Safe Steps In The Return To Play Decision

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • The coach will often have to make a decision on return to play 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 she is really ready. The emphasis on the sideline should always be directed towards athlete or child safety.sideline test balance

Returning to play prematurely can lead to a more serious injury. In my clinical practice over the last 21 years I 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.

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 many movement based sports 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 Ankle, Hip, Knee, Tips and Training | Leave a comment

Is It OK For A Young Athlete To Play In Pain?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Deciding whether the young athlete is having “discomfort” vs. “pain” is a very individual process as each person’s perception of pain is different
  • Getting the exact diagnosis by consulting a sports physician is advisable
  • Young athletes with minor injuries and discomfort can often continue playing, but caution and individual guidance are important

“What’s the difference between discomfort and pain? And is it ok for me to keep playing if I just have a little bit?” Those are two of the most common questions I’m asked by injured young athletes, and I’m guessing the same is true for our sports medicine colleagues across the country. The answers are different from person to person, and specific to the type of injury too. OLYMPUS DIGITAL CAMERA

In the NFL elite level adult athletes know that there’s risk involved in their sport- their profession. Professional football is a sport where it’s expected that a player will get his body beaten on a weekly basis, and dealing with the pain is part of the game. Medication is sometimes used to get a player through Sunday. I have a very hard time using that approach in a young athlete who has a long lifetime of activity ahead.

There are many factors that go into a decision whether we allow a young athlete to play through some discomfort, whether we recommend that they take time off, or whether we prohibit them from playing. Key amongst the factors is the exact diagnosis of the problem, and some other factors we consider are the athlete’s age, sport, position, time during the season, and importance of the event or competition.

Knowing the exact diagnosis is important

We have to start the decision process with the diagnosis. It’s not enough to just say “knee pain”, we need to be specific. One of the problems I have with certain health practitioners is that decisions about treatment and play are made without a specific diagnosis. See a qualified medical practitioner to get a diagnosis, and then using a combination of the other factors a skilled sports medicine specialist will advise in making a decision that allows for safe sports participation.

Understanding again that individual decisions need to be made between the player, parents, and physician, there are still a few general comments I can make. Many types of tendonitis can be managed with braces during play and ice/stretch/massage after a playing session. Most fractures and stress fractures will require holding the young athlete from play until healing is complete. All hamstring injuries get rehab until healed. Ligament injuries to the knee will generally not allow return to play until fully healed, but some ligament injuries around the ankle can allow play with a brace.

Everyone has a different response to pain

One person’s mild “ache” is another person’s “severe pain”. I usually recommend against playing if the young athlete tells me he or she needs medication like Advil or Motrin in order to play. To me that’s a sign that we need to get that injury properly healed. For many other injuries it is sometimes safe to continue playing, although performance might suffer.

Sometimes it is safe for the young athlete to play through some discomfort, but start with the exact diagnosis from a qualified physician and get the physician’s guidance for timing on return to play.


Posted in Parents, Psychology, Sideline Sports Doc Miscellaneous | Leave a comment

Start Saving The ACL When Kids Are Very Young

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published scientific study attempts to explain why puberty leads to an increased risk in ACL tears for girls and boys but tends to affect girls more
  • An increased Body Mass Index is a risk factor for ACL tear regardless of age or sex
  • The results suggest that ACL tear prevention programs should start before puberty in girls

This blog is focused on providing a sports medicine physician’s perspective on issues affecting youth sports health and participation. Our fundamental belief is that youth sports done right has numerous benefits, which can lead to a lifetime of good health habits. But as an orthopedic surgeon I’m often troubled by the younger ages at which we see some types of injuries, and the younger ages at which surgical care is done for these injuries. Two particularly bothersome areas are ACL tears in the knee and Ulnar Collateral Ligament tears in the elbow. ????????????

Let’s take a look at ACL tears in athletes as young as age nine. A recent publication by Stracciolini and colleagues sheds light on the pediatric ACL problem in very young athletes. Their study shows that boys appear to injure more ACLs before puberty while girls catch up later through their teenage years. The study also shows that higher Body Mass Index (BMI) is associated with a higher risk of ACL tears, regardless of age and sex. Why BMI is independently associated with ACL injury is puzzling. Could it be that the immature neuromuscular system is not yet capable of absorbing the added forces produced by an increased BMI? There are implications for improving the young athlete’s health from each of the points raised in the paper.

First, this study shows that ACL injuries make up a higher proportion of the total number of sports injuries as kids move through puberty. This is especially true for girls and is in line with other studies showing that girls have a higher injury ratio than boys starting at around age 12. In contrast to boys, girls may have greater generalized joint looseness after the onset of puberty, and it seems that the joint looseness is a risk factor for ACL tear. There is also some evidence that changes in the hormones estrogen and progesterone associated with the menstrual cycle are risk factors for girls.

Second, the authors also showed data that supports an association between higher Body Mass Index and the risk of an ACL tear. This risk was present regardless of age and sex. In other words, at any age, if two young athletes are compared and one has a “normal” BMI for age and the other has an elevated BMI, the athlete with the elevated BMI has higher risk for tearing an ACL.

There are many factors involved in the exact process of ACL tears but the authors attempt to tie everything together like this: After the onset of puberty and a rapid growth spurt, there is increased bone length and increased overall body mass. This leads to increased height of the center of mass and decreased core stability. Poor core stability places the ACL at risk.

Wow, that was a lot to digest in a small amount of space. The practical implications are these: puberty results in a significant increased risk for ACL tears in girls, and an increased BMI increases ACL tear risk in boys and girls regardless of age. One strategy for girls would be to introduce school or team ACL injury prevention protocols before puberty. This has the potential to reduce ACL tear risk into puberty and later years. Start saving your ACL as early as possible!



Posted in Knee, Sports Science | Leave a comment

Kneecap Instability: A Troublesome Issue For Girls

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Kneecap instability can be a frustrating source of pain and limited function for the young female athlete
  • A combination of anatomic and sport-specific factors is involved in creating the instability
  • Kneecap instability can often be treated successfully without surgery but surgery may be needed for recurring instability
  • Recovery can be very long, sometimes taking six to 10 weeks without surgery and four to nine months with surgery

The kneecap can be a source of trouble for young athletes, especially girls. There are some features in a growing young girl’s anatomy that place her at risk for kneecap instability. When combined with some sports in which a high amount of twisting torque is involved we have a recipe for problems such as the kneecap partially shifting (“subluxation”) or completely shifting out of place (“dislocation”).A00707F02

In a growing girl there are changes in the shape and length of the pelvis and legs that are normal, such as a widening of the pelvis and an increase in the angle the legs form at the knees. These changes tend to cause an increase in the angle of pull on the kneecap, resulting in the kneecap sitting towards the outside of the knee.

The changes in the angles are normal but when combined with sports that require twisting of the body around the knee, it can create a situation where the normal motion of the kneecap is overwhelmed by the outward pull. The result can be kneecap instability. A classic situation that we start to see in springtime is instability of the right knee in a right-handed softball batter. Other sports where we’ll often see kneecap instability are basketball, soccer, and lacrosse.

What the athlete feels with patellar instability depends on how far out of place the patella has moved and how much damage occurred when it happened.

Some general symptoms the athlete may experience include:

  • Pain, usually in the front of the knee near the kneecap
  • Feeling the kneecap shift or slide out of the groove
  • Feeling the knee buckle or give way
  • Hearing a popping sound when the patella dislocates
  • Swelling
  • A change in the knee’s appearance — the knee may appear misshapen or deformed
  • Apprehension or fear when running or changing direction.

Treatment for kneecap instability has improved substantially over the last 30 to 40 years. Gone are the days of placing the knee in a cast, with total immobilization for perhaps 6 weeks. A recent scientific publication in the journal Sports Health outlines the changes in our treatment process for this common problem.

Nonsurgical treatment usually works for first-time patellar dislocations, but surgical treatment is recommended for first-time dislocations accompanied by cartilage injuries. Nonsurgical rehabilitation takes some time, and six to 10 weeks is common before full sports are allowed. Surgery is sometimes needed to stabilize a kneecap that repeatedly becomes unstable. The surgery can be very successful but the rehabilitation can take quite a long time. I have seen a four to nine month timeline to return fully to sprinting, twisting, and jumping sports after surgery.



Posted in Basketball, Knee, Lacrosse, Soccer, Softball | Leave a comment

Keys To Sideline Concussion Diagnosis

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published study shows that the addition of vision testing (the King-Devick test) to our standard testing with symptoms, cognition, and balance can improve diagnostic accuracy of concussion to 100% in young athletes. This testing should be done by athletic trainers or team physicians.
  • For the medically untrained coach your priority is not to diagnose a concussion but only to suspect a concussion, remove the athlete from play, and send the athlete to a physician for proper diagnosis and management.

For healthcare professionals, it seems that we are starting to settle on four main areas to examine when evaluating athletes for concussion: their symptoms (how the athlete is feeling), cognitive testing (their thought process), balance testing, and now a fourth important component: rapid eye movement vision testing. eyeball

Before we go any further I’d like to point out that the medically untrained coach on the sideline needs to do one thing above all else: you only need to have a suspicion that the young athlete might possibly have a concussion and then you must remove the athlete from practice or the game. A physician skilled in sports concussion management should evaluate the athlete. Let the physician make the call as to the right time to start the gradual return to play progression. You can download a simple sideline concussion assessment guide from our website that can show you how to suspect a concussion.

The issues for certified athletic trainers and team physicians on the sidelines are a bit different than the issues faced by the medically untrained coach. We have to make a diagnosis with a strong measure of certainty and do it quickly. In the NFL there is literally an entire team of doctors and trainers specifically tasked with concussion evaluation but for high school and club sports it will have to be the trainers making the call, sometimes with a team physician present.

We typically rely on a simplified version of the Sport Concussion Assessment Tool version 3 (“SCAT3”) that allows us to rapidly but incompletely evaluate symptoms, simple memory, and a scaled-down balance test. The simplified version can be done in about 3 minutes; the full version requires about 15 minutes. The 3-minute screening is reasonable but still it’s possible to miss athletes who actually have a concussion. The full 15-minute test improves our diagnostic accuracy but it’s not perfect either, and we never have 15 minutes at a sports contest to do the whole test. Studies have shown that the full 15-minute test can miss 10% of athletes with a known concussion.

So we need to do better. Is there an objective, rapid test that can improve our diagnostic accuracy? This is where adding a vision function test called the King-Devick test comes in. A recently published study shows that adding the King-Devick test to the SCAT test increases diagnostic accuracy to 100% in young athletes. The beauty of the King-Devick test is that it can be done in 2 minutes or less and uses an iPad or computer with person to person reliability. Anyone can do it. The New York Times published recently on the King-Devick test. Please note that the NYT article shows illustrations of the test through cards but the King-Devick test is proprietary, with multiple patents and copyrights to its name so the proper legal access to the test is through the company website. The company has an online version that costs $15 and is produced in association with the Mayo Clinic, but I’m a bit skeptical about an online version for use at high school or club events because the right technology and connectivity doesn’t always exist.

To use the King-Devick test each athlete needs to have a preseason baseline test done when they are healthy. Essentially, the athlete reads a set of numbers on the test panels and is timed in seconds. The athlete with a suspected concussion can be given the King-Devick on the sideline and the results compared with the athlete’s baseline. If it takes longer to do the test it likely indicates a concussion. Combine the judgment of a skilled athletic trainer, the King-Devick test plus the simple SCAT and we now have a 5-minute set of tests that are highly accurate.

Simple. Inexpensive. Reasonably fast. Accurate. Published scientific evidence. This combination should make life quite a bit simpler for the trainer and physician tasked with sideline diagnosis of concussion.






Posted in Concussions, In the News, Sports Science | Leave a comment

The Female Athlete Triad: A Serious Problem Needing Careful Attention

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The “female athlete triad” is a combination of eating disorder, lack of menstrual cycle, and low bone density
  • This is a complex medical issue requiring care from a number of medical professionals
  • If not treated, the female athlete triad can be a career ender as well as have lifetime consequences

There’s an excellent article about American teenage runner Mary Cain in yesterday’s New York Times. Ms. Cain is a teenager but she’s a professional athlete who trains at Alberto sideacheSalazar’s Oregon running facility. Ms. Cain has an entire team of professionals including nutritionists and physical therapists who are tasked with keeping her healthy. The story is also illuminating in pointing out that many female athletes are not so fortunate, indeed Mary Decker likely had her career cut short by something we now know as “the female athlete triad”. This is a very serious condition that can be career threatening and in extreme forms it can also be life threatening.

Female athletes who focus on being thin or lightweight may eat too little or exercise too much. Three interrelated illnesses may develop when a girl or young woman goes to extremes in dieting or exercise. Together, these problems are known as the “female athlete triad.”

The three problems are:

  • Eating disorder

Abnormal eating habits (i.e., crash diets, binge eating) or excessive exercise can lead to poor nutrition.

  • Menstrual dysfunction

Poor nutrition, low calorie intake, high-energy demands, physical and emotional stress, or low percentage of body fat can lead to hormonal changes that stop menstrual periods.

  • Premature osteoporosis (low bone density for age)

Lack of periods disrupts the body’s bone-building processes and weakens the skeleton, making bones more likely to break.

Females in any sport can develop one or more parts of the triad but the greatest risk are those in sports that reward being thin for appearance (such as figure skating or gymnastics) or improved performance (such as distance running).

Psychologists recommend that female athletes should consider these questions:

  • Are you dissatisfied with your body?
  • Do you strive to be thin?
  • Do you continuously focus on your weight?

If the answers are yes, you may be at risk for developing abnormal eating patterns, and that in turn can place you at risk for the female athlete triad.

Disordered Eating

Eating disorders often start with an excessive preoccupation with body shape and weight, specifically, the intense desire to stay as light and thin as possible.

Females are five to 10 times more likely to have disordered eating compared with males, and the problem is especially common in females who are athletic. Some people starve themselves (anorexia nervosa) or engage in cycles of overeating and purging (bulimia).

Others severely restrict the amount of food they eat, fast for prolonged periods of time or misuse diet pills. People with disordered eating may also exercise excessively to keep their weight down.

Disordered eating can cause many problems, including dehydration, muscle fatigue and weakness, an erratic heartbeat, kidney damage, and other serious conditions. Not taking in enough calcium can lead to bone loss. Hormone imbalances can lead to more bone loss through menstrual dysfunction.

Menstrual Dysfunction

Missing your period is a significant cause for concern. With normal menstruation, the body produces estrogen, a hormone that helps to keep bones strong. Without a menstrual cycle the level of estrogen may be lowered, causing a loss of bone density and strength (premature osteoporosis).

If this happens during your teenage years, it may become a serious problem later in life when the natural process of bone mineral loss begins after menopause. Amenorrhea may also lead to stress fractures.

Premature Osteoporosis (Low Bone Density for Age)

Bone mass and bone quality decrease, making your skeleton fragile. Low bone mass puts you at increased risk for fractures.

See your Primary Care Doctor immediately

Recognizing the female athlete triad is the first step toward treating it. See your primary care doctor right away if you miss a menstrual period, get a stress fracture in sports, or think you might have disordered eating.

Your doctor will perform a complete physical examination and may use laboratory tests to check for pregnancy, thyroid disease, and other medical conditions. In some cases, a bone density test will be recommended.

Treatment for the female athlete triad can be successful but takes quite a bit of time and effort. This is one condition that is extremely important to get right, the consequences extend far beyond sports.



Posted in Nutrition, Psychology, Running, Sports Science | Leave a comment

Car Tires And Cancer

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Artificial turf fields continue to grow in popularity, many of these fields use ground-up car tires (crumb rubber) as infill material
  • Many scientific studies have shown the safety of crumb rubber for use in athletic fields, but some of the research is old
  • Some health advocates claim there is a link between artificial turf fields and cancer formation
  • Proving a causal link between crumb rubber infill and cancer formation will be a long-term and difficult task, but at the least some additional study of turf fields could be very helpful

Here in the San Francisco Bay Area where I live, our elected representatives have a strong history of taking up populist causes. One area currently being debated is the subject of whether the ground-up rubber particles found in the infill portion of artificial turf sports fields poses a health risk to the players, specifically, could the material lead to cancer in some players.TurfCrumbRubber201310

On the surface it’s always seemed to me to be a very good idea: millions of car tires were sent to landfills where they take up space and possibly contribute to production of hazardous gases, or possibly leak toxic products into the water table. Recycling these car tires and contributing to a consistently good playing surface for young athletes made sense to me.

But recently, some environmental and health advocacy groups have claimed that the crumb rubber infill, used in artificial fields since the 1990s, has contributed to cancer cases in soccer, football, and field hockey players.

On the whole, re-use and recycling of used car tires has been enormously successful. Prior to 1990 there was a very limited market for used car tire products but since 1990 it is estimated that about 90% of used car tires are repurposed. According to the EPA, only about 10% of used car tires end up in landfills today. 55% are estimated to be burned as fuel; 10% are retreaded and resold; about 20% are used in civil engineering projects, and the rest are used for various other purposes. Some of the tires are ground up into particles called “crumb rubber” and can be used as infill in artificial turf sports fields.

My feeling as a team physician is that the absolute best playing surface for most outdoor field sports is perfectly manicured natural grass. Unfortunately, most communities cannot maintain perfect natural grass fields, and the newer versions of artificial turf fields have achieved a price point where it makes sense for many communities to install these fields. We debate whether injury risk to knees and ankles is higher on artificial turf than perfect grass, but I know one thing for sure: it’s better to be on artificial turf than a beat up and rutted grass/dirt field.

Health risk to knees and ankles is one thing, but cancer risk is entirely different. The potential problem with the crumb rubber infill is that they contain toxic substances such as heavy metals and chemicals. Is it possible that simply coming into contact with the crumb rubber on your skin can cause health problems?

There have been many tests of the toxicity of the crumb rubber, almost all of which have supported the safety of crumb rubber for use in sports fields. One often-cited study is by Liu and colleagues, which you can access here. The Liu article is a bit dated (from 1998), but concludes “In total, these laboratory tests indicate scrap tires are not a hazardous waste.”

Then there is the question of forming a link between the crumb rubber and “cancer”. Cancer is not a disease that is easily characterized; it requires a very specific and nuanced approach to description. Lung cancer is not skin cancer, skin cancer is not leukemia. You get the point, we need a more scientific approach here. Also, it’s incredibly difficult to ascribe a cause to a specific type of cancer, since there can be many factors leading to cancer formation. Witness the fact that it took several decades to prove that cigarette smoking can cause lung cancer.

The tire reuse and recycling industry, and several health advocacy groups are bunkered down in their positions. From what I can read from the available literature, it seems that there isn’t strong evidence to say we should tear out artificial turf fields now due to proven cancer risk. But some of the evidence in favor of safety is old and our thinking could evolve with additional scientific study. Given the growing popularity of artificial turf fields it is possible that the study of the crumb rubber could now qualify as a public health issue, meaning that it might be time for the EPA to start a new round of widespread testing.




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The Sports Balancing Act

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Competition, on many levels, is a good thing if it allows us to set lofty goals for ourselves and to become the best we can be
  • Competition for any individual young athlete needs to be carefully balanced
  • In my opinion it is principally the parent’s job to figure out where the proper balance is for their child
  • S. sports organizations should provide options for participation from elite competitive athletes to recreational athletes

Today’s post deviates from our usual focus on sports medicine science and instead I’d like to offer some observational personal opinion in an attempt to expand on last week’s post. girls lacrosse

As everyone knows, the universe of youth sports is becoming far more competitive even at the youngest age groups. Even so-called “rec leagues” have become competitive in many respects. To be sure, I’m generally in favor of competition, as I’ll expand on below, but the nature of sports forces parents to become active participants in ways they may not have anticipated. Simply leaving everything to the coaches won’t work (do you leave everything to the teachers at school without providing any motivation/cajoling to complete homework?). The challenge for parents is to figure out when encouragement becomes too pushy, and you’ve gone beyond motivation to pressure.

As the Aspen Institute report points out, it’s hard to strike the right balance and to make things right for young athletes. There are numerous benefits to sports, fitness, and competition but going over the line can create undue stress for the young athlete, possible burnout, and possible overuse injuries. This line is different for every person, and on an individual level watching carefully is the parent’s job, not the coach’s job. For the parent this can be a very difficult process as we are often swept into the pressure of conforming to the standards of our community. This makes it even more important to pay very close attention to the individual goals and needs of your child.

Competition is generally good when it is used constructively to get the best out of any person. Kids compete in school to perform the best they can in class, they compete later in high school on standardized tests to achieve minimums needed to gain admission to the college of their choice. Setting lofty goals is important because it allows you to see how high you can climb, even if those goals are sometimes out of reach. Disappointment is a feeling as powerful as success, both with important lessons for personal growth.

Youth sports can give kids those chances to work hard, to succeed, and to fail. The challenge for us as coaches and parents is to do better than we are now, to look at each individual and provide opportunities for growth through sports. If you’re child is highly internally motivated and you’re raising the next truly elite athlete then by all means you should reach as high as you possibly can. And for 99% of the rest of the kids let’s make sure we can provide a better environment that allows them to compete on their terms, to be the best they can be and still provide the balance that allows a kid to be a kid.

Posted in Coaches, Parents, Psychology | Leave a comment

Creating a Culture of Lifelong Fitness

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The Aspen Institute recently published a summary of their ongoing research into youth sports participation in America. The report focuses on improving access to the largest number of kids, and includes high cost as one of the main reasons kids drop out or don’t start in the first place
  • My own opinion is that one place every adult can take action now, with proven benefits to encourage lifelong fitness in their kids is for the adult to focus on lifelong fitness himself/herself

There is an interesting recent publication produced by the Aspen Institute, summarizing their ongoing efforts to do a deep dive study into many aspects of youth sports participation in America. The objective was to analyze the essential elements of the youth sports machine but also then to suggest ways to improve the culture of youth sports to Screen Shot 2015-02-16 at 12.50.29 PMencourage participation for the broadest segments of youngsters. You can view an online version of their report here, which I recommend for all adults involved as parents, coaches, or administrators.

The overall premise is solid: lifelong physical activity has enormous benefits for everyone in terms of improved health and quality of life. Further, the authors believe that starting kids off on a pathway for physical activity early in life- and then keeping them going through teenage years- will encourage lifelong fitness. There is definitely validity in these points.

The authors point out a number of factors that cause kids to drop out of sports, including cost to participate in club sports, competitive nature of some sports that might cause many kids to feel uncomfortable, long time requirements, coaches who might not promote a culture of participation and instead overemphasize winning, and others. These too are mostly valid points, and I encourage you to form your own opinions on this.

There are two points I’d like to make with my two cents to add to the conversation. First, some competition is a good thing and almost all kids (and adults) will benefit from this to help them grow to their fullest potential. Once again though it is a question of balance, and the desires of the individual young athlete. Many kids are very happy to participate in sports in which there are coaches, practices, and games in which scores are kept as long as coaches and parents don’t get too crazy. A small number of kids are internally driven to compete at the highest levels and will favor specific teams that give them the best chance to play in college or possibly professionally, and will do so in spite of the coach’s attitude. We need to have systems in place to cater to each of these groups and many kids in-between.

Second, the best thing I believe we can do as parents or other vested adults is to be fit ourselves. Seeing parents, teachers, coaches, and others regularly participate in physical activity is a powerful motivator. While we ask the big questions about what sports should be in America I’d start by looking in the mirror and see if the person looking back is the one you want your kids to be. Harsh? Maybe. Go take some action and make a difference.



Posted in Coaches, Parents | Leave a comment

Legal Supplements for High School Athletes

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Supplement use is common amongst high school athletes
  • Supplements such as creatine and protein powder have good safety profiles for use in teenagers
  • You must purchase from a very high quality manufacturer otherwise you risk having banned substances or dangerous substances in your supplement mix

This week, I had a number of parents enquire about the safety of various supplements vitaminstheir high school aged sons were considering using to prepare for spring and summer football practices. I want to provide a very brief review, focusing on creatine and protein.

The first thing I’d like to mention is that the best source of building blocks and fuel for your body is through high quality real food. Having said that, I know that a high percentage of our high school athletes take various supplements and this trend will continue. And the second important thing is that you absolutely must purchase from a very high quality manufacturer of the supplements.

There are four substances commonly used as supplements by high school athletes: creatine, protein powder, HMB, and stimulants like caffeine. When used correctly these supplements can be safe and effective.

Creatine is a nonessential amino acid naturally produced in the liver. Creatine is believed to have a number of important functions in the body, and in particular for athletes creatine is effective at increasing power and force in short bouts of increased exertion and in repeated efforts of maximal exertion (sports requiring short sprints or power). Creatine has been extensively studied in adults and is known to be generally safe, and legal in professional sports leagues and the NCAA. There are a few studies about creatine use in adolescent athletes and these also show a good safety profile. The possible side effects from creatine supplements include muscle cramping, dehydration, and upset stomach. If you’re taking creatine you need to really focus on hydration, especially during warm weather and summer two-a-days.

Protein supplements are also used commonly by high school athletes, mainly to assist in improving muscle mass and strength. Protein supplements purchased from a highly reputable manufacturer are often combined with creatine and HMB (see below). Without any doubt whatsoever your best source of protein is through natural sources such as grass-fed beef, free range chicken, or wild fish such as salmon. A typical 165 pound teenage athlete will need about 125 grams of protein per day, and you can easily get about 75 to 100 grams through your healthy diet. It could be reasonable to supplement with about 25 to 50 grams of high quality protein powder. There are many, many formulations available, and I think the manufacturer is extremely important. See below for one I like. As with creatine, be sure to stay really well-hydrated if you are taking protein supplements.

The last two legal supplements I want to mention are HMB (Beta-hydroxy-beta-methylbutyrate) which is a metabolite of the amino acid leucine, and the stimulant caffeine. HMB is typically combined with creatine and has been shown to increase lean body mass and strength in progressive resistance exercise training. Adult studies of HMB show a good safety profile but there are very few studies in the adolescent athlete. It is legal, but I am unconvinced so use with caution and if possible you might just leave HMB out of your supplements.

Caffeine is an interesting substance found in many different drinks and athletic snacks. Technically, caffeine is banned by the NCAA but it is legal up to a certain limit. It has been shown to improve aerobic performance in runners and other endurance athletes. But the flip side of caffeine is that if it is consumed just before race time you could be asking for trouble with stomach cramps and bloating, and possibly being jittery or hyperactive.

I want to conclude by telling you again that your best source of proper building blocks for muscle and performance are through high quality natural sources from real food. But I also know that supplement use amongst high school athletes is very common and we need to deal with that safely. You need to be extremely careful about who you buy from as unreputable manufacturers might have banned substances in their supplement powder “mix”, there might even be dangerous substances such as stimulants that can cause heart issues. One manufacturer I like is EAS. Check them out if you feel like you’d like to go down the supplement pathway.



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