What Are The Psychological Things That Great Athletes Do? Radio CaptainU Interviews Scott Kaufman, Professor of Psychology at NYU.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Each athlete should focus on developing an individual or core skill, rather than constantly comparing themselves to their peers
  • Focused, deliberate practice in which you push yourself beyond your limits is very helpful in creating a core competency

Scott Kaufman is a very interesting expert, self deprecating, funny, and provides a number of outstanding insights into the mental side of athletic performance training. The talk generally focuses on training, and not specifically on in-game mentality. Kaufman’s background is in basketball, so many of the examples he provides are basketball focused. But I feel the concepts are applicable to most sports.

One of the first points he makes is for an individual to follow his/her own pathway and to approach development as a unique process. Put energy and time into a specific skill. He believes this is a good way for almost any athlete to create a core competency that will allow them to participate at the highest level possible.

Kaufman is a believer in deliberate practice, which is a type of practice where you are repetitively and intentionally pushing yourself beyond your limits. Even pushing through in small ways is a key component to advancing your skills.

He also advocates using mental imagery or visualization of success, and often using guidance from a mentor to help you with this.

The goals of this type of training is to develop a go-to set of skills, see yourself succeeding at this skill, and in turn this gives you the best chance to succeed when you do get into a game situation.

And finally, Kaufman closes with some interesting anecdotes about his pathway as a high school basketball player and his desire to make it to the NBA. He kept that in mind until he started playing high school basketball with a fellow named Kobe Bryant.

Posted in CaptainU, Psychology, Training | Leave a comment

Uruguay Deserves A Red Card For Concussion Management: US Youth Sports Must Do Better

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • During the World Cup the Uruguay team allowed a player with an obvious concussion to continue playing in the same game, risking permanent injury to the player
  • Youth Sports organizations in the US must take the lead and require proper concussion recognition for their coaches.
  • Youth Sports organizations must provide clear and consistent rules for return to play; a qualified physician’s clearance should be mandatory

In a group stage game last week, Uruguay’s Alvaro Pereira sustained a concussion. To debate whether he did or did not have a concussion is ludicrous- it’s a concussion even by 1950s definitions.  Take a look here, along with some commentary by Taylor Twellman: http://www.espnfc.com/fifa-world-cup/4/video/1905674/fifpro-seek-concussion-investigation Álvaro Pereira

There’s quite a bit of debate about what professional soccer must do to provide an appropriate way for medical personnel to evaluate a concussion (or any other potentially serious injury, for that matter). Rules in professional soccer essentially penalize a team for evaluating a player with an injury. And disturbingly in the Uruguay scenario the player and coaching staff were allowed to overrule the doctor, and the referees allowed the player back on.

Professional soccer has many questions to ask and answer about how they want to address the issue of on-field injury evaluation. And from their atrocious approach there are actually lessons that we can apply to youth sports in the United States.  Let’s have a look.

Lessons For U.S. Youth Sports

The first take-away is that there must be a uniform process that strongly favors player safety.  No more guessing about who’s in charge. No more inconsistent education for coaches. I’ve spoken to many high ranking decision makers in youth sports over the years and it’s interesting to listen to the pushback we get when discussing our available programs for in-game or in-practice injury recognition and management. Common statements are “we can’t afford this”, “our board won’t support this”, “we can do this ourselves”, “we can’t force our coaches to do any more than we are already making them do”, etc. etc. etc.  The reality is that coaches do want the education and they expect that the service organizations to which they are paying fees to provide the education.  Our youth sports leagues must take the lead and require the proper education and support to ensure uniform application of player safety rules.  Leaving it to the discretion of local leagues or making it optional simply will not work.

The second lesson is specific to concussions. We can’t expect a concussed player to determine whether he/she is fit to play, and we can’t expect a coach without medical training to make a diagnosis of concussion. The coach must be educated enough to suspect a concussion, remove the player from play, and then let a qualified physician make the actual diagnosis.

And the final lesson is about return to play.  When a youth sports coach decides to remove a player from play due to suspected injury the rules of the league, the club, and the referee need to stand behind the coach. The reality is that the coach can often be pressured by the player, the parents, or teammates to allow an injured player to play. The safest thing to do- especially in a problematic issue like concussion- is for the league to require written clearance from a physician to determine return to play.

We are making progress with player safety in U.S. youth sports but we can do better. It will be a big step forward when our youth sports organizations take a stand for uniform requirements favoring player safety.

Posted in Coaches, Concussions | Leave a comment

When Can I Play Again After Meniscus Surgery?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Recovery is highly variable, but generally speaking most young athletes can return to sprinting, cutting, and jumping sports at about 6 weeks after partial meniscus removal surgery
  • Generally speaking, most young athletes will return to sprinting, cutting, and jumping sports at about 4 months after meniscus repair with stitches
  • Beware about claims to return fully to sports at 2 weeks after surgery- this is very rare
  • Success rates are very high with properly followed rehab

This weekend I watched Costa Rica defeat Uruguay in a World Cup game, with this huge upset made possible in part because star Uruguay striker Luis Suarez was unable to play due to recovery from recent knee meniscus surgery. Many sports commentators felt fairly certain Suarez would be ready to play, only about 3 weeks after his surgery. But most orthopedic surgeons would honestly tell you it would be unusual for a player that relies on speed, quickness, and the ability to turn on a dime to be fully ready that quickly.

So how long should it realistically take? A00358F02

The meniscus is a shock absorber in the knee, a horseshoe shaped structure situated between the two major knee joint bones. There are two menisci in each knee, and either meniscus can be torn in patterns generally like the ones shown in the photo (from OrthoInfo, the American Academy of Orthopaedic Surgeons).

If surgery is done for a torn meniscus it will most often be a partial removal, which is somewhat like trimming a hangnail from your toe.  It’s a relatively quick procedure (usually about 15-20 minutes) and weightbearing is allowed immediately after surgery. The second possible procedure is called a meniscus “repair” where stitches are placed in the meniscus to sew it back together. After a meniscus repair there is usually a period of partial weightbearing on crutches that lasts several weeks.

The type of surgery performed has a major influence on the speed of the rehabilitation. With the commonly performed partial meniscus removal there is an early emphasis on minimizing swelling and regaining motion. Comfortable walking generally takes about a week or two. The highly variable part is return of power, speed, and the ability to cut hard or pivot. This is the part that takes the longest time and will usually take 2-4 weeks. So if we add the weeks up it will be a minimum of 3 weeks and perhaps up to 6 weeks for full return to sprinting, cutting, and jumping.

With meniscus repair with stitches there could be 4-6 weeks on crutches, followed by regaining full walking ability, and finally getting the knee sport-ready with strength, power, and speed.  There is some overlap in the phases but when all the time is added up you’re looking at 3 to 4 months until the player is ready for unrestricted sprinting, cutting, and jumping.

In the discussion above I’ve focused on return to sprinting, cutting, and jumping. So the timeline for return to sports will depend on whether you need to do those things in your sport. If you are a cyclist or swimmer you should expect a faster return to your sport. Distance runners will generally return to full training faster than sprinters but likely longer than cyclists.

Circling back to World Cup soccer, Mr. Suarez is now coming up on four weeks after his surgery. If I were a betting man I would expect to see him in the starting lineup for Uruguay this week. Young athletes should expect a high chance of successful return with proper rehab and time after surgery.

Posted in Knee | Leave a comment

Can Strength Training Be This Simple And Effective? Radio CaptainU Interviews Author Mark Rippetoe.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Radio CaptainU interviews nationally renowned strength coach Mark Rippetoe, who states that young athletes can make massive strength gains in 4 months, lifting about 3 times per week with only 5 basic lifts
  • Five key lifting activities will provide the greatest return for your effort: squat, deadlift, pushup, pullup, bench press
  • You can lift and train far less often than you think, as long as you are smart about using the key lifts. 3 days a week, about 30-45 minutes.
  • Rippetoe claims that these basic lifts done perfectly will show massive gains in all areas related to strength such as power and even accuracy
  • I believe the young athlete must receive direct one on one supervision at the start of a strength program in order to have perfect form and reduce injury risk

Mark Rippetoe is a very interesting fellow. From his base in Middle America he’s gained a very devoted following of individuals who have achieved huge strength gains in relatively short periods of time.  Rippetoe focuses on five or six key lifts, which done properly will lead to a base of substantial strength.  From that strength base other aspects of sport performance including power and even accuracy will improve.  His book is a fitness best seller.

His contention is that the fitness industry in the U.S. has grown by spreading a misconception that lifting has to be complex. He states further that the idea that only a few simple moves done with conventional barbells, with only 3 sets of 5 reps for each move, can be difficult to grasp for some people just because it’s so simple.  Where’s the video app?  What about constant feedback from your wearable electronic fitness tracker connected to the cloud? According to Rippetoe all of those technical things are unnecessary and even detrimental to real strength gains.

I must say I really like these ideas.  The lifts themselves are simple and relatively inexpensive to access the equipment.  But the key is that to do these safely without creating an injury risk, I believe the young athlete must have proper direct supervision from a skilled strength trainer. Listen and learn!

Posted in CaptainU, Tips and Training | Leave a comment

Manage The Heat And Humidity So You Don’t Go “Lebroning”

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Ok, even the most diehard Miami Heat fans must have thought the photos of various people “Lebroning” were a little bit funny. But the reality is that a severe muscle cramp and heat illness can be very serious.  There’s been a lot of discussion about how soccer players are preparing for the heat and humidity of Brazil.  With many young athletes exposed to heat and humidity over the summer, let’s take a look at how the professionals prepare, and some take-aways that can be used by the young player. OLYMPUS DIGITAL CAMERA

Preparation/Before The Event

Professional teams with significant resources will do several things prior to a major tournament or game to try to acclimate their players.  For example, for the upcoming World Cup many teams are training in Florida to simulate the heat and humidity of Brazil. Some teams in Europe are training indoors in climates adjusted for higher heat and humidity.  For all the World Cup players there will be sophisticated metabolic and biochemical analyses performed to tailor a hydration and nutrition plan. For NFL teams that will start formal training camp later in the summer they will have their players start OTAs early and each player has a personalized training plan prior to formal camp.  And for all professional athletes regardless of sport, being at their peak fitness prior to important summer events is critical.

Take-away for the young athlete: be as fit as possible prior to any important summer event played in heat and humidity.  Fitness training must start several weeks before the event. Pay close attention to nutrition and hydration.

During The Event

The most critical factor during the event is proper hydration.  Professionals will have personalized hydration plans prepared during the pre-event phase.  Hydration will go a long way to minimize the chance of heat illness and cramps during the event.  Cooling strategies have also become complex and scientifically driven.  In the World Cup be on the lookout for Adidas’s super high-tech cooling vests which will be worn by players from 9 Adidas sponsored teams during pregame.  A lot of our athletes in our orthopedic practice have started using fairly inexpensive evaporative cooling towels placed on the back of their necks during practice and game time-outs or halftime.  There are many brands available and I like these a lot- they work.

Take-away for the young athlete:  pay close attention to hydration. You can find a very simple hydration strategy in this post.  And an important take-away for the coach and parent: recognize signs of possible heat illness and take action early.

After The Event

There is a solid level of scientific evidence showing that starting nutritional recovery in the first 20 minutes after the event is the most effective time to refuel.  There are many fluid recovery drinks commercially available. Avoid anything containing high fructose corn syrup or caffeine.  I like low fat chocolate milk as an excellent “natural” recovery drink.  A carbohydrate based meal (such as pasta) is also an excellent choice.

From the physical standpoint most teams will perform something called “active recovery”, which is a form of mild muscle activation.  This can be done with a simple light jog followed by a stretching routine.  Professional athletes will often use other modalities such as electrical stimulation, cryotherapy (cold therapy), deep tissue massage, and compressive cooling.

Take-aways for the young athlete: Individual and team athletes should do a light active recovery session after the event. Start your fluid and nutritional refueling as soon as possible after an event, and ideally within 20 minutes.





Posted in Football, Heat Illness, Hydration, Nutrition, Prevention, Soccer, Sports Science | Leave a comment

The Home Field Advantage Is Real! Radio CaptainU Interviews author Toby Moskowitz: Scorecasting

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • University of Chicago business school professor Toby Moskowitz discusses his fascinating book, Scorecasting
  • The book is a “Freakonomics” type of analysis to some of our commonly held sports beliefs
  • The home field advantage is real
  • The “hot hand” is probably a myth
  • Challenge the “conventional wisdom”, especially what you hear from sports announcers

How many youth sports games have you attended when you were convinced the ref was a “homer”?  Particularly in sports such as soccer, where the referee is in charge of subjective parts of managing the game such as time added for injury, the behavior of the ref often favors the home team. The home field advantage is real in every sport, but maybe not for the reasons you think.

What about the “hot hand”- should you really keep feeding your shooter who is on a streak with a high number of shots made?  Well…maybe.  In any given game I think we can’t deny the value of feeling confident, and confidence often comes from the play that came just before the current one.  So if you feel good about your shooting it will probably positively affect your next shot.  But if you look out over the whole season the “hot hand” is likely a myth.  There will be hot streaks, there will be cold streaks, and in the end things will probably end up where they belong.

Scorecasting is a fascinating book.  While not specifically aimed at youth sports, it is a book any sports fan will enjoy.  Toby Moskowitz along with co-author Jon Wertheim ask us to challenge the “conventional wisdom” when we are watching sports, especially when it comes to the words of the sideline announcers. What are some of the subtle factors behind what you are seeing on the field? This book will give you a lot to think about.

Listen to this interview conducted by CaptainU’s Avi Stopper with author Toby Moskowitz for a great summary:

Posted in CaptainU, In the News, Psychology | Leave a comment

End Of Spring Running Season: Watch Out For Shin Splints And Stress Fractures

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Shin splints and stress fractures are common running injuries, typically caused by overuse in training
  • Shin splints can often be treated by simple measures
  • Stress fractures need proper evaluation by a physician

Shin splint syndrome and stress fractures in the foot and leg are common in runners. I have been seeing a large number of these injuries in high school athletes, especially towards the end of cross country or distance running seasons. Both shin splints and stress fractures are characterized as overuse injuries. These injuries happen with repetitive loading (meaning: running), and the pain or fracture occurs when the load exceeds the A00407F01foot or leg’s ability to withstand the load.

Shin Splints or Stress Fracture?

Runners with shin splint syndrome typically have a generalized discomfort or pain along the inner border of the lower leg bone, the tibia. A “shin splint” refers to inflammation or microtears at the site where muscle inserts on to the inner portion of the main leg bone, the tibia. Usually the pain comes on gradually over a number of days or weeks, and often increases to the point where pain is present even with light daily walking.

A stress fracture refers to a crack in a bone that typically starts from repetitive overload. A stress fracture in the foot or leg can come on suddenly and often has a very localized area of pain or discomfort.

In my opinion shin splint syndrome and stress fracture are somewhat related because a runner with ongoing shin splint syndrome who attempts to continue training and competing can go on to develop a stress fracture.  There is a concept in biomechanics called “tibial shock” in which loads are repetitively delivered to the tibia during running.  If the loads exceed the leg’s ability to withstand them the initial response is usually shin splints, and if continued repetitive loading occurs the next structure to fail is the bone.  I like to think of leg pain in runners as a spectrum ranging from relatively mild and annoying to the most severe condition, a stress fracture.

Causes: Too Much, Too Soon Combined With Mechanical Factors

When we look at runners with shin splints or stress fracture we like to try and identify the cause of the problem so it can be avoided when the runner gets back to running. The most common training factor is a recent increase in training intensity or duration. Other factors may include a recent change in running style or change in running shoe. When intensity or duration increases too rapidly, that means the bone was subjected to “too much, too soon.”

Another very common cause is flatfoot and/or overpronation during running. With an overpronated foot the muscles along the inner portion of the leg will contract to provide support for the arch. With continued use this support can become overstressed, leading to injury.

What To Do

If you’ve had a sudden onset of what you would describe as localized pain in the foot or leg, I would recommend that you see a sports medicine specialist prior to starting any treatments.  This could be a stress fracture and needs proper evaluation before you do anything on your own.

But if you have a nagging discomfort on the inner aspect of the leg this could be a shin splint.  For discomfort that’s only been present for a week or two you should back off your mileage significantly or stop completely.  Cross train with an AlterG Antigravity Treadmill or elliptical trainer until pain free.  Use a “stick” for self massage.  Wear a calf support during exercise. And use Superfeet or similar arch support if you have flatfoot.  When you restart running you need to start with a very low mileage and intensity, then ramp up no more than 10% per week, as long as you remain pain-free. If these simple measures are not successful, if your pain increases, or if you have pain lasting more than about 3 weeks I’d recommend that you see a sports medicine specialist.

Happy running!



Posted in Running, Treatment | Leave a comment

Predictors Of Elite Performance In Endurance Athletes?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Unfortunately, there is no single best measurement that can predict elite level performance in endurance athletes
  • Multiple factors such as VO2 max, running economy, genetics, and training methods likely all play a role
  • Almost all elite level endurance athletes will use High Intensity Interval Training for some portion of their training, making it the most effective training method

I’ve recently written a post about the one best predictor of elite level performance in predominantly anaerobic sports such as football (it is power, roughly the ability to produce maximal force in the shortest time). I received a number of questions about predictors of elite performance for endurance sports such as distance running. Do these predictors exist for endurance sports, and are there a small number of predictors that a young athlete can focus on?  It turns out that the issue for endurance sports is a bit more complex, as several factors appear to be important and there is no single best predictor.  Let’s take a look at what the evidence shows. east African distance runners

For scientists and sophisticated coaches focusing on runners, there are a number of key measures correlated with running success.  Maximal oxygen uptake (referred to as VO2 max), running economy, anaerobic threshold, body type, genetics, and training methods have all been studied and seem to have roles.  No studies have shown that there is one dominant characteristic.

VO2 max is the maximum rate that oxygen can be taken from the air and taken to the cells in the body during physical activity.  VO2 max has been extensively studied in a number of different endurance sports, with differing levels of athletic ability.  There is no conclusive “number” correlating to all endurance sport athletes but elite marathon level runners generally have VO2 max values ranging from 70 to 85 ml/kg/minute.

Other sophisticated measurements include running economy, and the amount of time a runner can run at VO2 max.  The amount of time an athlete is able to run at VO2 max is a strongly linked with elite level performance but again it turns out not to be completely predictive. Body fat measurements have also been extensively studied.  Generally speaking, “elite” female and male runners have body fat around 8%, “good” runners around 10.7%, and “average” runners around 12.1%.

And how about the incredibly high percentage of elite level distance runners from the east African countries?  Is that due to genetics, training at altitude, or training methods? It is too difficult to figure out which factor is the most important.

Are you confused yet?  I am!  There are just too many factors involved in elite performance in endurance sports.  These factors are likely different by sport (cycling vs. running, for example), different by distance, and probably different for males vs. females.  One thing I did find as far as training methods that seems to be correlated with making any individual athlete the best he/she can be: high intensity interval training.

In high intensity interval training the athlete participates in very short but high intensity training sessions often involving sprinting.  When done correctly, high intensity interval training is effective for almost all levels of athletes in just about any type of endurance sport.  We’ll cover this further in a future post.  For now here’s your take-home message: there’s no single best predictor of elite level performance in endurance sports, but almost all elite endurance athletes will use high intensity interval training during their workouts.

Posted in Performance, Running, Sports Science, Training | 1 Comment

Building A Winner On Field and Off. Radio CaptainU Interviews Northwestern University Head Football Coach Pat Fitzgerald

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Pat Fitzgerald, head football coach at Northwestern University provides his insights into key elements of building a winning football program and embedding life skills into the mindset of his student-athletes
  • He emphasizes getting the right “fit” from a sports, academic, and campus culture standpoint
  • His most important piece of advice- for football and life activity- is to challenge yourself to give your best effort to whatever you’re doing

Pat Fitzgerald is the head football coach at Northwestern. In 2012 they ended a 63-year drought by winning a bowl game.  Fitzgerald has gone on to create a solidly competitive program in an ultra competitive conference, while at the same time creating a culture where 100% of Northwestern’s four-year players have graduated.

He finds himself at the center of the current controversy in college football, where a judge has recently ruled that Northwestern’s varsity football players have the right to unionize.  Fitzgerald has argued passionately about the mission of college athletics, stressing the need to remain focused on being students for life as well as competing at the highest possible level.

In the interview below, you’ll hear how he emphasizes several points with his players.

  • Build a culture of unity: team first, then teammates, then self
  • Most critical piece for him in recruiting a Northwestern player is the “fit” within the university and the team from a character, skillset, and academic standpoint
  • Hold players to a high standard of personal excellence in all their activities
  • When playing in any important game, be grateful for the opportunity you’ve been given

Fitzgerald is a high class individual, and proof that a highly competitive program can be created within a school known first and foremost for academic excellence. As the debate about pay-for-play in college football continues, Fitzgerald will be an important voice.

Posted in CaptainU, Football, Parents | 1 Comment

We Need To Rethink Tackle Football For The Youngest Players

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • There is increasing pressure on youth and adolescent football leagues to reduce concussion risk in the younger players
  • Possible solutions include “heads up” tackling, better helmets, and eliminating tackle football at the younger age groups
  • Football’s governing bodies might be wise to consider a model similar to USA Hockey’s American Development Model (ADM), with age restrictions on tackling
  • This emotionally charged issue needs careful objective analysis soon, as the sport could be at a crossroads for youth participation

Let me say from the start that I love NFL football. Let me also say that I’ve seen shifts in participation at the high school and younger levels that have the potential to rapidly reduce the number of young football players. One factor I consistently hear from parents who hold their sons from tackle football is the need to reduce concussion risk. football coach_2

There is increasing pressure on the local leagues and national governing bodies for football to recognize the risks on the young developing brain, and to take strong steps to reduce the concussion risk in the youth football player. One step being taken by some leagues is to eliminate tackle football until a certain age group, typically around age 13 or 14.  This New York Times article highlights the decision by one Texas league to do just that, and the generally supportive response from the parents. The league decided for a number of reasons that to introduce tackle football to 7th graders and younger was an unacceptable risk. They are promoting flag football in those age groups and phasing in tackle from 8th grade and up.

There are several facts that have emerged over the past several years regarding risk of concussion in the younger age groups. Amongst those are the facts that the young developing brain is more susceptible to injury than a mature brain (meaning it takes less force to produce a concussion in a young athlete than an adult), concussions in young athletes can take longer to recover than older athletes, and there is a significant size differential possible in boys age 13-14 who are going through puberty.  It also appears that the rate of concussion is rising, although some of that may be due to increased awareness and diagnosis of concussion amongst medical professionals.

Parents are definitely holding kids back from tackle football specifically due to concussion risk. USA Football promotes coach certification for Heads Up tackling, which is certainly a step in the right direction.  Helmet manufacturers are making safer helmets. I believe age restrictions on tackling will be coming soon from the national youth football organizations. My opinion is that we will need to carefully and objectively examine this issue further, and consider something similar to what USA Hockey has done with the ADM which places a minimum age of 14 for body checking. Let’s address this issue now and improve football safety for all young players.



Posted in Coaches, Concussions, Football, Hockey, In the News | Leave a comment