Bad Behavior Causes Injuries

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Part of the reason for rules in sports is to help ensure the safety of the athletes playing the sport
  • It’s estimated that perhaps 10% of the injuries in youth and high school sports are the direct result of fouls or other illegal activity.
  • Rules changes and stricter enforcement of rules could have a positive effect in reducing injury rates and youth sports, however, it can be difficult to implement this from the practical standpoint

Rules of competition exist in all sports mainly to satisfy two needs. First, the rules are in yellowcard-2place to ensure as reasonably as possible that all competitors have a fair chance at winning. And secondly, the rules are in place to help ensure the safety of the participants.

Over the last several years national governing bodies in many sports have been asking serious questions about rules changes necessary to improve the safety of their athletes. To name just a few, the US Soccer Federation enacted sweeping rules changes regarding heading of the ball for younger players designed to reduce the risk of concussion. USA Hockey has an age restriction below which it is illegal to perform body checking. And football at all levels from peewee up through the professional ranks now has fairly stiff penalties in place for targeting.

Is it possible to estimate how many injuries actually occur from fouls or illegal play? As it turns out the question is fairly complicated and there is not a lot of research for us to look at.

There is one published study from Collins and colleagues in the journal Injury Prevention published in 2008 that sheds a little bit of light on the issue.

Injuries related to fouls and other illegal activity in sports

The authors used RIO (Reporting Information Online), an injury surveillance system, to collect data on injuries in high school sports in the United States. For the 2005–06 and 2006–07 academic years, they captured injuries in boys’ football, soccer, basketball, wrestling, and baseball and girls’ soccer, volleyball, basketball, and softball. They attempted to compare differences between sports (boys’ and girls’) for injury rates, and in particular, the proportions of those injuries related to illegal activities and fouls.

There were some interesting results:

The authors estimated that 98,066 injuries occurred nationwide during those years as the result of an action that was ruled illegal activity by a referee/official or disciplinary committee. They calculated an injury rate of 0.24 injuries related to illegal activity per 1000 athletic competition-exposures.?Boys’ and girls’ soccer had the highest rates of injury related to illegal activity.?Girls’ volleyball, girls’ softball, and boys’ baseball had the lowest rates of injury related to illegal activity. ?Boys’ and girls’ sports overall had similar rates of injuries related to illegal activity.?Of all injuries in these sports, 6.4% were related to illegal activity. ?The highest proportions of injuries related to illegal activity were found in girls’ basketball, girls’ soccer, and boys’ soccer (in that order). ?The lowest proportions of injuries to illegal activity were found in girls’ softball, boys’ football, and girls’ volleyball.

Furthermore, these injuries resulting from fouls were fairly severe. About 6% required surgery and about 10% required the athlete to hold out from play for a year.

This study shows that at the high-school level, injuries from fouls and illegal activity caused more than 10% of all injuries in four of the nine sports (boys’ soccer, girls’ soccer, boys’ basketball, and girls’ basketball). The authors argue – and I agree with them – that any risk factor that causes such a high percentage of injuries should be examined for ways to modify that risk.

In that sense, better rule enforcement and punishment of players guilty of fouls and other illegal activity might actually decrease a sizable portion of youth sports injuries. Since over 5% of these injuries needed surgery and 10% were season-ending injuries, it seems to be an especially important effort.

In theory, cutting down on injuries related to dirty play and fouls makes sense. As a practical matter it is harder to actually achieve. But better rule enforcement and punishment by referees and education of athletes, parents, coaches, and referees by sports medicine healthcare providers might be a much needed first step.

Posted in Prevention | Leave a comment

Spleen Injuries – Sneaky And Possibly Dangerous

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The spleen is the most commonly injured abdominal organ during sports
  • An enlarged spleen, such as from mononucleosis, places an athlete at additional risk of injury to the spleen
  • Emergency treatment is critical to ensure the health of the athlete after a possible spleen injury

This week I was working with a college lacrosse player who was seeing me for ongoing lacrosse stick checkissues with groin pain. Unrelated to that he indicated to me that in the past season he was hospitalized for a week due to a laceration of his spleen. The laceration occurred during a lacrosse game when he was diving for a ball and an opposing player’s stick hit him just underneath his left rib cage. My patient was fortunate in that he has made a full recovery and should go on to have normal function of his spleen. But others have not been quite so lucky.

A young man named Evan Murray, a 17-year-old three-sport athlete at Warren Hills Regional High School in New Jersey took a hit in the backfield during a football game in 2015. According to witnesses who spoke to the media, Murray walked off under his own power but later collapsed. As he was placed on a stretcher to be taken to a local hospital, he told his teammates he would be fine and gave them the thumbs-up sign.

But tragically, Evan Murray didn’t make it.

According to the County Coroner’s Office, the cause of death was a lacerated spleen that caused massive internal bleeding. Dr. Ronald Suarez found that Murray’s spleen was abnormally enlarged, making it more susceptible to injury.

What is the spleen?

The spleen is an organ in the upper far left part of the abdomen, to the left of the stomach. The spleen plays multiple supporting roles in the body. It acts as a filter for blood as part of the immune system. Old red blood cells are recycled in the spleen, and platelets and white blood cells are stored there. The spleen also helps fight certain kinds of bacteria that cause pneumonia and meningitis.

Some medical conditions can result in an enlarged spleen, and an enlarged spleen is a risk for rupture. One of these conditions commonly seen in young athletes is mononucleosis, otherwise known as “mono”. For this reason, most physicians will require an athlete to rest for several days after mono before return to sports. This gives the spleen a chance to return to normal size.

Mechanism of spleen injuries

While death from spleen injuries is thankfully rare, the spleen is actually the most frequently injured abdominal organ in sports. A direct blow to the left side of the upper abdomen in contact or collision sports like football, lacrosse, or hockey, can injure the spleen in a healthy athlete.

Recognition of spleen injuries

A huge amount of blood travels through the spleen. Laceration or rupture can lead to massive bleeding into the abdomen that can be catastrophic.

Spleen injuries can be hard to diagnose at the time of injury. A player might have upper left abdominal pain after a hard tackle to the body, or being hit by the backend of a stick. He might complain of left shoulder pain from blood irritating the diaphragm. A doctor or athletic trainer might find tenderness when feeling the abdomen or ribs over the spleen.

Recognition and treatment of athletes with spleen injuries

Immediately after the injury, the athlete may have very few complaints and the exam could look nearly normal. It’s incredibly important therefore to pay close attention and act quickly if the young athlete develops any signs of abdominal pain. Evaluation of the athlete at a hospital is critical if there is any question of a serious injury.

Many athletes with ruptured spleens require surgery and sometimes removal of the spleen. Some types of spleen injuries can be successfully treated without surgery. My young patient required a week in the hospital. These athletes usually do well and lead healthy lives, often returning to sports.

Evan Murray’s death was devastating for his hometown. Maybe one positive outcome will result from this tragedy. Parents, coaches and athletes can become more aware of these injuries so that no more athletes die from them in the future.

Posted in Football, Hockey, Lacrosse | Leave a comment

The Stephen Curry Model For The Young Athlete

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • This week I’d like to direct you to a Wall Street Journal article about Golden State Warriors superstar Stephen Curry and his multi-sport childhood.
  • Delaying single sport specialization is a model we’ve written about many times, and here is yet another example of how it can work successfully

I write this post from the San Francisco Bay Area, where we’re pretty spoiled these days BN-OB392_CURRY0_J_20160517150801with our professional sports teams. After last night’s game 7 win against OKC, the Warriors are in the NBA finals and the Sharks are in the NHL finals. And coming off Memorial Day I’m going to provide a short post highlighting a Wall Street Journal article titled: The Stephen Curry Approach To Youth Sports. I’d encourage parents and coaches to have a look.

The essence of the article is that Curry- now arguably the best player in the NBA- spent a lot of time as an adolescent and teenager playing sports other than basketball. It is well documented that coming out of high school Curry was not heavily recruited by any of the traditional major basketball powers and ended up at Davidson.

Sure it can be argued that he has genetics on his side, as his father Dell was a long time NBA player, and sure it can be stated that Steph spent a lot of time around NBA players as a kid. Undoubtedly that had a major influence in his game. But still, genetics and environment doesn’t mean you’ll end up as a professional athlete.

Here’s some food for thought from the article: “Curry is already the most popular NBA player among kids. His approval ratings these days are close to ice cream’s. There was once a time when children wanted to be like Michael Jordan. Now they want to be Curry. But following his example doesn’t mean they have to grow up as the best shooter who ever lived. It may be as simple as dabbling in other sports when they’re still young.

That’s because Curry is also the poster child for a saner approach to youth athletics. In an age of hyper-specialization, Curry has reached the pinnacle of his sport by doing the exact opposite. He played basketball, but he also played some baseball, football, soccer and basically everything else in a sports buffet. What worked for Curry, experts say, could work for everyone.”

I wholeheartedly second that opinion. Multi-sport participation up until around age 14 makes a lot of sense from the body development and physiology standpoint, and probably psychologically too. It also seems to have some magical effect in reducing the chances for overuse injury.

What’s the worst that could happen from that approach? You’ll likely end up with a healthier and happier kid. When they start showing real interest in single sport focus, perhaps age 14 or so or at least age 12, then go for it with their sport of choice.

Posted in Basketball, Parents | Leave a comment

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.

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