Keys To Sideline Concussion Diagnosis

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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






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The Female Athlete Triad: A Serious Problem Needing Careful Attention

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

The three problems are:

  • Eating disorder

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

  • Menstrual dysfunction

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

  • Premature osteoporosis (low bone density for age)

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

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

Psychologists recommend that female athletes should consider these questions:

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

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

Disordered Eating

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

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

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

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

Menstrual Dysfunction

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

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

Premature Osteoporosis (Low Bone Density for Age)

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

See your Primary Care Doctor immediately

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

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

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



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

Car Tires And Cancer

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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

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




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The Sports Balancing Act

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

Posted in Coaches, Parents, Psychology | Leave a comment

Creating a Culture of Lifelong Fitness

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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



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Legal Supplements for High School Athletes

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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



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Will We Need To Rethink Tackle Football For 12-Year-Olds?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published scientific study showed that retired NFL players who started playing tackle football before age 12 scored substantially worse on tests of brain function than other players who started after age 12
  • Both groups scored worse than the average person
  • This study is important because it does not focus on concussion, it looks at the age at which the player started taking day to day contact in football

A scientific article was published on January 28, 2015 in the journal Neurology that will add to our discussion about the appropriate age to introduce tackling in youth football. You can view an abstract of the article hereOLYMPUS DIGITAL CAMERA

The article focused on the age at which retired NFL players began playing tackle football, and then correlated that age to their performance on tests of brain function after their retirement. The researchers chose age 12 as the cut-off because this is a critical age for brain development; children 12 and younger are still very immature in terms of brain development whereas those over age 12 are more mature. That’s an oversimplification but it will frame our discussion.

The key study result was that those players who started playing tackle football at age 12 or younger scored about 20% worse on almost all tests of brain function compared to those who started tackle football after age 12. If you’re wondering whether 20% is a big deal or not the answer is most definitely “yes it’s a big deal”, in fact I’d say it’s an astoundingly large number. Additionally I’d like to point out that even the “over 12” starting point performed worse than average, so both groups did poorly but those players starting before age 12 did really poorly.

And to be clear this study was not looking at concussions it was simply looking at the age at which the players started playing tackle football. In other words the study authors are really just looking at the effect of the routine day to day hits that occur in tackle football.

This is a well-designed study but does have some limitations. First of all, it studies former NFL players, so these players have gone well beyond high school and sustained many, many substantial impacts. We don’t know then what the effect would be on a boy who stops playing football after high school- is their brain function affected later in life too? And secondly, it’s just one study of a relatively small number of players, the results will need to be studied with a larger group of individuals.

Some organizations such as USA Hockey have taken a strong stance by introducing a minimum age for full body checking (it is legal starting at the under-14 age group). The study published this week in Neurology is just one study and can’t fully predict what the effect of the hits are on a young brain but it should at least prompt parents and leagues to ask some tough questions.

Opponents of age restrictions on tackling often argue that tackling is a critical component of high school and adult football, so the technique should be taught early on. There are also plenty who would say that imposing age restrictions creates a culture of softness that detracts from the game. For now, each of us ought to ask our own questions and do our own research. We may come to a time fairly soon when the governing organizations for youth football in America impose age restrictions on tackling. Stay tuned, the debate will heat up I’m sure.



Posted in Concussions, Football, Hockey, Sports Science | Leave a comment

Tech Watch: Movement Based Concussion Evaluation

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Movement based testing of brain function is a concept that could be used to add objective information in the evaluation of an athlete with a suspected concussion
  • One company is developing a testing method that bears watching as they go through scientific study to validate their service

The diagnosis of concussion for medical professionals can be tricky, and a determination of proper timing for return to play can also be somewhat subjective. To be clear, as far as the coach is concerned on the field of play I would not recommend that you make a “diagnosis”, you should suspect a young athlete may have had a concussion, remove him/her from play, and refer to a qualified medical professional for proper diagnosis and return to play guidance. Please download this free, simple on-field concussion guide if you’re a coach or parent from our website. PEG testing concussion

Trained medical professionals, however, like to rely on more than just judgment and suspicion. Ideally, we like to have some objective data obtained in the preseason for healthy athletes and then obtain data after a suspected concussion to compare. In the best cases, there is no ability for the athlete to “game” the system by manipulating the test in the preseason phase. (as a side note I’ve never actually seen any of our high school aged athletes do this in my 20+ years as a team doc, but stories of this type of behavior are common…).

With that in mind there are several attempts at objective measurements of brain function, too numerous to mention all of them in this brief post. Some of these include ImPACT computer based cognitive testing, the King-Devick test that tracks eye movements, and simple reaction time tests using home made equipment.

But there’s one company that’s caught my eye and is worth following as they progress: Performance Evaluation Group, based out of Cleveland, Ohio. As compared to the methods above that use primarily static (no body movement) testing, this method tests an athlete with movement through a foursquare grid with heart rate elevated. A baseline preseason evaluation is recommended, followed if necessary by a post-concussion evaluation. Physicians can use the data as an objective part of their overall concussion assessment and return to play planning.

I’ve had a chance to speak with Lee Miller and Pete Laikos of PEG. The company’s in the very early stages of their service rollout and at this point one of their main goals is to increase awareness of movement based methods in the overall concussion evaluation toolkit. They are working with a number of physicians in Ohio, including the world-renowned Cleveland Clinic to produce some data on effectiveness. They have currently unpublished data on about 1500 kids and also have another pilot study starting up. The company currently markets the service in northeast Ohio and plans a broader rollout after further validation.

If a young athlete is suspected of having a concussion, the company uses the most recent Zurich protocol, which calls for a slow return to activity once the athlete is completely symptom free. In the earliest phase the company would use their computerized balance-only assessment and compare it to the baseline. As the athlete progresses through the Zurich protocol they can then participate in the movement based testing.

My thoughts are that this is a technology worth watching. Movement based testing is interesting, as it does tend to recreate game situations, and even the balance testing is done in a highly objective fashion.  The testing itself looks fun and my guess is that kids will actually give their best effort in the preseason testing. Additionally, our current return to play protocols include gradual resumption of activity, ranging initially from very light activity and increasing to full practice activity over a minimum of 5 days. The PEG movement technology could be used on about day 3 of the post concussion protocol and may be able to help predict ability to advance further. It will be very important to see the data they produce in the next phase of their scientific study to validate this point. This company is in the early phase of some reasonably uncharted territory, but has the potential to be a valuable tool if they can prove the validity of their method.



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Science Or Magic After Injury?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Stick with scientifically proven methods to get you back as quickly as possible after an injury, avoid experimental treatments
  • Always start with the correct diagnosis. This can be done through a Certified Athletic Trainer or a physician
  • Physical therapists can use manual therapy, ultrasound, electrical stim, and exercise therapy to help you recover

Aaron Rodgers made numerous references in his news conferences over the past two weeks to suggestions made by well-meaning Packers fans to speed his recovery from a calf injury. A brief description can be found in this New York Times article. Unfortunately for him and for the Packers, it did appear that the calf issue hampered his mobility especially in the second half yesterday. Maybe he could have tried an injection of horse placenta??? I don’t think so. therapy-ultrasound

If you’re a young injured athlete with an important event coming up soon, and you want to recover as quickly as possible what’s the best way to do this? You want to stick with proven and safe methods performed by skilled professionals. Here are some basic steps:

  1. Get the right diagnosis. If you’re at a high school or club with access to a Certified Athletic Trainer (ATC) then that’s where you start. An ATC can assess your injury and come up with a reasonable plan to return you to play. For more significant injuries you may be referred to a sports medicine physician, or if you don’t have an ATC I’d recommend you go to the physician. The diagnosis will guide every decision. Some injuries are mild and will allow return to play in a short time and others may need extensive rehab or even surgery.
  2. Get treatment from a skilled professional. Again, the ATC is an excellent resource if you have access, otherwise I strongly recommend a sports-focused physical therapist. A physical therapist knows when to push you and perhaps more importantly, when to back off. Here are the types of scientifically based treatments you can expect to receive:
  3. Manual Therapy Used for almost any type of injury. This hands-on approach separates physical therapists from other health practitioners. Although manual therapy may refer to many things, therapists usually employ common tactics like stretching, massage, and hands-on strengthening exercises to reeducate the body into proper movement and mechanics.
  4. Ice Especially useful for joint injuries. Ice can be a major component of injury treatment. By constricting blood vessels after application, ice is an effective way to reduce and even prevent inflammation immediately following an injury, potentially speeding recovery.
  5. Ultrasound Useful for muscle strains and other connective tissue injury. Ultrasound is essentially a way to apply heat. By using sound waves (undetectable to the human ear) to generate heat deep in the body, ultrasound can help loosen up tissues in preparation for manual therapy or exercise. The therapist applies ultrasound using a wand, and you’ll feel the heat deep within the tissue.
  6. Electrical Stimulation Excellent for maintaining and restoring muscle strength. Electrical stimulation, also referred to as ESTIM, is a common treatment option to restore muscular function following an injury. By applying a minor but steady electrical stimulus through pads placed on the skin, therapists can cause contractions from muscles that may otherwise remain dormant. I especially like ESTIM for maintaining muscle strength around a joint injury, but without stressing the joint.
  7. Partial Weight Bearing Running Outstanding way to keep running and maintain fitness for some lower extremity injuries. A truly outstanding tool is the AlterG Antigravity Treadmill, which provides precise body weight unloading while still allowing the athlete to run. The loads on the leg are reduced but the running mechanics are maintained. You can do running in a pool but the mechanics are different. The AlterG treadmill is available at many physical therapy facilities around the country.



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Returning To Sports After ACL Surgery

By Geoffrey Abrams, M.D.

Assistant Professor of Orthopedic Surgery, Stanford University

And Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Most surgeons will like to see at least 90% strength in the operated knee and 100% motion compared to the normal knee before allowing a return to sports
  • We often use “functional testing” such as hops or 3-D motion analysis to provide more data on readiness
  • High school aged athletes will typically take at least 9 months after surgery before they are successfully able to pass all the tests and return to cutting, pivoting, or power based sports

Last week we wrote about the timing of ACL surgery for high school age athletes, and in the post one of us (Dr. Mishra) stated that he hasn’t seen a high school age athlete be truly ready to return successfully to sports participation until at least 9 months after surgery. That statement was based on his experience gained performing more than 3000 ACL reconstructions in athletes over a 20 year period, and carefully evaluating those athletes along with their physical therapist, rather than through scientific study. ACL hop test

In an effort to evaluate the science behind return to play decisions, Dr. Abrams wrote a paper on the topic in the Orthopaedic Journal of Sports Medicine. You can access the full text of the paper here.

One of the main reasons we wait until the knee is truly ready for return to sports is to protect the new ACL from a retear. There is huge variability in published medical studies about retear rates after ACL reconstruction, with a range from 3% to about 49%. Such a wide range may be due to the fact that little agreement exists on criteria for return to sports.

Generally speaking, we look at knee range of motion, strength, and movement based tests (also known as “functional testing”) when attempting to judge an athlete’s readiness for return to sport. Other factors to consider are the demands of the sport, the playing level of the athlete, and even the young athlete’s own assessment of their readiness. We will typically ask the physical therapist to assess motion and strength (quadriceps, hamstrings, hip rotators) and compare the operated knee to the opposite normal knee. Most surgeons like to see the operated leg at 90% or more strength and 100% motion before they will allow a return to sports.

Recently there is more emphasis on movement-based tests, since these tests might be better at assessing the types of movements the knee will face during sports activity. A variety of hop tests are the most commonly used type of functional exams used to determine readiness for return to play, and more sophisticated testing with 3-D motion analysis is occasionally used. Regardless of the type of functional test used, we have found that these tests are an important part of determining the athlete’s ability to safely and effectively return to sports.

When we put all the factors together we’ll almost always see a 9 month or longer timeframe for the high school aged athlete to pass all of the tests and return to cutting, pivoting, or power based sports.

Why is it that we frequently hear of professional athletes returning to their sport at 6 months, or even as soon as 4 months after surgery? There are many factors involved here. A professional athlete’s job is to get themselves ready to play after surgery, and they literally are able to access help 24/7 through trainers, therapists, and other professionals. Additionally, their bodies are more mature than the high school athlete’s body, which often makes it possible for the professional athletes to push themselves harder in rehab.

If you’re a high school athlete, you’ll be going to class, studying after school, and you may even want a social life J. You’ll work really hard on your rehab, and when you pass your tests for knee motion, strength, and function you’ve got a great chance to return successfully to your sport. Just count on that taking at least 9 months.







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