Ban Youth Tackle Football? Provocative NYT Article Is Worth A Read.

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Author Gregg Easterbrook recently published an excellent thought-provoking article in which he stated the risks of brain injury might be significantly reduced by banning tackle football until at least age 12
  • One cited scientific study showed that contact sports participation was the highest risk factor for late development of chronic traumatic encephalopathy (CTE)
  • Another cited study stated that starting tackle football before age 12 is a critical risk factor for later poor brain function
  • Football may need to follow hockey and soccer???s direction in placing a minimum age on tackle football

Each month we see more published scientific data that allows us to dig deeper into the OLYMPUS DIGITAL CAMERAsubtleties of concussion risk and outcomes. A recent Tuesday Morning Quarterback article in the NYT by Gregg Easterbrook suggests that the data to date is compelling enough that he is recommending a ban on youth tackle football. The article is provocative and thought provoking, and I recommend any parent of kids playing contact sports have a look.

Mr. Easterbrook forms his opinion from personal experience and also relies upon two recently published scientific studies.

The first cited study, from the Mayo Clinic and published in December 2015 was a study of brains with documented chronic traumatic encephalopathy (CTE). The take home message from this study: CTE was only found in men with a history of participation in contact sports. The authors concluded, ??Exposure to contact sports was the greatest risk factor for CTE pathology.??

I have a few thoughts on the first cited study. First, it???s a fairly small sample and other researchers with access to similar data would be helpful in validating the findings. Second, it???s a retrospective study meaning that the data was acquired by looking backwards (the study subjects were deceased??) so it???s difficult to make completely accurate predictions about cause and effect based upon this data. And my third personal opinion takeaway: the findings are likely real, and they likely are predictive. We just need more data.

The second study sought to correlate age at which former NFL players started tackle football and their subsequent poor performance on standardized cognitive tests. This study, published in March 2015 is particularly relevant to young athletes. The authors tested 42 former NFL players, ages 40 to 69. The players took various cognitive tests to measure their brain function and were also asked questions about the age at which they started tackle football, number of estimated concussions, etc. The authors concluded that ??There is an association between participation in tackle football prior to age 12 and greater later-life cognitive impairment measured using objective neuropsychological tests. These

findings suggest that incurring repeated head impacts during a critical neurodevelopmental period may increase the risk of later-life cognitive impairment.??

In other words, they feel that if a boy starts playing tackle football before age 12 he is at greater risk of developing poor brain function as an adult than those boys who started tackle football after age 12.

My take on the second cited study: it is powerful stuff. Sure there are limitations to the study design. The men were asked to recall events that happened 30 to 60 years prior; that can be tough for even a sharp as a tack Nobel prize winner so there may be some recall bias here. Rules for tackling when these men were young were very different than they are today; direct head contact was likely more common then. But still this is data that should not be dismissed as sensationalist or over-reaching.

We have certainly seen that other sports such as hockey and soccer now recommend minimum age ranges for full body checking (hockey) and heading (soccer) due to the fact that they felt the data available required them to do so. USA Football has definitely taken positive steps with their Heads Up Tackling and Heads Up Blocking programs but currently the age at which tackle football is allowed is 5. It???s time to have a closer look at this. My opinion on this issue is as it is with all other health and safety issues for young athletes: a safer sport has a much better chance of keeping kids in the game for life.





Posted in Basketball, Concussions, Football, Hockey, Lacrosse, Parents, Soccer | Leave a comment

The Future Of Sports: The Young Athlete

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent report called The Future of Sports sheds light on opinions from a group of futurists touching on many areas in the world of sports. While aimed principally at adults, the report also has several aspects that will affect the young athlete. It is worth a read.
  • Genetic screening and enhancement is likely on the horizon for the next decade, extending to the youngest athletes.
  • Genetic screening has a considerable downside as the youngest athletes could be excluded from sport participation based upon their genetic profile
  • Crowdfunding is a positive development that can improve the financial position of youth teams and organizations
  • Adventure sports and extreme sports are attracting many more young athletes and could siphon some of those athletes from mainstream sports

By now I???m sure many of you have seen the fascinating report The Future of Sports, Future of Sports reportproduced by Delaware North, owned by Jeremy Jacobs, owner of the Boston Bruins. The authors assembled several groups of futurists to look at the sports universe through 11 broad categories. One key theme: technological advances have dramatically accelerated the pace of change, what used to take decades now likely takes 1-5 years.

I wanted to give you some of my personal insights on this report as viewed through the lens of the young athlete. Much of what was written is not applicable to the young athlete but there were several key components that are worth looking at.

Let???s start with the Preface. One area mentioned in the preface but not specifically studied in the report is the influence of performance pay for collegiate athletes. This will only intensify the competitiveness for young athletes, as the carrot at the end of the stick is a chance to actually be paid to play college sports. Aside from the technical points raised in the report, it???s my opinion that the professionalization of collegiate sports will have a profound effect on the high school and middle school aged athlete.

The Athlete

Genetic manipulation will become commonplace within 10 years and is predicted to rapidly spread to young athletes. At least 8 genes are linked to super athleticism, and selectively identifying??CRISPR??creates the opportunity for unprecedented accuracy in gene editing. This would in theory allow parents of young athletes to manipulate their children???s genomes

  • in the near future, genetic screening for traits will become much more prevalent e.g. two copies of ACTN3 gene= likely sprinter, mutations in EpoR= endurance athlete
  • the ugly flip side of genetic trait testing: young athletes could be denied hope of ever competing from an exceptionally young age, told there is no chance for them to progress to the highest levels
  • use of stem cell based treatments will accelerate, allowing for faster recovery from injury, followed by life extension, and finally for performance enhancement
  • will genetic screening and enhancements lead to separate leagues for ??enhanced?? vs ??natural?? athletes?

Sponsorship and Advertising

For owners of brands, getting their brand message out has become complicated as traditional TV, radio, and print advertising has suffered. Social media and crowdsourcing are becoming increasingly popular

  • For youth teams and leagues, raising funding through crowd funding has become easier and much more popular
  • Selling ownership interest in athletes (e.g. Fantex) is becoming popular and may ultimately extend to the youngest athletes

eSports and Fantasy Sports

eSports tournaments are very big business now, many of the major tournaments command $10M+ prize money. Celebrity gamers are rising in popularity and it???s plausible that sometime soon the celebrity gamer will rival the physical sports athlete for popularity

  • the young generation raised on gaming is a natural fit for competitive gaming
  • Robert Morris University actually offers scholarships for League of Legends gamers
  • competitive gaming leagues offer some of the same viewership benefits of physical sports
  • For young people and their parents: the challenge is to keep kids physically active as the immersive experience of gaming continues to advance
  • Fantasy leagues such as FIFA Pro Clubs from EA Sports will reach college and high school levels, likely reaching into younger and younger participants
  • Opportunity: can body movement sensors e.g. Wii and Kinect actually put some physical activity behind gaming?

Extreme and Adventure Sports

Participation in extreme and adventure sports is exploding, even amongst the youngest participants

  • for the young athlete these sports offer possibilities of free expression and a counterculture atmosphere compared to traditional sports
  • but how long can that atmosphere last as money moves in rapidly?
  • current environmental limitations exist too, as resources such as prime surf spots or the best snow covered mountains become fought over and possibly scarce
  • advancement in to the youngest age athletes will also require improvements in safety technology as injury rates are currently high

Overall I found this report to be a fun and interesting read. Sometimes provocative and scary, sometimes optimistic. One thing is for sure: we???re going to be in for some major changes very soon!


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

Injury Recognition Matters. US Club Soccer Partners With Sideline Sports Doc To Bring Injury Recognition Training To Coaches.

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Brian Cole, M.D.

Professor of Orthopedic Surgery, Midwest Orthopaedics at Rush

Head Team Physician, Chicago Bulls (NBA)


Tal David, M.D.

Synergy Specialists Medical Group, San Diego, CA

Head Team Physician, San Diego Chargers (NFL)


Bert Mandelbaum, M.D.

Kerlan Jobe Institute, Santa Monica, CA

Head Team Physician, Los Angeles Galaxy (MLS), FIFA F-MARC


Key Points:

  • US Club Soccer becomes the first major US youth soccer organization to require comprehensive injury recognition for all coaches
  • The training will provide a sideline evaluation process for injury recognition, as well as specific guidelines for some injuries such as concussion, knee, and ankle
  • We believe the training will make the game safer for all kids and promote growth in youth soccer

Injuries are an unfortunate reality in youth sports, but that doesn???t mean gloom and doom. In fact, from the injury standpoint we???d say there has been no better time to be a young athlete in America than now. What? Does that sound controversial? Let???s explain.??logo

Thanks to scientific study over the last couple of decades we???ve made huge strides in proper recognition and treatment of injuries in young athletes. As recently as 20 years ago we paid far less attention to issues about overuse and burnout, medical conditions such as heat illness did not have the types of preventive strategies we have in place now, and our knowledge of the seriousness of concussion was not really on the radar. We???ve made great progress in the care and treatment of injuries to the knee and ankle. And there is a training program for soccer players that is proven to reduce lower extremity injury rates and at the same time improve performance.

One area that hasn???t received as much attention as we???d like is on-field injury recognition for youth coaches. But that is changing now too. We???d like to announce an unprecedented partnership between US Club Soccer and Sideline Sports Doc. Unprecedented because US Club Soccer is the first major U.S. youth soccer organization to require completion of comprehensive injury recognition training for their coaches in order for the coach to obtain a passcard.

The training covers serious injuries such as concussion or spine injuries, but perhaps more importantly it provides a method that the non-medically trained coach can use to evaluate just about any injury on the field. Clear, concise, reliable. The training is focused on providing practical information for the coach that results in confident injury recognition for the range of injuries commonly encountered by the youth soccer coach. We fill the gap between prevention and treatment.

We believe that proper training in injury recognition for the non-medically trained youth coach is an important piece of the overall health and wellness for the player. With US Club Soccer???s initiative we???ve taken another step forward and say again: there???s never been a better time to be a young athlete in America.





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

The Multi-Sport Prescription

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • We have a strong cultural bias towards early sport specialization, with the belief that specialization from the youngest ages is the best way to achieve elite status as teenagers or young adults
  • However, early sport specialization is correlated to increased risk of sport-ending overuse injury and burnout
  • The vast majority of NCAA athletes report that they participated in multiple sports as kids and didn???t specialize until around age 15
  • A recently published scientific review article provides valuable summary recommendations as I note below, including benefits of early multi-sport participation and limitation of hours in sport per week (max hours per week= child???s age in years)

Close to 30 million adolescent and teenage kids in the United States play club or 6-17-09-7 XATHLETEScompetitive sports, and yet somehow that doesn???t translate to a lifetime of fitness. Furthermore, early sport specialization doesn???t ensure a better chance at securing elite status as young adults. I???d love to see more kids playing sports because they really want to, and then have that lead to a lifetime of strong fitness habits. I???d also like to see those kids who truly have the desire and potential to be elite athletes get the chance to develop. So how do we create a structure that encourages broad participation for most kids and elite development opportunities for those who want it? Many experts in childhood sports medicine are drawing upon their experience and published scientific literature to recommend multi-sport participation for the young athlete, and later sport specialization for the highly motivated athlete.

A recently published review article by lead author Gregory Myer in the journal Sports Health offers a number of valuable insights. There???s a very common belief that single sport specialization from a very early age (just past diapers in the case of one Tiger Woods??) is the best way to gain elite status as a teenager, or a college scholarship, or professional greatness. This may in fact be true for sports such as figure skating or gymnastics but it doesn???t appear to be true for almost all other sports, especially team sports. Retrospective reviews of NCAA athletes in several sports have shown that close to 90% of the athletes played multiple sports as a youngster and didn???t specialize in a single sport until around age 15. Clearly, it???s common for high-level collegiate athletes to come from a multi sport background.

And furthermore, there is a strong and growing body of evidence that points to single sport specialization in the young athlete as a key factor in developing overuse injuries (potentially sport ending injuries), burnout, and decreased interest in lifetime fitness.

The summary recommendations from the review article make sense, although I would point out that it would be helpful if future studies could prove a cause and effect relationship (for example, following the hours based recommendations leads to fewer overuse injuries, etc.). Here are the key points in my opinion:

  1. The youngest athletes should avoid single sport specialization and should be given opportunities for sampling several sports through free unstructured play
  2. Participants in gymnastics, diving, and figure skating should wait until early adolescence to specialize
  3. Participants in tennis, golf, and most team sports should wait until middle adolescence to specialize
  4. Participants in endurance sports, track, and distance events should wait until late adolescence to specialize
  5. Children who do participate in more hours of sport per week than their age in years and who are specialized in sport activities should be closely monitored for indicators of burnout and overuse injury

These recommendations won???t be easy to implement across the board as there is a strong cultural bias towards early specialization. But I do hope that increased awareness of the possible problems with specialization will start the conversation towards a better environment for young athletes to succeed for life.



Posted in Coaches, Parents, Prevention, Sports Science | Leave a comment

Data Can Reduce The Emotion Surrounding Concussion Policy

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Good objective data can help guide decisions regarding concussion policy and can also help reduce the emotional intensity surrounding some of the decisions
  • Objective data specific to young athletes is hard to come by but more research is being conducted
  • We can use data on collegiate athletes to at least start our decision process and extend some of the thinking to young athletes. One good study was recently published and provides detail on concussion mechanism.

I think it will be quite a while before we are able to analyze the impact of concussions on concussion_girlsyouth sports in a less emotional and more objective fashion. In the last year or so I???ve had coaches in a number of sports who I know well and respect make exasperated comments to me. For example, a football coach stating that if we continue to take a very broad approach to concussion recognition that it will ??mean every kid who takes a hit might have a concussion and it could end the game as we know it.?? Girls??? lacrosse coaches telling me that requiring headgear on all girls would change the nature of the game and embolden more aggressive stick play, potentially increasing the number of concussions. And soccer coaches swearing to me that they???ve ??never seen a concussion caused by heading the ball.?? Each of these comments represents an interesting point with some merit. But there???s also a lot of emotion involved, these coaches generally love the game as it???s currently played and they are having a tough time adapting.

I get that. And certainly we can find comments at the other end of the emotional spectrum too but in the world of sports medicine it???s generally unwise to make ??always?? and ??never?? type statements. One way to help make measured and objective decisions is to use data to help guide us.

The data pertaining to young athletes can be very hard to come by. We are gathering a decent amount of data for professional athletes and high level collegiate athletes but that data likely will not be applicable to young athletes, adolescents, or teenagers. But we can at least start using the data available to make reasonable extensions to the youth game and help guide research specific to young athletes.

One recently published study in the American Journal of Sports Medicine sheds some light on the exact sport actions that lead to concussion in NCAA athletes.

What they studied:

The study by Zuckerman et al used the NCAA Injury Surveillance Program starting with the 2009 fall season through the 2014 spring season. 25 sports were included, for men and women. The data relies on the athletic trainers from each of the schools to accurately report injuries to the database. The study analyzed the data by sport, over time, and also examined the type of impact in the sport that caused the injury. For example, was the concussion caused by player to player contact, player to equipment contact, or player to ground contact. One aspect of this study I like is that it does get down to a granular level.

What they found:

The majority of concussions occur during competition, even though athletes spend far more time in training than competition. Some sports such as football, women???s ice hockey, and men???s lacrosse appear to be increasing concussion rates over time but for other sports the data was not clear. As far as the mechanism of concussion, that was also interesting. In women???s soccer the data showed that 11% of concussions occurred from ball contact while heading a ball. And in women???s lacrosse about 11% of concussion occurred from stick contact while defending.

This is one study, in an older group of players, with different rules and often different equipment than is used in the youth game. So there are some limitations but studies like this can help take some of the ??always?? and ??never?? out of the concussion discussion for young athletes and help guide us towards more objective decisions.






Posted in Concussions, Football, Lacrosse, Soccer, Sports Science | Leave a comment

Seven Cool New Concussion Technologies That Could Be Game Changers

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The GE/NFL/Under Armour Head Health Challenge is an extraordinary competition designed to produce radical improvements in concussion diagnosis, safety equipment design, and materials. I believe some of the technologies could find their way to the youth sports landscape fairly soon, and I highlight some of the projects below.

Our focus at Sideline Sports Doc is on youth sports, and specifically to focus on topics of Head-Health-Challenge-II-Infographic-12.3.15interest to parents and coaches of young athletes. To start off 2016 I???d like to highlight seven very cool new technologies that have the potential to improve sideline concussion recognition for athletes in all sports, and to reduce concussion risk in football.

Collaboration between GE, the NFL, and Under Armour has been under way for several years, called the Head Health Challenge. The Head Health Challenge is a three-part competition amongst researchers and developers from universities, private industry, and the government. Part 1 of the challenge hopes to lead to methods of improved concussion diagnosis; the technologies are impressive but geared towards clinicians and are unlikely to make it to the sidelines of a youth club sport. Parts 2 and 3 however, have applications that in my opinion could positively affect every level of sport from professionals down to youth leagues.

The Part 2 winners were announced in December 2015; Part 3 winners are expected to be announced in the fall 2016. Here???s my take on the seven finalists for the Part 2 challenge, which focused on sideline concussion diagnosis and improved materials for impact absorption:

  1. Rate-dependent tethers developed by the Army Research Laboratory, Aberdeen, MD

What It Is: smart materials in flexible tethers connect the helmet to the torso. The materials are fully flexible at low speeds allowing for head movement during sport movements but they become rigid at high impact, reducing whiplash or rotational movement of the head.

Why It???s Important: there is increasing evidence that whiplash or rapid back-and-forth movement of the head is one of the main contributors to concussion. Techniques such as neck strengthening can reduce concussion risk, and an external tether would be somewhat like your airbag in your car inflating during a crash- the tethers would reduce the rapid movement of the head. Very early testing is now underway, and I see great potential for this technology even in the youngest age groups.

  1. Revolutionary football helmet design from the University of Washington.

What It Is: new testing underway to design a football helmet that can better absorb impacts.

Why It???s Important: Designs like this could be incorporated into conceivably any type of sport helmet at any age group.

  1. Viconic/General Electric shock-absorbing synthetic turf underlayer.

What It Is: a novel underlayer for synthetic turf fields can reduce impact when the head or body hits the turf.

Why It???s Important: One way to get a concussion is with an impact of the head hitting the ground. With more and more fields now made from synthetic turf, a field with better shock absorbing ability has the potential to reduce concussion risk. This technology also has great potential but I believe it will require very careful study as it may change risk of lower extremity injuries too (higher risk, lower risk, neutral risk- all will need long term study)

  1. UCLA and Architected Materials, Inc. are developing a new energy-absorbing microlattice material for improved helmet performance.

What It Is: a truly unique lattice structure material allows for shock absorption, improved airflow, and ability to modulate specific areas to reinforce.

Why It???s Important: This material has the potential to dramatically reduce impacts to the skull and brain and could be used in any application with a helmet. This could improve safety in the military, football, hockey, lacrosse, cycling, etc.

  1. Helmetless tackle training, University of New Hampshire.

What It Is: a back to the basics approach with a remarkably radical concept: if you teach proper tackling technique without a helmet and shoulder pads in practice, will it improve tackling technique during games?

Why It???s Important: this clinical study aims to get at the heart of basic concepts of muscle memory, technique, and psychology. If the researchers are able to prove their premise then I see every reason to believe their concepts could be used to teach proper tackling at every level of the game.

6 and 7. Two new methods for sideline concussion diagnosis: Emory University and Georgia Tech iDETECT system; University of Miami, University of Pittsburgh, and Neuro Kinetics Inc. I-Portal PAS System.

What It Is: each of these systems aims to utilize very subtle changes in neurologic function (such as eye movement tracking) to provide immediate diagnosis at the point of injury.

Why It???s Important: an objective, portable, and fast method of diagnosing a concussion would be an enormous benefit to trainers and physicians on the sidelines. This technology would take much of the guesswork out of concussion assessment.








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

Perspectives on US Soccer???s required changes for youth heading

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

This week???s post is a little bit ??holiday light?? as I???d like to point you to an excellent video segment from San Francisco???s station KTVU.??Screen Shot 2015-12-15 at 11.51.44 AM

As expected, there has been considerable debate surrounding the US Soccer Federation???s recently recommended changes to rules about heading in practices and games for younger age groups. From my standpoint as a sports medicine doctor the changes make a lot of sense and I fully support them, while I also recognize that changes to the policy are likely to occur over the next several years as additional scientific research becomes available. It is a first step in the right direction.

I like this brief television segment as it highlights some perspectives from a youth coach, and also from Mike Woitalla, the highly respected Executive Editor of Soccer America magazine. It???s true that coaches will need to change the way they coach younger players, but it???s possible this will improve skill level in other areas of the game.

Have a look and decide for yourself. Lots of questions remain about sport concussion in young athletes, but the steps taken to make youth sports safer by US Soccer Federation, USA Football, and USA Hockey are providing a direction that is likely to stay.






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

Snowboarding Injuries to the Foot and Ankle

By Adam Bitterman, DO

Fellow, Foot and Ankle Surgery

Rush University Medical Center


and Johnny Lin, MD

Assistant Professor, Midwest Orthopaedics at Rush

Rush University Medical Center

Key Points:

  • Snowboarding is growing in popularity, especially amongst young people
  • Lightweight boards with less rigid boots lead to faster speeds, with an increase in injury risk
  • Injuries to the foot and ankle with snowboarding may include fractures, sprains, and tendon injuries.
  • Most injuries can be successfully treated but will require accurate diagnosis and treatment from your doctor

As snowboarding continues to grow in popularity, so too does the number of injuries snowboardingsustained. According to a 2010 report, there were nearly 8.2 million people who snowboard versus 11.5 million who participated in skiing. Currently, there are younger and younger participants snowboarding and therefore more accidents and injuries each year. The surge in injuries from snowboarding may be due to it being a relatively new sport and the inexperienced beginners are more prone to hurting themselves. Yet, some believe that it may be the experienced snowboarder who is more at risk since they are likely to take risks and attempt to navigate more challenging slopes1.

As the sport has evolved so too has the equipment. Lightweight boards and boots have resulted in faster speeds traveling down the more challenging slopes ??? another reason for the surge in these injuries2. Less rigid boots lead to less support around ankle and foot, thus resulting in ankle and foot sprains, strains and fractures.

Landing from a jump may lead to the foot being rotated inward or outward as it sustains an upward force from the ground. These rotational forces combined with the upward force from the ground impact may result in a break. Ankle fractures may involve the tibia (shin bone) or the talus. The tibia bone may have a single break or breaks at multiple sites. The inside of the ankle, also known as the medial malleolus could be fractured or the outside may have sustained the force, which would lead to a lateral malleolus fracture. In regards to the talus bone, snowboarders are at increased risk of breaking their lateral process, commonly referred to as the ??snowboarders fracture??.

Treatment of these ankle injuries depends on the type of break and the amount of displacement of the bone pieces. Fractures with significant distance between the bone fragments are usually best treated with surgery. By doing this, the broken segments are realigned in their normal anatomic position and fixated with appropriate implants. In cases where there are small fragments or too many to address individually, the decision may be made to leave them alone and allow them to heal and incorporate in their current position. Nonoperative management may also be chosen for ankle fractures that have little to no displacement. This decision will be made in close consultation with your doctor.

Generally these injuries are rehabilitated with nonweightbearing using crutches with the length of time being dependent on the specific treatment. Functional physical therapy may be needed to help return the individual to their baseline activity level. Once again, each individual situation is different and you???ll discuss specifics with your doctor.

Injuries to the foot or ankle that do not lead to a break may be the result of overuse and repetitive stress on a particular area. These injuries can be contusions, sprains or stretching of ligaments, or strains due to tendon inflammation. Appropriate treatment will likely include a period of rest and immobilization of the painful ankle while the painful process resolves on its own.


  1. Ishimaru D, Ogawa H, Sumi H, Sumi Y, Shimizu K. Lower extremity injuries in snowboarding. J Trauma. 2011;70(3):E48-E52.
  1. Mahmood B, Duggal N. Lower extremity injuries in snowboarders. Am J Orthop (Belle Mead NJ). 2014.43(11):502-5.
Posted in Ankle, Foot, Snowboarding | Leave a comment

Hockey Training Tips: Off-Ice Balance Training

By Steve Chmielewski, DPT

Physical Therapist at Athletico, Westchester, IL

Key Points:

  • This blog post first appeared in Sports Medicine Weekly, founded by our partner Dr. Brian Cole
  • The author points out the need for proper balance training as part of off-ice preseason hockey preparation, to improve power and reduce injury risk especially to the knees
  • A simple single leg balance progression is outlined

Lower extremity strength training is a priority when considering a comprehensive training iStock_000014161453XSmallprogram for youth hockey players. Most coaches consider dynamic stretching, functional strengthening and plyometric training to be enough. However in a sport where agility and balance are essential it is important to consider how players can improve these components off the ice.

In the hockey community the term ??bender?? is often used to describe a player that has ankles falling inward which is known as rearfoot or hindfoot valgus. ??From a coaching and overall performance perspective, it is obvious that this is not an ideal foot position when performing a hockey stride. Power from each stride will be reduced as the player transfers his/her kinetic energy through the trunk, hips and knees into the ice effecting both the player???s speed and agility. This may have a significant impact on the player???s overall skill development when practicing edge work and stopping drills. With a lack in development, the athlete may ultimately have limited confidence pursing pucks along the boards or in congested areas of the ice. This can foster the development of a timid player who may be less likely to compete in these areas, thus further stunting his/her development and ultimately his/her long-term participation in the sport.

From a biomechanical and injury prevention perspective, a chronic weakness and malposition of the ankle may also place added stressors on the knee and lead to an increase risk for knee pain limiting his/her participation throughout the season. One can argue that the support from the boot of the skate should counter the athlete???s lack of strength, but it must be understood that the stiffness of the boot will break down over time and potentially expose the athlete???s strength deficits over time.

With 25 different muscles in the lower leg and foot one may wonder, ??How can I strengthen my ankles to better myself on the ice????? Simple single leg balance activities on the ground are a great place to start. When standing on one leg it is important to focus on keep 3 points of contact with the foot: (1) the big toe, (2) the little toe and (3) the heel. The athlete is expected to be able to hold this position for 30 seconds, 4 times, prior to adding tasks or changing the surface (couch cushion, pillow). Common tasks such as turning one???s head, closing one???s eyes, stickhandling, juggling balls, and squatting can be incorporated into the individual???s single leg stance training to improve his/her coordination.

If a specific individual is unable to maintain a neutral foot position while balancing barefoot on a flat surface, a towel can be placed under the middle half of the foot to improve the overall ankle control. It is important to note that pain during any type of balance training activity is not acceptable and should be assessed by a physician or licensed physical therapist. These conditions may require formal therapy to address specific deficits within the hips, knees and ankles to restore good balance and control.

Simple Progressions

1) Stand on one leg, eyes open on a firm surface ???> progress to a couch cushion or other unstable surface

2) Stand on one leg, eyes closed on a firm surface ???> progress to a couch cushion or other unstable surface.

3) Other activities you can attempt to master

  • Single leg stance while passing around a ball around in the locker room
  • Single leg jumps forward and backward/side to side over a line (3 sets of 10 jumps in each direction)

By Steve Chmielewski for Athletico




Posted in Hockey, Knee, Tips and Training | Leave a comment

Safety Rules Changes Needed To Grow Youth Sports

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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

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






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