Keep Moving When You Dance

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Dance classes are very popular amongst adolescent girls, but a recent study shows that only about one third of a typical dance class involves moderate to vigorous physical activity
  • Several organized sports practices as well as dance activity might be improved to encourage larger amounts of movement based activity


You would think that dance equals movement, right?

Many prominent national health and medical associations recommend that children and ballet classadolescents participate in at least 60 minutes of moderate to vigorous physical activity on most days of the week. There are multiple physical and psychological benefits of that type of activity, however, several studies have shown that in general only 42% of children and 8% of adolescents are meeting these guidelines. It’s no secret that starting at the youngest ages we’ve become a much more sedentary society.

The emphasis has shifted away from the schools to provide physical activity, and these days a considerable amount of physical activity among adolescents occurs after school in structured or organized programs such as sports teams or dance lessons. Dance is particularly popular among girls, which means it has the potential to make up the gap in physical activity typically seen in adolescent girls. Dance has many health benefits such as muscle and bone strengthening, increased flexibility, improvements in balance and spatial awareness, and enhanced cognitive functioning.

A recent published study attempts to put some objective data behind the amount of physical activity typically found in dance class. New research shows that over all, the level of physical activity in children’s’ and teenagers’ dance classes is surprisingly low. On average, students spend only about one-third of their class time in moderate to vigorous physical activity.

The study used accelerometers to measure activity. Accelerometers can underestimate actual activity since they measure arm or upper body movement, but still the amount of activity the kids spent actually moving is quite low. In fairness to the dance instructors, their dance classes are usually designed around teaching dance skills and are not the type of dance class found in an aerobics studio. Dance instructors in dance studios are there to promote an art form, which is a great idea.

But the takeaway lesson is that many types of sport or dance activity don’t actually involve a lot of activity. In my experience this is certainly not limited to dance. If you observe many types of organized sports practices you’ll find a lot of kids standing around as instructions are yelled at them, or as drills are done in a sequential one v one design.

As a coach or instructor you’ve got a great opportunity to structure your sessions around more movement, which will usually lead to a better, fitter young athlete. And as parents spend some time observing the sessions and if necessary encourage more vigorous activities.



Posted in Dance, Sports Science | Leave a comment

Exercise For Your Vision Might Save Your Brain

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Published research from the University of Cincinnati shows that visual field training has the potential to significantly reduce concussion rates in college football
  • This very early research needs to be repeated for applicability in youth and high school football as well as other sports, but may have promise


I do hope that someday we’ll have a tighter handle on reducing concussion risk so we won’t have to write about it quite so much, but until then I’ll continue to highlight some developments in science that could benefit young athletes. This week I’d like to focus on an interesting preliminary study from the University of Cincinnati showing that training for improved peripheral vision has the potential to decrease the incidence of concussions in football. W_EagleVisiontraining

Peripheral vision training has become commonplace as a performance enhancement tool for some sports. Training athletes for better peripheral vision reportedly improves a batter’s ability to hit a baseball, a tennis player to return a serve, a quarterback to see receivers, and other sport specific tasks. Fighter pilots and NASA astronauts use peripheral vision training to improve their critical job performance.

Is it possible that improving peripheral vision might somehow allow an athlete to avoid the serious hits that lead to a concussion? Would improved peripheral vision decrease the blind side hits that lead to an unexpected jarring of the head and neck? Researchers working with the University of Cincinnati football team conducted a study to find out.

From 2006 to 2009, the University of Cincinnati football team averaged about nine concussions a year. From 2010 to this most recent season, the team’s average concussion rate has dropped below two a year. Researchers attribute the large decrease in concussions to peripheral vision training for the players using a Dynavision light board on its football players.

The theory behind the improvement is that improved peripheral vision allowed the players to avoid the most vulnerable positions that would typically result in an unexpected impact. By seeing and sensing the impact before it happens the player is in a better position to protect himself from the hit and thus have a chance to avoid a concussion. You can read the study here.

My initial take on this study is that it is promising, especially for collegiate football, it makes sense, and certainly can’t hurt. We will of course need additional research to prove that the vision training caused the decrease in concussions, but this small study is very interesting. It’s also hard to say how applicable the training would be in reducing concussions in sports with different concussion mechanisms, such as soccer where many concussions occur in head to head impact while trying to head the ball. It would also need some data in younger age groups, and cost is likely to be an issue for high schools.

So more research is needed, but visual training is catching on in sports at the youth level, in college and beyond. The hope is that by seeing the field of play in a different light, more athletes will avoid a concussion that takes them out of play.


Posted in Concussions, Football | Leave a comment

Elbow “Tommy John” Surgery: Are You Better Than Before Surgery?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • A common myth is that Tommy John surgery will actually make the elbow better than a “normal” elbow- this is not true
  • But results from surgery on a torn elbow ligament show that about 88% of high school aged athletes can successfully return to pitching
  • Plan on recovery after surgery taking about one year


Last week I wrote about some of the overuse factors that can lead to elbow ulnar collateral ligament injuries in baseball and softball players. This week we’ll dig into some of the myths and facts surrounding the surgery itself. elbow UCL stress test

As more and more professional athletes successfully return to high levels of play after “Tommy John” surgery (properly known as ulnar collateral ligament reconstruction), many young athletes, parents, and coaches have come to recognize that elbow ligament injuries in throwing athletes are not necessarily career ending. As public awareness about Tommy John surgery and its success stories have grown, so too have some myths and misunderstandings about the surgery.

Tommy John surgery will actually make me a better pitcher than before my surgery.

A common myth about Tommy John surgery is that having surgery when the ligament is not completely torn will actually add velocity to a player’s pitches. The fact is that most pitchers with elbow ligament injuries will go through a period of several months where they are losing velocity, control, or endurance long before the surgery. Then, responsible orthopedic surgeons will typically ask the young pitcher to go through several more months of nonsurgical rehab before deciding on surgery. By the time the surgery comes around it may have been 9 or more months since the last time the pitcher pitched pain free and effectively. With surgery we are attempting to get the elbow back to that old level, and with proper body conditioning and mechanics it may be possible to improve on that baseline. The surgery’s goal is to get as close to a normal elbow as possible. It would be wrong to think that the surgery makes the elbow itself better than before the surgery or that operating on a normal elbow can somehow make it even better.

Pitch counts and innings counts are separate in different leagues and don’t cross over or add up.

Wrong! All pitches and innings count as far as the elbow is concerned. The ulnar collateral ligament is typically injured as a result of cumulative damage over time and it really doesn’t care what league you’re pitching in. Staying just under the limit in two leagues in the same week will add up and exceed the overall limit. If an athlete is participating in multiple leagues and playing on multiple teams it is the collective responsibility of the player, parents, and coaches to ensure that the TOTAL pitch or inning count doesn’t exceed the recommended limit.

Having Tommy John surgery means my career is over.

Wrong again. Results from Tommy John surgery are generally very good. For professional athletes having elbow reconstruction surgery the success rate is about 90%, and recent studies have shown success rates of about 88% for high school age pitchers. If you follow the plan and go through proper rehab chances are high that you’ll successfully pitch again.

If I have surgery, I’m out for the year.

Finally, this is mostly true. Recovery from ulnar collateral ligament reconstruction usually takes about 12-16 months before you’re fully back on the mound but occasionally you can be back by about 9 months. If you’re having surgery it’s best to plan on a year for recovery.



Posted in Baseball, Elbow, Softball, Treatment | Leave a comment

Risky Behavior For Baseball And Softball

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Baseball and softball pitchers need to be aware of the burden placed on young shoulders and elbows by playing on multiple concurrent teams, or by overpitching
  • Players would be wise to follow published recommendations for good pitching behavior by Dr. James Andrews and the American Sports Medicine Institute


It’s springtime, which means it’s time for sports medicine physicians and physical therapists to see an uptick in the number of shoulder and elbow injuries in young baseball and softball pitchers. Somehow it seems to me that we haven’t made much of a dent in reducing the numbers of these injuries. My orthopedic practice is just one small data point but the conversations with kids and parents continue yet the injuries keep coming.Grant Lewis

Here’s an illustrative example. I recently saw a promising high school softball player for elbow pain. The concern was for a possible ulnar collateral ligament injury. She informed me that she has a scholarship commitment to pitch at a prominent D1 university, so she is “in”. In spite of that she pushed pedal to the metal before seeing me, pitching concurrently for her high school, club team, and traveling tournament team. Fortunately her story has a happy ending. She had a mild ligament strain that responded well to rehab, and she then cut substantially back on her pitching to focus on total body conditioning. She even enjoys her last few months as a senior in high school.

Our continuing national conversation on youth sports injuries may be most apparent in baseball and softball leagues and organizations across the country – often talk involves increasing pitch counts, overburdened arms and pitchers who are burnt out before even completing their high school playing career.

Until recently we’ve had a limited amount of solid data to back up our general feelings about the burdens of overpitching these young arms. To better grasp how behavior and activities has influenced injury patterns, a group of researchers from the American Orthopaedic Society for Sports Medicine (AOSSM) led a national survey of young players. Some highlights of their research are included below.

Of 754 participating pitchers:

-43.4% pitched on consecutive days

-30.7% pitched on multiple teams with overlapping seasons

-19% pitched multiple games a day during the 12 months prior to the study

These numbers alone are concerning, especially considering they suggest sizeable amounts of young arms are going against recommendations from Dr. James Andrews and the prestigious American Sports Medicine Institute (ASMI).

The study goes on to say that those pitchers reporting these activities had a greater chance of experiencing arm pain related to pitching, leading to an increased risk of injuries. Those with arm pain had 7.5 times greater odds of suffering a pitching-related injury.  The full study was published in the American Journal of Sports Medicine and is available here.

If you’re a parent or coach of a young pitcher please watch out for your young arms. It’s early in the spring for most players; let’s hope they have a successful summer without a trip to the doctor.

Posted in Baseball, Elbow, Shoulder, Softball | Leave a comment

Sunscreen Is The Smart And Simple Choice To Reduce Skin Cancer Risk

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Many types of cancers are strongly associated with repeated exposures to cancer triggers, and the association between sun exposure and some types of skin cancer is strong
  • Sunscreen is a simple and effective way to reduce sun exposure risk
  • Only about 20% of young athletes routinely use sunscreen for daytime outdoor sports
  • Coaches are in an excellent position to positively influence the young athlete’s attitude and use of sunscreen

Veteran soccer referee Randy Vogt wrote an excellent piece in Soccer America’s Youth Soccer Weekly about the importance of sun protection for referees. The article encourages referees to take care of themselves with appropriate protection (hat, sunscreen), which sometimes requires the ref to challenge traditional dogma. I couldn’t agree more. In this week’s post I wanted to examine the issue of skin cancer risk with an eye towards the young player. sunscreen_kid

Sun exposure increases risk of skin cancer in many outdoor sports and young athletes rarely use sunscreen

Ultraviolet (UV) radiation that comes with sun exposure is estimated to be one of the most important risk factors for nonmelanoma and melanoma skin cancers. Athletes practicing outdoor sports receive considerable UV doses because of training and competition schedules with high sun exposure, and in alpine sports, by altitude-related increase of UV radiation and reflection from snow- and ice-covered surfaces.

Young athletes commonly have an indifferent attitude towards sun protection. In several published studies it’s been shown that only about 20% of outdoor sport athletes routinely use proper sunscreen for daytime practices and games. For most of the athletes the reasons cited for lack of sunscreen use were mostly psychological. They simply don’t think about it, they don’t know the association between sun exposure and skin cancer, or they may even be practicing resistance because some parents force sunscreen on to the young kids.

There are some physical reasons for not using sunscreen too, such as complaints that sunscreen combined with facial sweat will sting the eyes, and some sunscreens are “greasy” resulting in decreased grip. These are valid points but the newer generation of sport sunscreens are designed to really minimize these problems.

Repeated “exposures” are key factors in several types of cancers

Our understanding of risk factors for various cancers is advancing rapidly over the past several years. One fundamental concept is that repeated exposures to some toxic substances can lead to cell damage and this in turn can lead to formation of cancers. I don’t want to get overly technical here but for those of you interested I’d encourage you to take a look at this video by Dr. Craig Thompson, CEO of the Memorial Sloan-Kettering Cancer Center in New York. Dr. Thompson explains the process in clear terms but here are some cancers with known links to exposures:

  • Cigarette smoking dramatically increases lung cancer risk
  • Women with exposure to the human papilloma virus are at risk for cervical cancer
  • Obesity and consumption of toxic foods (especially processed sugar) is associated with cancers of the digestive system
  • Sun and ultraviolet radiation increases skin cancer risk

Dr. Thompson states clearly in the Wall Street Journal article that the links between some exposures and cancer is compelling and methods to reduce the risk are fairly simple and withn reach for all of us. He writes:

“Don’t smoke, use sunscreen, avoid unnecessary radiation exposure, get vaccinated. Sometime this decade, it is expected that obesity, driven in large part by excess sugar intake, will surpass tobacco exposure as the No. 1 cause of preventable cancer in the U.S. Already, in terms of population health, we are putting this new scientific knowledge to use.”

Coaches need to set the example for the young athlete

Some of the studies on sunscreen use in young athletes note that the athlete may be practicing a form of resistance towards their parents if the sunscreen is slathered on before practices and required by their parents. It’s hard to know whether that might or might not be true, but one thing is common in most sports: if the coach requires it, it will generally be done. In my opinion the coach is in a great position to positively influence good behavior in young athletes. Use sunscreen yourself and put a large container in your sideline kit for your young athletes. If the sun’s out ask them to use it. It takes virtually no time, there’s nothing to lose and much to gain.





Posted in Prevention, Sports Science | Leave a comment

Skyrocketing Rates Of ACL Surgery In Young Athletes

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • A recent study revealed a 924% increase in ACL surgery performed in the under-15 age group between 1990 and 2007
  • This study along with other data point to the need to do ACL tear prevention training in the youngest age groups



A recently published study in the open source Orthopaedic Journal of Sports Medicine revealed some amazing – and somewhat disturbing – trends in ACL surgery. The authors examined data on ACL surgeries performed in the United States from 1990 to 2007. From the youth sports perspective one of the key findings was an astounding 924% increase in surgeries performed on individuals younger than 15 years old. allograft ACL

This study focused on people who had surgery to reconstruct the ACL, thus it does not give us data on how many people actually sustained ACL tears in any given year but it gives us insight into the trends favoring surgery in the young athlete. The data used is already old, with 8 years elapsed between the end of the data set and now so I suspect the numbers of young athletes opting for ACL surgery has only increased.

There are two possibilities for the huge rise in ACL surgeries amongst young athletes. First, there could be many more ACL tears in young athletes. And second, the number of young athletes with ACL tears electing to have early surgery rather than delaying it into their later teenage or early adult years is also increasing.

Both reasons are plausible and there is evidence to support both mechanisms. We know that overall numbers of adolescents participating in organized sports rose during the study period, and several studies point to an increased number of those athletes sustaining ACL tears. This is particularly true amongst girls. So it is likely that the number of adolescents with ACL tears increased considerably from 1990 to 2007.

Additionally, there is evidence that U.S. based surgeons favor ACL surgery over nonsurgical options for almost all age groups compared to their European colleagues. This type of treatment bias likely contributes to the rise in ACL surgery for young athletes too.

Regardless of the reasons behind the trends I believe it is clear that more adolescents sustain ACL tears nowadays compared to 20 or more years ago. I wrote recently about the need to start ACL protection training as early as possible, and these surgical trends support the same theme: ACL tears are happening more often in young athletes so we need to do whatever we can with training and rules enforcement to give these athletes the best chance to compete with healthy knees for as long as possible.

Posted in Knee, Treatment | Leave a comment

Safe Steps In The Return To Play Decision

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • The coach will often have to make a decision on return to play during competition
  • One tactic would be to observe the player in pregame warmup for any pain or poor movement
  • A second in-game method is to make sure the player is pain-free, has no swelling, and can pass a sideline functional test of jog, cut, sprint, and jump


One of the toughest decisions in youth sports is determining when a player who has suffered an injury is ready to return to action. It’s very easy to get caught up in the moment of competition and perhaps put an injured player back in the game before he or she is really ready. The emphasis on the sideline should always be directed towards athlete or child safety.sideline test balance

Returning to play prematurely can lead to a more serious injury. In my clinical practice over the last 21 years I see one or two kids each week with a significant injury that started out as some kind of minor injury. For whatever reason they kept playing and that minor injury turned into something more significant.

Sometimes it was because they were put back in the game too soon. Sometimes it was because they failed to report it to the coach. Sometimes they played for weeks with a chronic, nagging pain.

If you think a kid’s not really ready, it’s better to sit them – maybe lose them for a few days – rather than to let them get back in before they’re ready and lose them for weeks or months.

Ideally the real decision on return to play is not in the hands of the coach, it is in the hands of a trainer or physician – someone who’s really trained and qualified to make that decision. This would certainly be the case when returning from a serious injury such as a fracture, concussion, or injury that required surgery.

But there are many settings where someone who is professionally qualified isn’t there to make a remove-from-play or return-to-play decision. This is common in competition on the field of play. In that case it’s really going to come down to the coach to make a reasonable decision.

When Players Insist They Are Ready To Play

Players want to play and this means that they will often insist they are ready to play when perhaps they are not. This is where the decision becomes really tough. You really need to be their advocate — to be their voice.

As the kids get older they’re going to have better reasoning abilities. They’re also going to have other motivations to stay in the game – and perhaps not tell you everything.

With kids, you’ll often have to make the tough decision for their own good. What if you’re at an away tournament? What if it’s your star player? What if you have to play a man-down? You still want to err on the side of safety. Here are two simple observational tactics to help you determine safe return to play for in-game situations:

Pregame: watch closely when they don’t think you’re watching

You might have a situation where a player was injured during practice midweek and you’ll have an opportunity to observe them in pregame warmup on the weekend. If you can see them limp, favor one side, or appear in pain with warmup movements those are red flags indicating an injury that may not be healed well enough to allow safe return to play. Your best course of action would be to hold the player from play.

In-game: do a functional test

In many movement based sports you’ll be dealing with injuries to the lower extremities – hip, knee, ankle, foot.

You’ll need to confirm that the player is really pain free. If you can be reasonably confident they are really pain free and have no visible swelling then you’ll need to put them through a functional test. On the sideline ask the player to jog, cut, sprint and jump and observe closely. If they player can do that comfortably and with no visible problems that is a very good indicator of return to play. That’s basically saying if a kid gets back to “normal” – they can play.

In a game situation there are of course many grey areas, decisions are rarely black and white. If you follow the advice above for the functional test you’ll generally be safe, but if you have any doubts don’t take a chance and risk turning the mild injury into something serious. Hold them out and advise them to consult a medical professional.


Posted in Ankle, Hip, Knee, Tips and Training | Leave a comment

Is It OK For A Young Athlete To Play In Pain?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Deciding whether the young athlete is having “discomfort” vs. “pain” is a very individual process as each person’s perception of pain is different
  • Getting the exact diagnosis by consulting a sports physician is advisable
  • Young athletes with minor injuries and discomfort can often continue playing, but caution and individual guidance are important

“What’s the difference between discomfort and pain? And is it ok for me to keep playing if I just have a little bit?” Those are two of the most common questions I’m asked by injured young athletes, and I’m guessing the same is true for our sports medicine colleagues across the country. The answers are different from person to person, and specific to the type of injury too. OLYMPUS DIGITAL CAMERA

In the NFL elite level adult athletes know that there’s risk involved in their sport- their profession. Professional football is a sport where it’s expected that a player will get his body beaten on a weekly basis, and dealing with the pain is part of the game. Medication is sometimes used to get a player through Sunday. I have a very hard time using that approach in a young athlete who has a long lifetime of activity ahead.

There are many factors that go into a decision whether we allow a young athlete to play through some discomfort, whether we recommend that they take time off, or whether we prohibit them from playing. Key amongst the factors is the exact diagnosis of the problem, and some other factors we consider are the athlete’s age, sport, position, time during the season, and importance of the event or competition.

Knowing the exact diagnosis is important

We have to start the decision process with the diagnosis. It’s not enough to just say “knee pain”, we need to be specific. One of the problems I have with certain health practitioners is that decisions about treatment and play are made without a specific diagnosis. See a qualified medical practitioner to get a diagnosis, and then using a combination of the other factors a skilled sports medicine specialist will advise in making a decision that allows for safe sports participation.

Understanding again that individual decisions need to be made between the player, parents, and physician, there are still a few general comments I can make. Many types of tendonitis can be managed with braces during play and ice/stretch/massage after a playing session. Most fractures and stress fractures will require holding the young athlete from play until healing is complete. All hamstring injuries get rehab until healed. Ligament injuries to the knee will generally not allow return to play until fully healed, but some ligament injuries around the ankle can allow play with a brace.

Everyone has a different response to pain

One person’s mild “ache” is another person’s “severe pain”. I usually recommend against playing if the young athlete tells me he or she needs medication like Advil or Motrin in order to play. To me that’s a sign that we need to get that injury properly healed. For many other injuries it is sometimes safe to continue playing, although performance might suffer.

Sometimes it is safe for the young athlete to play through some discomfort, but start with the exact diagnosis from a qualified physician and get the physician’s guidance for timing on return to play.


Posted in Parents, Psychology, Sideline Sports Doc Miscellaneous | Leave a comment

Start Saving The ACL When Kids Are Very Young

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published scientific study attempts to explain why puberty leads to an increased risk in ACL tears for girls and boys but tends to affect girls more
  • An increased Body Mass Index is a risk factor for ACL tear regardless of age or sex
  • The results suggest that ACL tear prevention programs should start before puberty in girls

This blog is focused on providing a sports medicine physician’s perspective on issues affecting youth sports health and participation. Our fundamental belief is that youth sports done right has numerous benefits, which can lead to a lifetime of good health habits. But as an orthopedic surgeon I’m often troubled by the younger ages at which we see some types of injuries, and the younger ages at which surgical care is done for these injuries. Two particularly bothersome areas are ACL tears in the knee and Ulnar Collateral Ligament tears in the elbow. ????????????

Let’s take a look at ACL tears in athletes as young as age nine. A recent publication by Stracciolini and colleagues sheds light on the pediatric ACL problem in very young athletes. Their study shows that boys appear to injure more ACLs before puberty while girls catch up later through their teenage years. The study also shows that higher Body Mass Index (BMI) is associated with a higher risk of ACL tears, regardless of age and sex. Why BMI is independently associated with ACL injury is puzzling. Could it be that the immature neuromuscular system is not yet capable of absorbing the added forces produced by an increased BMI? There are implications for improving the young athlete’s health from each of the points raised in the paper.

First, this study shows that ACL injuries make up a higher proportion of the total number of sports injuries as kids move through puberty. This is especially true for girls and is in line with other studies showing that girls have a higher injury ratio than boys starting at around age 12. In contrast to boys, girls may have greater generalized joint looseness after the onset of puberty, and it seems that the joint looseness is a risk factor for ACL tear. There is also some evidence that changes in the hormones estrogen and progesterone associated with the menstrual cycle are risk factors for girls.

Second, the authors also showed data that supports an association between higher Body Mass Index and the risk of an ACL tear. This risk was present regardless of age and sex. In other words, at any age, if two young athletes are compared and one has a “normal” BMI for age and the other has an elevated BMI, the athlete with the elevated BMI has higher risk for tearing an ACL.

There are many factors involved in the exact process of ACL tears but the authors attempt to tie everything together like this: After the onset of puberty and a rapid growth spurt, there is increased bone length and increased overall body mass. This leads to increased height of the center of mass and decreased core stability. Poor core stability places the ACL at risk.

Wow, that was a lot to digest in a small amount of space. The practical implications are these: puberty results in a significant increased risk for ACL tears in girls, and an increased BMI increases ACL tear risk in boys and girls regardless of age. One strategy for girls would be to introduce school or team ACL injury prevention protocols before puberty. This has the potential to reduce ACL tear risk into puberty and later years. Start saving your ACL as early as possible!



Posted in Knee, Sports Science | Leave a comment

Kneecap Instability: A Troublesome Issue For Girls

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Kneecap instability can be a frustrating source of pain and limited function for the young female athlete
  • A combination of anatomic and sport-specific factors is involved in creating the instability
  • Kneecap instability can often be treated successfully without surgery but surgery may be needed for recurring instability
  • Recovery can be very long, sometimes taking six to 10 weeks without surgery and four to nine months with surgery

The kneecap can be a source of trouble for young athletes, especially girls. There are some features in a growing young girl’s anatomy that place her at risk for kneecap instability. When combined with some sports in which a high amount of twisting torque is involved we have a recipe for problems such as the kneecap partially shifting (“subluxation”) or completely shifting out of place (“dislocation”).A00707F02

In a growing girl there are changes in the shape and length of the pelvis and legs that are normal, such as a widening of the pelvis and an increase in the angle the legs form at the knees. These changes tend to cause an increase in the angle of pull on the kneecap, resulting in the kneecap sitting towards the outside of the knee.

The changes in the angles are normal but when combined with sports that require twisting of the body around the knee, it can create a situation where the normal motion of the kneecap is overwhelmed by the outward pull. The result can be kneecap instability. A classic situation that we start to see in springtime is instability of the right knee in a right-handed softball batter. Other sports where we’ll often see kneecap instability are basketball, soccer, and lacrosse.

What the athlete feels with patellar instability depends on how far out of place the patella has moved and how much damage occurred when it happened.

Some general symptoms the athlete may experience include:

  • Pain, usually in the front of the knee near the kneecap
  • Feeling the kneecap shift or slide out of the groove
  • Feeling the knee buckle or give way
  • Hearing a popping sound when the patella dislocates
  • Swelling
  • A change in the knee’s appearance — the knee may appear misshapen or deformed
  • Apprehension or fear when running or changing direction.

Treatment for kneecap instability has improved substantially over the last 30 to 40 years. Gone are the days of placing the knee in a cast, with total immobilization for perhaps 6 weeks. A recent scientific publication in the journal Sports Health outlines the changes in our treatment process for this common problem.

Nonsurgical treatment usually works for first-time patellar dislocations, but surgical treatment is recommended for first-time dislocations accompanied by cartilage injuries. Nonsurgical rehabilitation takes some time, and six to 10 weeks is common before full sports are allowed. Surgery is sometimes needed to stabilize a kneecap that repeatedly becomes unstable. The surgery can be very successful but the rehabilitation can take quite a long time. I have seen a four to nine month timeline to return fully to sprinting, twisting, and jumping sports after surgery.



Posted in Basketball, Knee, Lacrosse, Soccer, Softball | Leave a comment