Executive Editor, Soccer America Magazine

Note: the following article was published on May 10 in Soccer America Magazine’s Youth Soccer Insider. I agree with Mike’s opinions expressed here. While not specifically about youth sports health, I feel this is an important topic for all of us involved in youth sports. – Dev Mishra.

“The yells and insults from the sideline from the parents make kids more violent.”

– Utah referee Pedro Lopez, the brother-in-law of 46-year-old referee Ricardo Portillo, who died last week after being punched by a 17-year-old goalkeeper.

In addition to working as an editor of Soccer America my whole adult life, I have been a player, fan, referee, youth coach and soccer dad. I love the sport. I even like the smell of my daughter’s shinguards, which my wife wants left on the porch. (Apparently I suffer from Proustian Phenomenon).

During the last decade I’ve grown even fonder of soccer because I’ve been involved in the youth game. Watching youngsters explore the joys of the sport is simply delightful and makes one appreciate soccer even more when watching it played brilliantly at the highest levels.

But there’s something about soccer — all sports, in fact — that I loathe. And it’s that, for some reason, it brings out behavior in adults that would not be tolerated in any other setting.

At the professional level, coaches wearing suits on the sideline throw tantrums that would embarrass a toddler’s parents. Adult fans sitting next to children in a stadium yell obscenities at the top of their lungs. (Just one example that really bothered me recently: In Azteca Stadium in March — you probably heard this yourself if you watched it on TV – tens of thousands of fans chanting a horribly offensive slur at Brad Guzan each time he took a goal kick.)

But worst of all are the adults screaming from the sidelines at youth games. Whether it’s the coaches or the parents — what on earth makes otherwise civilized people believe that it’s acceptable to invade children’s playtime in such a way?

One can’t imagine an adult screaming at children on a playground but this is tolerated when they’re playing soccer. If you think your kid unfairly got a bad grade, you might discuss it with the teacher — but come into the classroom screaming and you may just get arrested. Yet usually well-mannered adults go raving mad at referees in front of children.

I watch many, many games, from youngsters in the park to the very top level with the world’s best referees. And I have discovered that the frequency at which referees make incorrect or questionable calls averages out about the same per game at every level. Why in the world would you expect a referee — very often a teenager — at the youth level to whistle a perfect game when the refs of the EPL, the World Cup, MLS, etc., can’t pull it off?

Besides, criticism from the parents and coaches is usually so biased, plus they’re generally not in a good spot to see the incident, that it’s very often wrong.

Our league, NorCal, has quite rightly called for a minute of silence before all the games this weekend.

I say, for the adults, let’s stay silent the entire game, every weekend. Sit back, relax, and relish the sights and sounds of children playing a wonderful sport. You’ll find it’s more enjoyable for everyone when there’s no screaming.

(Mike Woitalla, the executive editor of Soccer America, coaches youth soccer for East Bay United/Bay Oaks in Oakland, Calif. He is the co-author, with Tim Mulqueen, of The Complete Soccer Goalkeeper. Woitalla’s youth soccer articles are archived at YouthSoccerFun.com.)

President, Sideline Sports Doc

I’ve been on high school and D1 college football sidelines for close to 20 years now, and it doesn’t surprise me at all to read a press release of a recently conducted study that shows that a large percentage of high school football players would hide concussion symptoms from their coach or trainer.  A lot of kids just want to play, and unfortunately many are willing to risk long-term problems in exchange for staying on the field. 

The study from the Cincinnati Children’s’ Hospital Medical Center was scheduled to be presented today at the Pediatric Academic Societies annual meeting.  The press release quotes lead author Dr. Brit Anderson: “We aren’t yet at the point where we can make specific policy recommendations for sports teams, but this study raises concerns that young athletes may not report symptoms of concussions,” Dr. Anderson is an emergency medicine fellow at Cincinnati Children’s Hospital and the study’s lead author. “Other approaches, such as an increased use of sideline screening by coaches or athletic trainers, might be needed to identify injured athletes.”

The study researchers surveyed 120 high school football players. Thirty reported having suffered a concussion. These kids were educated about concussion, as 82 students reported that they had received concussion education. These young athletes recognized that headaches, dizziness, difficulty with memory, difficulty concentrating, and sensitivity to light and sound are concussion symptoms. More than 90 percent recognized the risk of serious injury if they returned to play too quickly.

In spite of their knowledge of concussions, 53% responded that they would “always or sometimes continue to play with a headache sustained from an injury,” and only 54% indicated they would “always or sometimes report symptoms of a concussion to their coach.”

Hiding injuries from coaches and trainers is a tactic that’s been around forever.  Whether it’s a concussion or an ankle sprain, the competitive athlete wants to stay on the field/court/ice.  Given that the risks of continuing to play through these injuries can be high, what are we as adult coaches or parents supposed to do?  Keep in mind that almost all club or recreational sport coaches will not have an athletic trainer on their sideline to ask for help.

Here are some practical points. We need to keep educating the young athletes about the risks, and we need to be educated ourselves about those risks.  These can be very difficult decisions for coaches and parents as removing an athlete with a suspected injury can run against the culture of the game.  We need to know our players well, to know what “normal” is for them. We can’t see every play so we need to be vigilant and watch the kids for signs of decreased performance, behavior that’s off their baseline, and when there is doubt we need to take the right path and pull them from play.

President, Sideline Sports Doc

Results from a three year prospective observational study on adolescent injuries suggests that there are significant increases in injury risk with certain training behaviors.  The study was conducted by Dr. Neeru Jayanthi and colleagues at the Loyola University Chicago Stritch School of Medicine, and presented recently at the annual meeting of the American Medical Society for Sports Medicine.  You can read a recap of the study here.

This is a very interesting study as the researchers followed a large group of adolescent athletes for three years and recorded a number of facts about the young athletes.  Hours of sports participation, numbers of sports played, and types of injuries were some of the key facts obtained.

The study focused on adolescent athletes.  There is no firm agreement about the definition of adolescence, but in general adolescence begins with the start of puberty (sometimes as early as age 11) and continues throughout the teenage years.  We would broadly define “early adolescence” around age 11-14 and “late adolescence” around age 15-19.

A total of 1206 athletes participated in the study, and over the course of the three years there were 859 total injuries, including 564 overuse injuries.  The overuse injuries included 139 serious injuries such as stress fractures in the back, arms, or legs, elbow ligament injuries and cartilage/bone injuries.  These serious injuries can often take months to recover from, and some will require surgery.  Unfortunately some will be sport-ending injuries.

Not only does the study point out the statistics of adolescent sport injuries but also starts to get at the core of the reasons for the injuries.  There are three topics to observe carefully: sport specialization, hours per week spent on training and games in a single sport, and the athlete’s age.

Single sport specialization was a significant risk factor for serious overuse injury, regardless of the athlete’s age or the number of hours played.

The number of hours spent per week playing a single sport was an age-dependent risk factor.  The researchers found that an athlete who played a single sport more hours per week than their age in years was at risk.  For example, an 11 year old who plays 12 or more hours per week in organized single sport activity is at risk.  This is an easy concept to remember.

Risk from single sport specialization tended to decrease once the athlete reached late adolescence, roughly defined as older than 15 years.

In my opinion this study provides compelling evidence for the risks of single sport specialization for the young adolescent athlete, something many sports medicine professionals have long believed.  The researchers will be doing a follow up study to see if they can then reduce injury risk by modifying some of the risk factors.

This is a tough topic to deal with at the national sport level, as trends are moving strongly towards single sport specialization even at the youngest levels.  If you’re a parent of a single sport athlete watch them carefully for signs of overuse.  Give them a day or more off each week, and if possible give them a month off somewhere during the year.  Practice and play fewer hours per week than their age in years. Their bodies will be better for it, and their performance will likely benefit too.

President, Sideline Sports Doc

There’s an ongoing debate in the running community about the value of so-called minimalist shoes, or even barefoot running.  Some running coaches advocate minimalist shoes as they believe it simulates barefoot running, and in turn, they believe there are benefits of barefoot running for injury reduction and improved performance.  Some evidence to support many opinions exists, and a recent study published in the British Journal of Sports Medicine provides additional data that we can use to guide usage in young experienced runners.  If you’re interested in the full study you can find it here.

The study was designed to look at various aspects of running gait in experienced adult runners.  The researchers looked at running barefoot, in a “minimalist” shoe, a racing flat, and the runner’s regular training shoe.

There are several interesting findings from this study:

• The minimalist shoe, the racing flat, and the regular training shoe all showed similar running mechanics
• The barefoot running condition was different than each of the shoe-wearing conditions
• Therefore, this study disproves the idea that a minimalist shoe is similar to barefoot running
• Barefoot running showed no changes in work at the hip compared to shoe-wearing
• Barefoot running showed decreased work at the knee compared to shoe-wearing
• Barefoot running showed increased work in parts of the ankle compared to shoe-wearing, especially increased work in the calf muscles/Achilles complex

So what might this mean for the young runner?  My first caution is the same one we use when looking at any study done with adult subjects- results in young runners could be very different.  Nevertheless I think there are some practical take-aways.

I Would Not Recommend Barefoot Running If You Have Severs Syndrome, Achilles Tendonitis, or Calf Muscle Strain

Most importantly, I would not recommend barefoot training for any young athlete with problems in the calf muscles (such as calf muscle strain or posterior tibial tendonitis), problems in the Achilles tendon, or the nagging common problem called Severs syndrome.  In the current study as well as reports from others we see that barefoot running promotes forefoot running, and that in turn puts more stress on the heel as well as calf structures.  If you have problems there it would be unwise to pursue barefoot running.

If You Have Problems In The Front Of The Knee Such As Osgood-Schlatter, Patella Tendonitis, Or Kneecap Tracking Issues, Barefoot Running Might Help

On the positive front, barefoot running seems to reduce certain stresses across the knee, especially “extensor moments”.  This means that barefoot running has the possibility of reducing pain for certain conditions in the front of the knee such as Osgood-Schlatter syndrome, patella tendonitis, or knee-cap tracking issues.  Those are very common problems in young athletes and barefoot running may offer the chance at resuming more comfortable exercise than running in shoes.  This is very interesting and needs further research.

President, Sideline Sports Doc

A side ache (also called side stitch) can be a real pain.  It seems to occur most often in runners and cyclists, but I’ve seen plenty of athletes in team sports that also experience side aches.  The athlete typically feels a sharp, localized pain just below the right rib cage. The pain can come on suddenly and cause the athlete to slow to a walk until the pain goes away.  It can be a source of major frustration as it will almost always affect performance negatively. 

Possible cause: consuming fruit juice immediately before or during event

Several retrospective studies have been performed regarding athletes with a history of side ache but none of these studies have given us the definitive explanation for the cause of side aches. The majority of the published research focuses on the type of food or fluids consumed pre-exercise, and the timing.

There seems to be no relationship to body mass index, skill level of the athlete, or gender.  But it seems to occur less frequently with older athletes.

The strongest association with the development of the side ache seems to be the timing and type of the preparticipation meal. One published survey of runners reported that consuming reconstituted fruit juices and beverages high in carbohydrate and osmolality (a measure of concentration), either just before or during exercise triggered the onset of a side ache, particularly in susceptible individuals. The symptoms didn’t seem to be related to the amount of food eaten.

A more complicated explanation put forth by some researchers is that stretching the ligaments that extend from the diaphragm to the internal organs causes a side ache. The jarring motion of running while breathing in and out is thought to stretch these ligaments. Interestingly, most right foot dominant people exhale as the left foot hits the ground. And in most surveys it is the group of runners who exhale with the right foot hitting the ground who tend to experience side aches more often than left foot exhalers. (are you confused yet?) However, no one has been able to prove that if you train a runner to now exhale with the left foot strike that it will eliminate the side ache.

Here’s an explanation I find a bit flimsy: exhaling when the right foot hits the ground causes greater forces on the liver (which is on the right side just below the rib cage). So just as the liver is dropping down the diaphragm rises for the exhalation. It is believed this repeated stretching leads to spasms in the diaphragm.

Trying to Prevent a Side Ache Based on our Limited Evidence

• Time your pre-event meal to allow it to digest prior to the event.  If you have a history of side aches I’d recommend one hour to digest your food.
• Avoid drinking reconstituted fruit juices and high carbohydrate fluids before and during exercise
• Stretching may relieve the pain of a side ache. Raise your right arm straight up and lean toward the left. Hold for 30 seconds, release, and then stretch the other side.
• Slow down your pace until pain lessens.
• Massage or press firmly on the area with pain. Bending forward may also help.
• If you continue to experience pain, see your doctor or qualified sports medicine physician.

President, Sideline Sports Doc

When sports medicine specialists counsel young athletes about the benefits and risks of resistance training exercise (otherwise known as “weight training”), we usually recommend body weight resistance for growing children.  You can get substantial strength gains with properly supervised body weight exercise even in young children, with no demonstrated risk to growth. 

Images of growth-stunted weight lifters from eastern European countries competing in the Olympics in the 1970s are ingrained in our memories.  Few people in our society today want this appearance for our kids.  But we know now that there are two factors contributing to the short stature of those Olympians of years past:  steroid use and excessive weights used in training.  That combination literally shut down their growth potential.

But body weight training is very different and safe for almost all kids.  I wrote a more detailed post about this, which you can read here.

And now we have more recent evidence of the benefits of resistance training for young children, with the benefits seen in adulthood.  The lead researcher presenting the findings at the specialty meeting of the American Orthopaedic Society for Sports Medicine is Dr. Bjorn Rosengren from Sweden.

Using data from the Swedish Pediatric Osteoporosis Prevention study, Dr. Rosengren and colleagues followed 362 girls and 446 boys for 6 years who received 40 minutes of physical activity per day. A control sample of 780 girls and 807 boys from three Swedish schools received 60 minutes of physical activity per week.

The group receiving 40 minutes resistance exercise per day “after the first 6 years, result in higher gain in bone mass in both boys and girls, higher gain in skeletal size in girls and did not affect the fracture risk”. Both boys and girls had higher spine bone mineral density (BMD), while girls had a higher femoral neck BMD than boys at follow-up.

The interesting part came in the long-term follow up of these two groups of young athletes when they were evaluated as adults. A second retrospective, cross-sectional study included a subsample of 46 athletes who had their BMD measured during their active career and measured against 24 people in a control group. The athletes had a 50% lower fracture risk after retirement than the control group, according to Dr. Rosengren.

That’s good evidence of the benefits of proper resistance exercise for children, with benefits lasting well into adulthood.

By now we’ve all heard about the tragic leg fracture sustained by University of Louisville basketball player Kevin Ware in last night’s NCAA basketball tournament game.  It was a gut wrenching injury to witness, even for orthopedic surgeons who are trained in dealing with these types of injuries.  But what should you do if you are an untrained youth sports coach facing a possible leg fracture in one of your young players?  

What Is A Fracture?
A fracture is the proper medical term for “broken bone”.  This can range from a tiny crack in the bone, to a very severe injury where the skin over the bone is broken, showing the exposed bone.  Regardless of how severe the injury is it is still a fracture.  A fracture can happen from any number of different causes, although in youth sports the most common reason is direct contact.  Twisting injuries can result in ankle fractures, a fall on the ground can cause a wrist or collarbone fracture, and there is a fracture that occurs from overuse called a “stress fracture”.  For the purposes of this post, the focus is on immediate basic evaluation and field management for fractures that occur from injuries on the field of play.

The Typical Story
The young athlete will often be able to tell you there was a “pop” or sensation of a “crack” at the time of injury- if you hear this description beware of a possible fracture.  Pain is almost always present, and can be severe.  Swelling can set in within minutes, and gentle pressure around the suspected area of injury will be painful.  If the elements above are part of your initial evaluation you should suspect a fracture.

“Splint It As It Lies” and DO NOT Attempt To “Set” The Break
This part is important- you should not attempt to treat the fracture by aligning it, setting it back in to position, etc.  If you are not specifically trained in management of fractures your best and most reasonable course of action it to call for professional help (EMT or other emergency medical provider).  If it is a lower extremity injury it is best to use whatever materials you have nearby to splint and stabilize the limb as you find it- cardboard boxes, pieces of wood, popsicle sticks, just about anything reasonably rigid can be used until the professionals arrive.  If it is an upper extremity injury it is still a good idea to temporarily stabilize it but in these instances the athlete’s parents can often provide transport by car.  If pain is severe or if you have any questions at all about what is reasonable then you should be cautious and call for professional assistance.  Apply RICE (rest, ice, compression, elevation) if possible, and try to remain calm and reassuring to the athlete.

President, Sideline Sports Doc

The annual meeting of the American Academy of Orthopaedic Surgeons was held last week in Chicago.  One of the interesting scientific studies presented at the meeting was a statistical review of ACL injuries in NCAA football, comparing injuries on artificial turf surfaces to natural grass surfaces.

The main author on the paper is Dr. Jason Dragoo of Stanford University, the head team physician for the Stanford football team. 

In order to determine the incidence of ACL injuries in NCAA football players and the effect of playing surface, the researchers computed the injury rate for competition and practice exposures. They used data gathered by the NCAA Injury Surveillance System for the 2004-2005 through 2008-2009 seasons focusing on complete ACL tears.

The results showed that college football players have a greater number of ACL injuries when they play on artificial turf surfaces, particularly on artificial surfaces with deep fill, compared to natural grass surfaces.  Furthermore, Dr. Dragoo noted in his presentation “The rate of ACL injury in NCAA football is significantly greater on third-generation artificial turf.”

The researchers found an incidence rate of 1.42 ACL injuries per 10,000 athlete-exposures on artificial playing surfaces and an incidence rate of 1.24 per 10,000 athlete exposures on natural grass. The rate of ACL injury on artificial surfaces was 1.36 times greater than the injury rate on natural grass. Non-contact injuries also occurred more frequently on artificial turf surfaces, according to the findings.

Dr. Dragoo said the rate of injury during games was increased by more than 10 times vs. during practice. Additionally, surfaces with higher amounts of artificial fill, including sand and rubber components or third-generation types of turf, had higher levels of injuries in comparison to the first- and second-generation types of turf that typically have a shorter blade length.

A study like this will certainly add to the debate of grass vs. turf, and I think it is important to ask these types of research questions.  But there are things we should pay attention to especially with regards to youth sports.  The athletes in this study are elite college football players, and these results could be different if we study 14-year-old girls playing soccer.  It also does not specifically give us reasons for the difference.  And the grass fields were probably perfectly maintained.

I’ve said it before and I will do so again here: my feeling is that there is no better playing surface for outdoor field sports than a perfectly prepared grass surface.  But the reality is that there are few if any youth programs that can maintain a perfect grass surface, and definitely the worst surface is a pockmarked grass and dirt field.  So I’d favor the perfect grass field, followed by a high quality turf field, and finally a poorly maintained grass field.

President, Sideline Sports Doc

Over the past several years we’ve seen a large body of evidence showing that adolescent and teenage girls have different muscular firing patterns than boys in activities such as landing from a jump, and hard cutting, pivoting, and sprinting.  It’s believed that the higher ACL tear rates seen in girls are due in part to these muscular differences. 

Because of that, several jump training, agility, and coordination programs have been developed (called neuromuscular training), with the goal that the overall result would be a reduction in ACL tear rates for these girls.  Soccer players have been studied the most, as female soccer players have some of the highest ACL tear rates of any sport.  These programs really do work, with proven reductions in ACL tear rates if athletes consistently perform the exercises.  Furthermore, they are designed to become part of the normal pretraining warmup routine.  Here are three that I like, and you can download free information from each of these sites:  Santa Monica Sports Medicine Foundation PEP Program, FIFA F-Marc 11+, and the Sportsmetrics WIPP program.  Each of those have slightly different flavors, take more or less equipment or field space, etc.  Pick one and use it.  It will work.

But an interesting set of questions remains focusing on timing and effectiveness.  As it turns out, younger boys and girls test the same in various strength, coordination, and agility tests until puberty.  Then the differences become apparent, as girls mechanics often change unfavorably compared to boys. Power, strength and coordination have been shown to increase with puberty in boys; however, the same changes have not been observed in girls. Altered mechanics associated with increased risk of injury in female athletes are apparent after the pubertal growth spurt, and they appear to coincide with peak prevalence of ACL injury.

Is there an optimal time to start ACL tear prevention training?  Intuitively we’d have to think that starting as early as possible would be best and recent scientific evidence is proving our intuition correct.  A study by Myer and colleagues in the January print edition of the American Journal of Sports Medicine shows that there is definitely an association between age at which neuromuscular training is started and effectiveness of ACL injury reduction.  Specifically, they showed a 72% risk reduction for ACL tears when training was started in early teens, and a 52% risk reduction for ACL tears when training was started in the mid to late teens.

From a practical standpoint the key take-aways are these:

• Neuromuscular training programs (often called “jump training”) do work.  Regardless of the athlete’s age, make these programs a habit.
• The risk of ACL tears is reduced if the training programs are started in the early teens.  Many coaches are under the assumption that these training programs are only for mid to late teens, but we know now that even the younger athletes will show significant benefits.  Start as soon as you can.

President, Sideline Sports Doc

There are so many possibilities for use of novel treatments such as gene therapy or stem cell application in the world of sports medicine.  For ACL tears in particular I often feel that we need a better way to treat these injuries.  We often get inside a knee at surgery and find that the ACL is very stretched but still visible, and yet we have no effective way to simply tighten or repair that ACL.  Current treatment requires us to substitute a new piece of tissue to replace the torn ACL- a procedure called ACL reconstruction. 

Gene therapy holds promise for repairing these stretched ACLs without the need for surgery.  In theory, genes can be introduced that cause the body to increase collagen production in the injured ACL and ultimately to restore it to its normal appearance and function.  A recently published study in the January edition of the American Journal of Sports Medicine by Madry and colleagues shows that the field of gene therapy for sports medicine injuries is advancing.  In this laboratory study, the investigators showed a new method with higher success rates than previous studies to increase collagen production, increase cell migration, and repair experimental lesions in a human ACL.  It does sound exciting, but we must understand that this is a laboratory study in a dish.  The scientific process is long and will require that the study be repeated by others, animal models will most likely be done, and ultimately human trials will take place.  The whole process- if done perfectly- is likely a decade or more away from possible use in injured athletes.

There are many orthopedic sports medicine conditions that could benefit from gene therapy.  The most common conditions would be osteoarthritis, other cartilage repair, ligament and tendon repair, and fracture healing.  There are also several genetically inherited conditions that may someday be treated with gene therapy such as muscular dystrophy, Gaucher’s disease, Paget’s disease, and Ehlers-Danlos syndrome.

With the rapid pace of advancments in genetic medicine one would think we’d be farther along than we are in developing treatments for sports medicine conditions.  Indeed it seems we’ve been hearing about the promise of genetics for at least the past twenty years.  But funding this type of research is expensive, and funding sources for researchers are harder to find in the current economic environment.  There are other reasons for a somewhat slower than expected pace in so-called “translational medicine”.  The public as a whole is skeptical about genetic therapy, which further complicates the funding issue. Drug companies, medical device companies, and foundations that provide sources of funding for research may be reluctant to fund truly controversial areas.  And yet high quality studies such as the one recently published are still getting done.  I view the field of genetic therapy as terrifically promising and hope that we can find ways to continue to progress in open, ethical ways.