some treatment that can actually shorten the recovery time and at the same time allow for continued modified activity. After physician evaluation there might be treatments such as short term medication, bracing, physical therapy, or working with an athletic trainer that can really help. My advice is that if you have discomfort or pain that causes you to come out of a practice or game then you should see a sports physician. And similarly if you are noticing decreases in performance that’s not corrected by proper form or training, it could mean there’s an underlying physical problem. Good evaluation, proper treatment, and perhaps a short time off can make a huge difference in the long run.

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Basketball: ankle bracing and balance training reduce ankle sprain risk

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Basketball players are at risk for ankle sprains, knee ACL injury, and general lower extremity injury
  • Using lace-up ankle braces and/or performing balance training can reduce the risk of ankle sprains and general lower extremity injury
  • Unfortunately, there is no currently proven training method that reduces the risk of ACL injury in basketball players
  • Basketball players should strongly consider using lace-up ankle braces for practices and games, and consider balance training programs too

I wrote recently on the effectiveness of the FIFA 11+ program to reduce the incidence of a basketball rolledankle2_3wide variety of lower extremity injuries in soccer, including ACL tears. That program works for soccer players, coaches should require it.

Does an equivalent program exist to reduce injuries in basketball players? Possible strategies that have been used for basketball players include ankle bracing, ankle taping, balance training, and jump/landing training.

A recent pooled analysis of published studies shows that the results for lowering injury rates in general lower extremity injuries and ankle sprains is very good, but unfortunately the training programs have not shown a reduction in ACL injuries.

Basketball movements place unique demands on the player, including a much higher percentage of vertical movements than soccer players, and higher percentages of lateral movements compared to volleyball. Balance, strength, or neuromuscular education programs would need to account for the specific movements required in basketball. It’s possible that the current ACL training programs for basketball do not fully train the athlete for these movements, future programs might show better results with modifications. It’s also possible that the current studies simply did not study enough athletes to show a statistical difference.

Ankle sprain reduction: braces and balance training work

Several well-designed studies have shown the effectiveness of lace-up ankle braces in reducing incidence of ankle sprains. The effect is particularly strong for an athlete who has had prior sprains, in reducing the chance for yet another sprain. Other studies have shown that using an ankle brace does not “weaken” the ankle. With this in mind, the easiest intervention for a basketball player would be to use a lace up ankle brace for practices and games. If you do happen to get a sprain with a brace on, my feeling is that the sprain is less severe than it would be without a brace.

Other strategies involve balance training. These programs typically involve training a few times per week for 8 to 12 weeks and have also shown effectiveness in reducing the incidence of ankle sprains. The programs have only one drawback: they are only effective if you actually do the training! Some coaches may not want to devote time to the training, and compliance amongst young athletes can be low.

Your best strategy then is to use a lace up ankle brace for sure, and also utilize the balance training programs if possible. It appears that these strategies will certainly lower your risk of ankle sprains, and it doesn’t appear that there are any negative effects from either strategy. We still need good training programs to reduce ACL injury risk though. I have a feeling we are close on that front and need some larger studies to prove effectiveness.

Until then, lace up your ankle brace and have a good season!

Posted in Ankle, Basketball, Knee, Tips and Training | Leave a comment

Don’t Let An Injury Stop You From Exercising

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Being injured doesn’t always mean you need to completely stop all exercise or sport activity.
  • Don’t be afraid to have a discussion with your doctor, physical therapist, or athletic trainer about modifications or alternate activity during your healing
  • With proper guidance you will likely be able to continue some type of physical activity and you might even be able to use the recovery as an opportunity to correct some pre-existing issues and come back to your sport even better

Injuries are often viewed as some kind of exercise or training death-sentence. The reality isArm Cast  often the opposite of that. When done properly, an injury will usually allow the injured athlete to continue some type of physical activity during their healing from injury, and when viewed psychologically the injury can offer the athlete a chance to come back better than before the injury.

Let me start with a typical example. A 12-year-old soccer player came in to my office this week with a wrist injury to his non-dominant arm. We found that he had a common wrist fracture called a “torus fracture”, treatable in a short arm cast for about 4 weeks. His initial reaction was that he would not be able to do anything at all with the cast on. But we drilled down into his activities and found many places where he could participate.

“Can I play soccer?” Well, yes and no. With padding we found that his coach would allow him to participate in practices, but unfortunately his league rules would not allow competitive play. But still it was something. “Can I go running?” Yes for sure. More progress. “There is a basketball tryout for my school team coming up in a couple of weeks, can I do that?” Actually yes, if the coach and school will allow it. He found that he could dribble and shoot without difficulty, and the school allowed it with padding. The point is that we went from “I can’t do anything” to “there’s actually quite a bit I can do.”

If you have an injury requiring some type of treatment for proper healing I’d recommend that you discuss alternative exercise carefully with your doctor, physical therapist, or athletic trainer. They will usually be able to work with you to find some activities you can safely do while your injury properly heals. Physical therapists and athletic trainers are highly skilled in recommending alternative activities- use their expertise!

Here are some other common examples:

  • If you had an ankle sprain requiring you to take time off running you might be able to use the elliptical trainer, bike, or do weight training
  • If you have an ankle injury being treated in a walking boot there might still be things you can do. Basketball players can shoot free throws, golfers may be able to chip and putt.
  • With a back injury you might not be able to do squats or Olympic lifts but it might be possible to do a flat bench press using lighter dumbbells.
  • And for serious injuries requiring surgery you will likely be able to do things in your recovery to make you even better when you return to your sport. For example many teenage girls who have an ACL tear treated with surgery might have had some problems with their landing mechanics on a jump that contributed to their injury risk. Proper rehabilitation after surgery should include jump training to improve mechanics and actually make this part of your body movement better than before your injury.

No one wants to be injured and for sure each injury will need to be addressed individually. If you are injured don’t be afraid to have specific discussions with your doctor or other members of your recovery team. You’ll probably be pleased to hear there are many things you can do to stay active during your healing.

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

5 Cool Technologies That Will Impact Youth Sports and Health

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • For this week a bit of a departure: I’m going to highlight some cool new technology that will be coming soon for use by you or the young athlete
  • Many of the technologies represent radical departures from the way we do things but whether “radical” means “better” is still tbd
  1. This temporary tattoo senses through your skin. A “biostamp” is a means of measuring many body functions completely unobtrusively. For the athlete I see this as a way of measuring critical environmental functions, especially body temperature, heart rate, and respiratory rate to warn the athlete of impending heat illness. This is a near-term product likely to become part of the next wave of wearable technology.biostamp620-1432239290871
  2. Will athletes take a concussion pill to save their brains? Harvard researchers have developed an experimental treatment that helps restore normal brain structure and function in mice that have sustained severe concussions. The treatment could lead to a drug that treats and reverses the effects from traumatic brain injuries, like those seen in boxers, football players and soldiers. A drug that can reverse brain damage caused by concussion would be enormously helpful. If you are a football playing mouse you’re in luck J. For the rest of us this promising treatment is likely several years away.
  3. Can this online avatar replace a face-to-face visit with a psychologist? Her name is Ellie and she’s always available to talk. There is unfortunately a steep rise in issues such as autism spectrum disorders, add/adhd, and even depression in adolescents. For young people today computer and handheld monitors are ubiquitous. Could low cost easy 24/7 access to a “therapist” improve mental health? Exercise and sports are often prescribed for at-risk young people.
  4. You’ll be able to feel virtual reality for sports and fitness training. Computer feedback is used extensively in sports training, especially sports involving highly technical movements. What’s been missing it the “feel” a person gets from actually making contact with an object, such as a golf club or a ball. Expect this to change rapidly with new haptic technology that is portable.
  5. This robot wins rock-paper-scissors 100% of the time. Ok this has absolutely nothing to do with youth sports, health, or fitness but it is nevertheless cool. Japanese researchers have created a robot that can play Rock Paper Scissors better than any human, every time. The robot doesn’t actually play by the rules: it uses a high-speed camera and electronic reflexes that are faster than a human’s to identify the opponent’s hand shape and then play the corresponding winning move.
Posted in In the News, Sports Science, Sports Technology | Leave a comment

Sport Specialization Can Increase Injury Risk Regardless of Hours and Months Played

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent scientific article suggests that single sport specialization in young athletes increases injury risk, regardless of the number of hours played- this is a new and important finding
  • The risk of injury increases considerably if the young athlete plays a single sport for more than 8 months out of the year, or more than 16 hours per week
  • Some highly technical sport movements also increase the risk of injury, such as baseball pitching, the tennis kick serve, or technically repetitive sports such as gymnastics, dance, swimming, and diving
  • If a young athlete does choose single sport specialization it would be wise to limit participation to a maximum of 8 months out of the year and 16 hours per week

This week I’d like to point you to a recent publication of an interesting scientific article about Sport Specialization, published in the journal Sports Health. The most interesting finding from the study is in the first bullet point above: early sport specialization is in and of itself a risk for injury in the young athlete, regardless of the number of hours played per week or months played per year.6-17-09-7 XATHLETES

My take on this is that it’s interesting and also perplexing. Why would sport specialization lead to an increased injury risk even if the number of hours played per week or months played per year is a reasonable or modest amount? There is some speculation about the reasons but no clear answers yet. The younger the athlete the greater the risk due to the presence of open bone growth plates, and some highly specialized repetitive sport movements could also reasonably increase risk- I get that. But we need more research in this area, which is likely to come in the next several years. The study I reference above is a pooled retrospective clinical review, so it can be difficult to take absolute recommendations from this but we can at least be reasonable.

In the meantime each family needs to assess their own child’s goals, ambitions, and risks for themselves. The 16-hour per week maximum really shouldn’t be that hard to do but I think the harder part will be the maximum 8 months of dedicated sport participation per calendar year. There’s a lot of pressure now for single sport athletes to play year round and in fact that’s generally viewed as a badge of honor by most of the parents I talk to.

When kids come to see the orthopedic surgeon it means they’ve already had a problem so our perspective is a bit skewed. On the plus side the super-elite sports world is full of athletes that will tell you they played multiple sports until somewhere in their mid-teen years and that’s a formula that leads to success competitively as well as from a health standpoint. I’d strongly encourage you to employ sport diversification and participation limits in your own kids’ lives.

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When Can I Return To Sports After ACL Surgery?

By Geoffrey Abrams, M.D.

Assistant Professor of Orthopedic Surgery, Stanford University


And Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Most surgeons will like to see at least 90% strength in the operated knee and 100% motion compared to the normal knee before allowing a return to sports
  • We often use “functional testing” such as hops or 3-D motion analysis to provide more data on readiness
  • High school aged athletes will typically take at least 9 months after surgery before they are successfully able to pass all the tests and return to cutting, pivoting, or power based sports

We’ve written previously about the timing of ACL surgery for high school age athletes, and in ACL hop testthe post one of us (Dr. Mishra) stated that he hasn’t seen a high school age athlete be truly ready to return successfully to sports participation until at least 9 months after surgery. That statement was based on his experience gained performing more than 3000 ACL reconstructions in athletes over a 20 year period, and carefully evaluating those athletes along with their physical therapist, rather than through scientific study.

In an effort to evaluate the science behind return to play decisions, Dr. Abrams wrote a paper on the topic in the Orthopaedic Journal of Sports Medicine. You can access the full text of the paper here.

One of the main reasons we wait until the knee is truly ready for return to sports is to protect the new ACL from a retear. There is huge variability in published medical studies about retear rates after ACL reconstruction, with a range from 3% to about 49%. Such a wide range may be due to the fact that little agreement exists on criteria for return to sports.

Generally speaking, we look at knee range of motion, strength, and movement based tests (also known as “functional testing”) when attempting to judge an athlete’s readiness for return to sport. Other factors to consider are the demands of the sport, the playing level of the athlete, and even the young athlete’s own assessment of their readiness. We will typically ask the physical therapist to assess motion and strength (quadriceps, hamstrings, hip rotators) and compare the operated knee to the opposite normal knee. Most surgeons like to see the operated leg at 90% or more strength and 100% motion before they will allow a return to sports.

Recently there is more emphasis on movement-based tests, since these tests might be better at assessing the types of movements the knee will face during sports activity. A variety of hop tests are the most commonly used type of functional exams used to determine readiness for return to play, and more sophisticated testing with 3-D motion analysis is occasionally used. Regardless of the type of functional test used, we have found that these tests are an important part of determining the athlete’s ability to safely and effectively return to sports.

When we put all the factors together we’ll almost always see a 9 month or longer timeframe for the high school aged athlete to pass all of the tests and return to cutting, pivoting, or power based sports.

Why is it that we frequently hear of professional athletes returning to their sport at 6 months, or even as soon as 4 months after surgery? There are many factors involved here. A professional athlete’s job is to get themselves ready to play after surgery, and they literally are able to access help 24/7 through trainers, therapists, and other professionals. Additionally, their bodies are more mature than the high school athlete’s body, which often makes it possible for the professional athletes to push themselves harder in rehab.

If you’re a high school athlete, you’ll be going to class, studying after school, and you may even want a social life J. You’ll work really hard on your rehab, and when you pass your tests for knee motion, strength, and function you’ve got a great chance to return successfully to your sport. Just count on that taking at least 9 months.







Posted in Knee, Sports Science | Leave a comment

Save Your Hamstrings? Save Your ACL? Use The FIFA 11+ !

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The FIFA 11+ warmup program results in reductions to all soccer related injuries by an incredible 30% to 70%
  • The program works for males and females, across multiple age groups
  • You must consistently use the program at least 2 times per week, all season
  • The head coach is in an excellent position to improve player health by requiring this warmup program

I listened recently to a presentation by Holly Silvers, one of the creators of the PEP FIFA 11warmup program for soccer that ultimately evolved into the FIFA 11+ program. I was astounded by what I heard- using the program consistently, at least 2 times per week produced reductions in all soccer related injuries by 30% to 70%.

For context, I’ve only seen those types of health-related reductions if a drug is involved, for example using statins to reduce LDL cholesterol or using insulin for a diabetic to reduce blood sugar. But for a physical intervention to reduce injury rates by this amount is really unheard of. I think other than the 11+ program you could only reduce injury rates this much by staying in bed all day.

The links at the bottom of this page will take you to FIFA’s F-Marc site where you can download the program, as well as see some supporting scientific information. Please review it critically yourself and I believe you’ll come to the same conclusion: this program works.

At Sideline Sports Doc we’ve been preaching the benefits of injury reduction for years now, so let’s review a few of these areas. Each of these can be achieved through use of the FIFA 11+:

  • Reduce injuries to the groin, hamstrings, knees, legs, ankles by 30% to 70% for males and females, across multiple age groups
  • Reduced injuries means you keep players in your squad longer
  • The program also improves soccer specific performance
  • Fewer injuries means lower health related costs. In many parts of the United States a severe ankle sprain will cost in excess of $3000 to diagnose and treat. These costs will often be borne by the parents through high-deductible insurance plans. If you’re a parent, wouldn’t you rather have a healthy child, and keep that money for something else?

Like any safety and preventive measure, this program is only good if you actually use it, consistently through the season, at least 2 times per week. The person in the best position to implement the program and positively influence player health is the head coach. Take a stand for player health by letting your players know that you are going to be doing the program all year, let them know that you are doing it because you really care about their health, safety, and performance.

Your players look up to you as their coach, and if you set the example they will do the program. Save a hamstring, save an ACL. Use the FIFA 11+.

The FIFA 11+ Program

FIFA Medical Assessment And Research Centre (F-MARC)

Comprehensive review article on results of the 11+ program

Posted in Ankle, Hamstring, Hip, Knee, Prevention, Soccer | Leave a comment

Sideline Tips: Safe Steps In The Return To Play Decision

By Dev Mishra, MD

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


And Bert R. Mandelbaum, MD DHL (hon)

Santa Monica Orthopaedic and Sports Medicine Group and Sports Foundation

Team Physician LA Galaxy, US Soccer, Pepperdine University

Member FIFA and CONCACAF Medical Committee and F-MARC

Assistant Medical Director Major League Soccer


Key Points:

  • The coach will often have to make a decision on return to play after injury during competition
  • One tactic would be to observe the player in pregame warmup for any pain or poor movement
  • A second in-game method is to make sure the player is pain-free, has no swelling, and can pass a sideline functional test of jog, cut, sprint, and jump

One of the toughest decisions in youth sports is determining when a player who has suffered an injury is ready to return to action. It’s very easy to get caught up in the moment of competition and perhaps put an injured player back in the game before he or soccer training closeupshe is really ready. The emphasis on the sideline should always be directed towards athlete or child safety.

Returning to play prematurely can lead to a more serious injury. In our clinical practices over the last 25+ years we see one or two kids each week with a significant injury that started out as some kind of minor injury. For whatever reason they kept playing and that minor injury turned into something more significant.

Sometimes it was because they were put back in the game too soon. Sometimes it was because they failed to report it to the coach. Sometimes they played for weeks with a chronic, nagging pain.

If you think a kid’s not really ready, it’s better to sit them – maybe lose them for a few days – rather than to let them get back in before they’re ready and lose them for weeks or months. An injured player is likely not an effective player, plus there is risk of making a minor injury a major one.

Ideally the real decision on return to play is not in the hands of the coach, it is in the hands of a trainer or physician – someone who’s really trained and qualified to make that decision. This would certainly be the case when returning from a serious injury such as a fracture, concussion, or injury that required surgery.

But there are many settings where someone who is professionally qualified isn’t there to make a remove-from-play or return-to-play decision. This is common in competition on the field of play. In that case it’s really going to come down to the coach to make a reasonable decision.

When Players Insist They Are Ready To Play

Players want to play and this means that they will often insist they are ready to play when perhaps they are not. This is where the decision becomes really tough. You really need to be their advocate — to be their voice.

As the kids get older they’re going to have better reasoning abilities. They’re also going to have other motivations to stay in the game – and perhaps not tell you everything.

With kids, you’ll often have to make the tough decision for their own good. What if you’re at an away tournament? What if it’s your star player? What if you have to play a man-down? You still want to err on the side of safety. Here are two simple observational tactics to help you determine safe return to play for in-game situations:

Pregame: watch closely when they don’t think you’re watching

You might have a situation where a player was injured during practice midweek and you’ll have an opportunity to observe them in pregame warmup on the weekend. If you can see them limp, favor one side, or appear in pain with warmup movements those are red flags indicating an injury that may not be healed well enough to allow safe return to play. Your best course of action would be to hold the player from play.

In-game: do a functional test

In most soccer injury situations you’ll be dealing with injuries to the lower extremities – hip, knee, ankle, foot.

You’ll need to confirm that the player is really pain free. If you can be reasonably confident they are really pain free and have no visible swelling then you’ll need to put them through a functional test. On the sideline ask the player to jog, cut, sprint and jump and observe closely. If they player can do that comfortably and with no visible problems that is a very good indicator of return to play. That’s basically saying if a kid gets back to “normal” – they can play.

In a game situation there are of course many grey areas, decisions are rarely black and white. If you follow the advice above for the functional test you’ll generally be safe, but if you have any doubts don’t take a chance and risk turning the mild injury into something serious. Hold them out and advise them to consult a medical professional.


Posted in Basketball, Coaches, Football, Lacrosse, Soccer, Tips and Training | Leave a comment