How About Some Hot Sauce With That Leg Cramp?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Muscle cramps are painful, involuntary contractions of a muscle
  • Many theories have been made over the years about cause and risks for muscle cramps, including poor warmup, dehydration, and electrolyte imbalances
  • New theories about muscle cramps focus on hyper-active nerve stimulus leading to the muscle cramp
  • One preventive approach is to fool the nerve into quieting down by drinking a pungent, spicy drink. Two prominent neurobiologists have developed a product called HotShot that may reduce muscle cramps.

I’m pretty sure anyone who’s ever played a sport has had a muscle cramp at some point in facebook_sharetheir life. Maybe the calf, foot, hamstring, or even the “side ache” which is most likely a cramp in the diaphragm muscle. They are annoying, tough to predict, and tough to prevent. But there is a new theory on preventing muscle cramps that is very interesting: the cramp is actually the result of a hyperactive nerve causing a muscle to contract, and you might be able to fool the nerve into quieting down by drinking a shot of really spicy liquid.

There have been many theories developed over the years about the factors that can increase an athlete’s risk of muscle cramps. For example, some of the common associations are:

  • Starting exercise without a proper warmup (might lead to microtears in the muscle, supposedly causing a cramp)
  • Dehydration
  • Electrolyte imbalances
  • Supplement use (especially creatine)

With these types of associations, sports medicine professionals have long advocated for athletes to do a proper warmup, make sure you’re adequately hydrated, and consider a sports drink with electrolytes. Other remedies such as drinking pickle juice are also reported to work, but how?

A muscle cramp is a forceful involuntary contraction of the involved muscle. And a muscle is given a signal to contract by the nerve that leads to the muscle. A recent article in the Wall Street Journal details the story of Nobel prize-winning neurobiologist Rod MacKinnon and his colleague Bruce Bean and their quest to end muscle cramps by attacking the problem at the nerve level.

Dr. MacKinnon became interested in the muscle cramp problem many years ago when he had severe upper extremity cramps when kayaking far off the Cape Cod shore.

Dr. MacKinnon and Dr. Bean’s idea: fool the nerve supplying the muscle to calm down by occupying the body’s nervous system elsewhere. Drink a really spicy drink, brain focuses on the spice, and the cramp stops. The actual science is quite a bit more complicated than that, involving complex ion-gating pathways, but hopefully you get the point.

Back to pickle juice. This odd concoction started showing up in the press surrounding endurance athlete habits maybe around 6 or 7 years ago. Originally it was believed that pickle juice might contain the right mix of electrolytes to ward off a cramp. But MacKinnon’s work suggests the mechanism might actually be that the bitter taste produces a stimulus that allows the nerve communicating to the muscle to relax.

Drs. MacKinnon and Bean have developed a product called HotShot that has a very pungent, hot taste and is in the early testing phase. The preliminary results seem to show that the electrical signals that may lead to a cramp are reduced as quickly as 15 minutes from drinking a HotShot and last 6 to 8 hours. Sideline Sports Doc has no relationship with the company or the researchers.

I’d emphasize that this is very early research, so we’ll await more evidence. Does it work for everyone, most people, some people? Does it prevent a cramp? Should it be used only if a cramp comes on? Is only the cramping muscle affected?

It’s a very interesting concept and who knows, maybe sometime soon you’ll be asking for some hot sauce with your leg cramp.



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

Taking The Ice Bath Plunge For Muscle Soreness- Helpful or Not?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Ice baths have been popular with adult endurance athletes for a long time, and are claimed to reduce soreness and improve recovery
  • The available evidence seems to indicate that post exercise ice – or heat – can reduce muscle soreness, and possibly reduce muscle microtrauma
  • There is no consensus regarding improved recovery or performance
  • Active recovery (meaning: a cool down jog or light cycling) clearly seems to be effective
  • I advise caution for the young athlete, as the published studies are done on adult athletes
  • I have a feeling there is more fad than fact here

I’ve noticed for a long time now that adult endurance athletes will often jump into an ice ice bathbath after a race or particularly strenuous training session. This practice is common in the triathlon and endurance running community. Like many things touted by elite adult athletes, the youth sports community seems to be giving this a try as well. I’ve seen this done at youth triathlon, youth running, and I’m now starting to see the ice bath plunge even at team sport events. So what’s the deal here? What’s supposed to be happening? Is there any evidence to support the claims?

The Belief And The Theory

I want to be clear that what we’re discussing here is jumping into an ice bath to help reduce muscle soreness, and not using ice for a swollen ankle or knee. Athletes who use ice baths usually do so for about 5 to 10 minutes.

Certain types of repetitive muscle exercise can cause injury to muscle fibers at the microscopic level. The micro damage actually leads to improved muscle performance and muscle growth over weeks of training, but in the first hours or days after intense exercise the muscles can become very sore. Athletes who use ice baths believe they are less sore, recover faster, and have better performance in the next training session.

Here’s what the ice bath is reported to do:

  • Constrict blood vessels, speed up removal of exercise related metabolic products like lactic acid
  • Reduce swelling
  • Reduce tissue damage

Ideally, the legs then go through a rewarming process that is supposed to re-establish good circulation, improve healing, and improve performance.

Is There Any Evidence For Effectiveness?

The published evidence examining ice water baths is not conclusive, but generally favors use of the ice baths to reduce pain. Whether the ice bath actually improves performance though, is debatable.

This review article stated that the use of ice baths is very popular, supported by many national organizations, and seems to improve the athlete’s comfort level. However they noted that measurements of power production were sometimes reduced after ice baths.

Another study published in 2015 in the Journal of Strength and Conditioning Research examined a blood marker of muscle damage called myoglobin and found significant reductions in myoglobin with cold or heat as compared to no recovery treatment after exercise. The authors concluded that using either heat or cold reduced muscle damage from intense exercise. The interesting part here is that heat worked just as effectively as cold to reduce muscle damage.

There are a number of older studies, similarly showing that ice baths are effective in reducing pain, but inconclusive regarding improved performance.

And finally, there are a few studies that compared active recovery (such as a cool-down jog or light cycling, combined with dynamic or static stretching) to ice bath or cold bath. The few studies available don’t show any substantial benefit to the ice bath compared to active recovery.

Final thoughts

So there are a few things we can take away from this brief review.

  • Ice baths done for a brief time (5 to 10 minutes max) seem to be helpful in reducing pain
  • …But heat might also be helpful in reducing pain
  • Both ice and heat appear to reduce the amount of myoglobin released in the blood, indicating that either ice or heat may reduce muscle damage from exercise
    • An active recovery cool down is important, regardless of whether ice or heat is used
    • The studies are all done on adult athletes, so I advise caution in young athletes

    Somehow I have a feeling the post-game ice bath will prove to be more fad than fact. But it’s probably not going away any time soon.

Posted in Performance, Sports Science, Therapy, Tips and Training | Leave a comment

Refueling After Training Or Games

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Muscle recovery after exercise requires a combination of carbs and protein.
  • Muscle is believed to recover better if refueling starts in the first hour or two after exercise.
  • Start as soon as possible (ideally in the first 20 to 30 minutes) if you’ll be doing more than one training session or game in the same day. Sooner is better.
  • Think food first for recovery. Chocolate milk is an excellent choice for drink, as is a fruit smoothie, and several foods. If you prefer a sports drink or bar be sure to purchase from a highly reputable manufacturer.

Here’s another of those subjects that seems to make some people very emotional- why is it chocolate milkimportant for young athletes to refuel after exercise, when should this happen, and what drink/food is best. The sports supplement industry has a massive foothold in this area, and for sure there are some great products available from highly reputable manufacturers. But I find that the two most important points are: sooner is better, and think food first.

When: Sooner Is Better, Especially If You’ll Be Playing Again Soon

Muscles require fuel to function properly, and after a training session or a game your muscles will need the right fuel to recover. It’s generally believed that in the first hour or two after exercise the muscles are most receptive to refueling. If you don’t properly refuel and recover it means that your performance in the next session will likely be less than what you want. Without proper refueling you can have all sorts of issues such as easy fatigue, poor strength, muscle cramps, or heat exhaustion. And you probably won’t play very well.

Let’s now say that you’re doing multiple sessions in one day, maybe 4 to 6 hours apart. I’m not a fan of this type of training or competition but I have a feeling it’ll be around for a while. If this is the case, then you’ll want to start refueling as soon as possible after the conclusion of your first session. I don’t think you have to obsess about starting to refuel the second your first session ends, but if possible it would be best to start in the first 20 minutes or so. This will allow you to finish the food or drink in enough time to have it digested in your stomach, and for the muscle recovery effects.

Examples would include:

  • Football two-a-days
  • Tournament play with more than one game in a day, such as soccer, basketball, volleyball, softball, baseball
  • Triathlete training with one session in the morning and another in the evening

If you have more time between sessions then you have more flexibility in your recovery options. Muscle recovery definitely continues for several hours after exercise, it just seems to be most efficient in the first hour or two.

What: Think Food First

I mentioned in last week’s “supplements” post that pretty much every nutritionist and sports scientist would recommend actual food rather than supplements for your performance nutritional needs and I would say that’s true for after-exercise recovery too. Muscles actually need carbs for recovery, so be cautious about high protein and low carb products when it comes to post exercise recovery. Many sports nutritionists like a 3 to 1 ratio of carb grams to protein grams in your recovery food or drink.

A couple of years back I purchased Nancy Clark’s Sports Nutrition Guidebook, and in my opinion it remains one of the most sensible and science-based sports nutrition guides around. Here are some suggestions from her book about appropriate post-exercise foods:

  • Fruit smoothie (Greek yogurt + banana + berries)
  • Cereal + milk
  • Bagel + (decaf) latte
  • Pretzels + hummus
  • Baked potato + cottage cheese
  • Turkey sub
  • Pasta + meatballs

Ms. Clark also advises: “do not consume just protein, as in a protein shake or protein bar. Protein fills your stomach and helps build and repair muscles, but it does not refuel your muscles.”

My Favorite Post-Exercise “Food”: Chocolate Milk

Sure, you can buy fairly expensive engineered recovery drinks, bars, and powders but I’ve always been a big fan of good ol’ chocolate milk. Consider that a typical 8-ounce serving of chocolate milk contains about 26 grams of carbs and 8 grams of protein (the 3 to 1 ratio), and actually tastes good. Who doesn’t like chocolate and milk? Drink up and play better!


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

Do’s And Don’ts Of Supplements For Young Athletes

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Supplement use in high school aged athletes is very common, especially amongst male athletes
  • Whenever possible get your “supplement” from food first, for example, lean meats and tofu are excellent natural sources
  • If you do buy, get your supplements from a highly reputable manufacturer to avoid the chance that you are inadvertently consuming something that is banned or dangerous

Last week I wrote about painkillers and how to use them occasionally, as well as some cautions. This week I’d like to follow that up with a brief discussion about supplements commonly used by young athletes.protein-muscles

Supplement use is incredibly common in teenage athletes, especially males. In my informal survey of the high school athletes I work with, I’d say that half of the male athletes are using protein and/or creatine supplements.

Let’s start with some definitions. Supplements are products such as protein powders, creatine, amino acids, high-dose vitamins, weight loss products, energy boosters, and more. Specific examples include protein powders, creatine products, and “energy drinks” like Monster.

Some supplements are legal, but aim for “food first”

Protein powders, creatine, and caffeine (up to some limits) are generally legal for high school and college sports. Whenever possible though, aim to get your “supplements” through real food. For example, excellent sources of supplemental protein would include lean meats and tofu. Creatine is found in meats and poultry. Caffeine would be in coffee, tea, and coffee.

If you choose to use supplements such as creatine or protein powder please be absolutely certain you are purchasing from a highly reputable manufacturer (see below) and be on the lookout for common side effects. For example, you need to really focus on hydration with creatine and protein powder to reduce side effects of muscle cramps and stomach cramps.

The problem with supplements: inadvertently consuming banned or dangerous substances

In the United States there is an organization called the Food and Drug Administration (aka “FDA”) whose job is to ensure as best as possible the safety of drugs used to treat medical conditions. One of the big issues with common supplements is that their production is not regulated by the FDA. This means that there are no assurances about what is actually in the supplement you are consuming.

Although manufacturers are required to list all ingredients on the label, a dietary supplement may contain a banned substance, even if not listed, due to contamination or poor manufacturing practices. There might also be outright deception or fraud from the manufacturer.

For example:

  • The product may not contain what is listed on the label (Example: a multivitamin could actually just be sugar or fillers).
  • The product may contain different amounts of the substances than listed on the label (Example: a product that states it has 60 mg of caffeine may actually contain 120 mg).
  • The product may contain (sometimes illegal) compounds that are not listed on the label (Example: a product that claims to be creatine could be laced with steroids, steroid precursors, or ephedrine).

Do: if you buy, do so from a highly reputable manufacturer

Even though the FDA does not regulate the supplement industry, some companies do a much better job of ensuring safety and purity of their products than others. For example, one company I really like is EAS, a company with a strong reputation that publishes its “100% Certified and Safe” pledge. And for disclosure, I have no relationship with the company, nor does Sideline Sports Doc. I just think they do it right. There are other companies that also do a great job.

Avoid anything that acts like a hormone, or gives outrageous performance claims

Absolutely avoid products that claim they alter the effects of hormones like testosterone, estrogen, and progesterone. Also beware of products that make extreme claims (example: “Build 25 pounds of muscle and lose fat in two weeks!”). If it sounds too good to be true, then it probably is. Exaggerated claims related to energy metabolism, body fat loss and muscle mass gain are especially high risk for containing an undisclosed banned substance.

Here are some Red Flag phrases to look out for. Avoid any products that have these in their advertising:

  • Energizer
  • Fat Burner
  • Metabolic Booster
  • Proprietary Ingredients
  • Testosterone Booster

Bottom line: get your “supplements” from food first. And if you really feel the need to add supplements follow some of the cautions above. Don’t risk your health or your eligibility to compete!



Posted in Doping, Nutrition, Performance, Tips and Training | Leave a comment

Using Painkillers To Play

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Over-the-counter pain relievers such as Tylenol or ibuprofen are commonly used to reduce pain and soreness from mild sports injuries.
  • It’s okay for young athletes to occasionally use these medications for sports related aches and soreness
  • If you ever find yourself in a situation where you must have the medication in order to be able to play, you should seek medical care
  • Never use a narcotic pain medication in order to help you take the field

Several factors cause athletes of all levels to continue to play through pain: the warrior 487624517_XSmentality, shame from showing weakness and letting others down, pressure from teammates and coaches, and the threat, imagined or real, of lost playing time.

For young athletes is it okay to take pain medicine in order to allow you to continue playing?

This is a very tricky question without simple answers, but there are some general guidelines that we can look to.

Types of pain medicines

For most young athletes when we talk about “painkillers” or “pain medicine” we are referring to commonly available over-the-counter medications such as Tylenol, or anti-inflammatory painkillers such as aspirin, ibuprofen, or naproxen.

Additionally there are prescription injectable pain medications and prescription narcotics, which would need to be carefully supervised by a doctor. Those would typically be used only during the recovery phase from a serious injury or from surgery.

Generally okay: occasional use for soreness

Let’s say that your team is starting off some pretty intense preseason training. It’s very common in this scenario to have aching muscles especially during the early days of training. At the end of the training session you should do a proper cooldown, you may want to apply ice, and when you get home in the evening it’s generally okay to take some anti-inflammatory medication such as ibuprofen to help you feel better.

Similarly, it’s common during the course of the season to have soreness or achiness in your muscles from continued play. As long as there’s been no real injury and as long as you would describe it as soreness, then that is another scenario where I would generally say it’s okay to take some pain medicine to help you feel better and continue playing.

Warning: if you can’t play without pain medicine then don’t play

If you find yourself in a situation where you absolutely have to have some type of ibuprofen, naproxen or other over-the-counter medication each time that you go out and train or play, then you are in a dangerous situation where you really need to seek medical help for this condition. There are real risks in continuing to play by relying upon usage of pain medication in this scenario. You may be masking the pain enough that you risk serious or permanent injury to an area, and there are risks to your stomach, liver, and kidneys from prolonged usage of many of these medications.

Ideally I would want you to seek qualified medical help in this case. At the very least you need to take some time off from play, get yourself comfortable enough so that you don’t need the medication in order to return to play.

Never: narcotic pain medication

In our orthopedic sports medicine group at Stanford we see a lot of athletes of all levels of play, and in my 23 year career I cannot recall a single time where I prescribed a narcotic in order to allow a young athlete to take the field. The same is true for every single one of my partners, as well as all other responsible physicians that we know.

The problem though is that it is all too easy for a young athlete to obtain narcotic medications illegally. And the consequences can be disastrous.

Consider this true story: a star soccer player in Southern California collided with another player and injured her already hyperextended knee. A doctor prescribed the opioid Norco. She soon obtained another opioid called OxyContin from a friend, and ultimately started using and even dealing heroin. She introduced her brother to the drug, leading to his death from an overdose.

What’s the connection? According to the National Institute on Drug Abuse, opioids are a close cousin to heroin, to which the brain responds in the same way. Plus, heroin is cheaper than opioids; an 80 mg OxyContin can cost up to $100 a pill on the street, but according to USA Today, a multiple-dose supply of heroin goes for $45 to $60. This is really scary stuff.

Fortunately most of our young athletes will only have to deal with the “occasional use for soreness” scenario. But if you ever find yourself in a situation where you absolutely need the medication otherwise you won’t be able to play, get yourself to qualified medical help quickly.







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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.

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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.



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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.




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