Hiding From Concussions

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recently published article in the American Journal of Sports Medicine showed that a large number of college athletes indicated that they had not reported prior concussions to trainers or coaches
  • Reasons for non-reporting essentially fell into two categories: player did not want to be removed from competition, or the player did not think that their injury was a concussion
  • Men were more likely to resist disclosing a concussion than women
  • The study points to the need for continuing education of players and coaches about the need to recognize and disclose a possible concussion
  • My suspicion is that similar trends occur in the younger age groups. Peer pressure and desire to continue playing are powerful forces.

We’ve known for as long as people have played sports that athletes will either not disclose girls soccer headeran injury, or that they would play through an injury. For some injuries this probably isn’t a big deal, but for other injuries continued play would be a real risk for making the injury worse or possibly having a second injury resulting in permanent damage. For concussions, repeated injury can be disastrous. So it’s in our best interest as parents, coaches, and players to do everything we can to encourage players to disclose possible concussions and stop hiding from them.

This study is interesting as it looks at reasons for not disclosing concussions, and it attempts to get an estimate of how often athletes do not disclose possible concussions. It is a retrospective (meaning backward-looking) study of former collegiate athletes at a major D1 university, so its direct application to youth sports might be limited. Still, I know with certainty that young athletes will also try to hide from concussions so there are points we can take away from this study.

About one-third of the surveyed athletes indicated that they had not reported at least one concussion during their collegiate playing career. Two-thirds of the football players indicated that they had not disclosed at least one possible concussion. On the women’s side 85% indicated that they had disclosed all possible concussions, although interestingly in women’s soccer the full disclosure happened only 58% of the time (this university is a perennial nationally ranked powerhouse in women’s soccer).

The motivations for non-reporting are not surprising. The most commonly reported motivations included the following: did not want to leave the game/ practice (78.9%), did not want to let the team down (71.8%), did not know it was a concussion (70.4%), and did not think it was serious enough (70.4%).

In collegiate sports, the pressure to continue playing can be powerful. Some athletes could be in line for professional sports careers, many athletes could feel pressure from teammates, coaches, and fans. These athletes will want to stay in competition, a factor that sometimes will override their knowledge of concussion as a serious injury. As clinicians or parents we need to acknowledge these forces and work with athletes to reduce fears surrounding concussion disclosure.

For the younger athletes, psychological motivations can be equally powerful although they may be dictated more from peer pressure than other sources. What we can do is be their eyes and ears. Coaches are incredibly influential in this area. A coach properly trained in concussion recognition can be a huge help in reducing the chances for another concussion, and the coach can model effective behavior that’s in the best interest of the athlete. Parents and teammates are other major influences for young athletes. Let’s all be smarter about concussions and help the young athlete to do the right thing.

Posted in Coaches, Concussions, Parents | Leave a comment

Ivy League Bans Tackling At Football Practices: A Sign Of Things To Come?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The Ivy League took the extraordinary step to ban all player-to-player tacking at football practices. The news was reported this week by the New York Times
  • The ban is designed to reduce the risk of concussion, other head injury, and other contact related injury to the neck
  • On field performance at Dartmouth, whose coach Buddy Teevens instituted the ban himself in 2010, actually improved as in-game tackling improved and the team won the league last year
  • My opinion: if the Ivy League collects data going forward that conclusively proves a reduction in injury then this trend will spread

In medical epidemiology, the term “exposure” can be broadly applied to any factor that OLYMPUS DIGITAL CAMERAmay be associated with an outcome of interest. When we are discussing concussion risk, or risk of injuries to the neck and head, “exposure” essentially means how many times you could possibly be hit in the head. The thinking here is very simple: reduce the number of player-to-player tackles, and you reduce the risk of possible injury to the brain, head, and neck.

We’ve seen limitations in player contact during practices and games at the youth level, but this is the first time that it has really been undertaken at the collegiate level. If the Ivy League is able to prove over the next few years that they actually have a reduction in injuries with this new policy, I believe that policies like it could spread certainly to the high school level and possibly to other collegiate leagues as well.

There will be plenty of detractors for sure. The naysayers will state that tackling is an essential part of football and if you’re not teaching tackling during collegiate practices you’ll end up with poor tackling during games, and possibly even increase injury risk during games. There is some merit to this argument, but note that the Ivy League is not stopping tackling practice they are simply stopping player to player tackling during practice. In the New York Times article you’ll see that the Dartmouth football team uses a mobile tackling simulator to improve tackling technique for their players. (very cool video- have a look!)

For this policy to gain broader acceptance outside of the Ivy League, the league will need to do a few things over the next few years. First and foremost they will need to produce before and after data showing an actual reduction in injuries. Even though this policy makes inherent sense, that type of cause and effect data will be required if it is to gain broader acceptance. And secondly, the coaches of the teams themselves will need to be convinced that performance during games has not suffered as a result of this change in practice technique.

I have a strong feeling that these points will be proven correct. In the end fewer injuries means healthier players, and healthier players means that they stay in the game longer. And that can only be beneficial for all fans of the game.


Posted in Back, Coaches, Concussions, Football | Leave a comment

Reduce Parent-Coach Misunderstanding With The Preseason Talk

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • It???s very important to have a discussion with parents prior to the club season to establish a decision process for dealing with on-field injuries
  • A good preseason discussion will reduce in season misunderstandings and stress especially around return to play protocols

It???s impossible to get through medical school without using memory aids such as mnemonics or acronyms. One mnemonic I find especially useful is ??5 P???s?? which translates to ??proper preparation prevents poor performance??. It highlights the usefulness of preparation in preventing bad outcomes. Youth sport coaches prepare for practices and games every day, and I???d like to appeal to you to prepare your team???s parents for in-season injury management with a preseason talk.??coach and parent meeting

A preseason get-together between the parents and coaching staff is common in many sports and typically used to give the parents information about contact numbers, practice and game policies, equipment, etc. ??Back in the day?? this took place in person but is now frequently done with a lengthy email. Regardless of the delivery method, this is an excellent time to also educate the parents about the coach???s attitude and policy towards injury recognition and management. But in my experience few coaches actually discuss injuries. Discussing certain aspects of injury recognition and return to play in the preseason can go a very long way to reducing misunderstanding and stress during the season.

The single biggest area where differences occur is in return to play after concussion. Here???s a common scenario: a young athlete is suspected by the coach of having a possible concussion. She is removed from play, the parents are notified, and the parents take her to her local pediatrician for evaluation. The pediatrician does an exam, determines that the athlete has no current signs of a concussion, and clears her to return to immediate play. This might sound reasonable to most of you but there are a few problems.

The parents and the pediatrician were probably well intentioned, but poorly informed. In this case the player would have been better served by visiting a physician skilled in sport concussion management. Many pediatricians are skilled in sport concussion management but most are not. In this case the issue was that the pediatrician was unaware of gradual return to sport protocols and released the player to full activity too soon. If the parents insist that their daughter was cleared for immediate play, but the well-informed coach knew there should be a gradual return to play it can create a lot of friction between the parents, player, and coach.

If the coach lays the groundwork for this scenario during the preseason it will reduce the chance of misunderstanding later on.

As a coach, you can play a key role in safe return from injury, improving performance, and responding properly to injuries when they occur. Here are some steps you can take in the preseason to ensure the best outcome for your athletes and the team:

  • Educate athletes and parents about injury recovery, especially concussion, during the preseason. Talk with athletes and their parents about the dangers and potential long-term consequences of proper return to play.
  • Recommend to the parents that physicians with specific training in sport concussion are the best evaluators after a suspected concussion.
  • Insist that the player follow a gradual return to play (minimum 5 days) after concussion, and ask the parents to present a written clearance note from the doctor. Let the parents know in the preseason that you???ll require this.
  • Ask the parents to provide written notes from the doctor for any serious injuries in which there was an extended period of time away from play, such as recovery from fractures or surgery.

Injuries are going to happen. Let???s make sure we have the right education for the coaches and the processes in place to deal with the issues properly. Have the key discussions before the start of the season.

Posted in Coaches, Parents, Prevention | Leave a comment

Foot and Ankle Injuries in Ballet

By Adam Bitterman DO and Simon Lee, MD

Rush University Medical Center

Foot and Ankle Section

Department of Orthopaedic Surgery

Foot and ankle injuries are extremely common amongst those participating in dance activities. Those impacting the lower extremity account for roughly 65-80% of all dancer injuries.. Currently, it is estimated that organized ballet dancing begins when children are as young as 6 to 8 in age and its popularity is increasing. As the demands of the dancing community increase so too does the evolution of the field of dance medicine.??ballet

Ballet dancers are prone to a wide spectrum of injuries to the lower extremity including soft tissue irritation and inflammation, stress fractures, osteoarthritis, sprains, impingement syndrome and acute fractures. At the professional level, injuries are noted to vary based on rank, gender, role, and experience level. This is in contrast to the amateur class where inexperience and inappropriate training may play a greater role in injury prevalence. One must keep in mind that male dancers and female dancers perform different maneuvers and act in different roles during a performance. Therefore, each has an elevated risk of certain injuries. Additionally, in the published medical literature, conflict still persists regarding age and injury; no general consensus exists regarding those injury characteristics of the older participant versus the younger dancer.

Whether participating in a purely recreational or competitive environment, these injuries are generally a result of overuse impact on the hard floors as well as sudden changes and bursts of activity. Participants in dancing activities usually begin preparing for such competitions and recitals at an early age and over time their training may increase in frequency and amplitude leaving them prone to both acute and chronic injuries. Other contributing factors include the extreme positioning that these dancers must endure. A classic example is the ??en pointe?? position, which leads to additional stress of the dancer???s body weight on the tips of the toes as well as the ankle. Also playing a role in a dancer???s injury pattern is their shoewear, or lack thereof. The usual ballet en pointe slipper may be broken in easily and lose its supportive nature rather quickly, which can contribute to injury.

Acute injuries most commonly affecting the ballet dancer???s lower extremity are ankle sprains. These ligamentous injuries are a result of the ankle being positioned in such a way that there is less inherent stability of the boney articulation; thus leading to more stress being incurred by these structures. Whether a partial tear or complete rupture, ankle sprains may cause the athlete to have immediate pain and difficulty bearing weight on the affected leg. Supportive treatment for these injuries includes resting the leg but also a focused exercise program to increase the strength of the supporting musculature. Compressive adjuvants may assist in providing additional support. Other acute injuries include fractures of the ankle or metatarsal bones, particularly the fifth metatarsal. These injuries may require surgical intervention and a period of rest to allow for more predictable healing and earlier return to dance.

Chronic injuries in the ballet dancer generally involve boney changes over time and pathology within the tendons traversing the ankle and feet. These injuries will obviously become more prevalent in dancers who have histories of more intense and longer periods of participation during their careers. In these athletes, impingement between the bones of the ankle joint can occur in the front as well as in the back. In order for dancers to achieve the en pointe position, they must maintain a hyperplantarflexed position of their foot lending to the boney pathology and pain in the back of the ankle. The great toe is also an area for concern amongst dancing injuries. Participants may develop bunions over time or degenerative arthritis and a stiff first toe. Additionally, they may complain of pinpoint tenderness underneath the great toe where the sesamoid bones articulate with the longer foot bones. Metatarsalgia may result from altered mechanics of the joints of the ball of the foot or an abnormal landing, or simply chronic repetitive overuse, which results in additional stresses in the area, which manifests as pain along the ball of the foot. Other complaints to the undersurface (plantar aspect) of the foot may include plantar fasciitis, which is an inflammation of the supporting tissue traversing the bottom of the foot to the heel bone. Tendinitis, also known as inflammation of the tendon, may affect the many tendinous structures that exist within the lower extremity. In particular, the Achilles tendon, the largest tendon in the body, may become irritated over time and lead to calf pain or weakness while attempting to perform certain maneuvers. Another commonly affected tendon is the flexor tendon to the big toe. This may result from a slight tearing or a diseased tendon, which manifests clinically as pain, weakness, and possibly locking of the toe.

Treatment of these injuries is generally conservative as surgical treatment may lead to changes in overall performance, prolonged recovery time and even risk early retirement from dancing. When determining a return to performance protocol, it is imperative that the dancing athlete has a good understanding of the risk of recurrence. After all, these injuries place dancers at risk for altering their performance or even shortening one???s career.

When evaluating for injury prevention it is often helpful to differentiate risk factors as intrinsic versus extrinsic factors. Intrinsic factors would be those that are inherent to each individual such as their anatomy, any prior injuries, or contributing medical issues. Extrinsic factors would be those such as the dance surface, training regimen and schedule for example. Being able to compartmentalize injury causality into intrinsic and extrinsic factors allows for better risk identification, stratification and ultimately treatment. Unfortunately, it is less feasible to change the floor material as opposed to ensuring appropriate stretching, strengthening and transitioning from low amplitude work to high intensity training. Having a good understanding of the modifiable risk factors will ultimately lead to safer participation in ballet.

Overall, it is important to treat dancing injuries aggressively in order to maintain essential foot and ankle motion and limit future disability. Understanding the mechanics of dance will lead to better identification, treatment and outcomes of many ballet related injuries.


Posted in Ankle, Dance, Foot | 1 Comment

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

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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

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





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

The Future Of Sports: The Young Athlete

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

The Athlete

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

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

Sponsorship and Advertising

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

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

eSports and Fantasy Sports

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

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

Extreme and Adventure Sports

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

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

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


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

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

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Brian Cole, M.D.

Professor of Orthopedic Surgery, Midwest Orthopaedics at Rush

Head Team Physician, Chicago Bulls (NBA)


Tal David, M.D.

Synergy Specialists Medical Group, San Diego, CA

Head Team Physician, San Diego Chargers (NFL)


Bert Mandelbaum, M.D.

Kerlan Jobe Institute, Santa Monica, CA

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


Key Points:

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

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

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

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

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

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





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

The Multi-Sport Prescription

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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



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

Data Can Reduce The Emotion Surrounding Concussion Policy

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

What they studied:

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

What they found:

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

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






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Seven Cool New Concussion Technologies That Could Be Game Changers

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  1. Helmetless tackle training, University of New Hampshire.

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

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

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

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

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








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