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

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

Shin Splints or Stress Fracture?

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

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

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

Causes: Too Much, Too Soon Combined With Mechanical Factors

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

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

What To Do

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

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

Happy running!



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Predictors Of Elite Performance In Endurance Athletes?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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

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

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

Posted in CaptainU, Football, Parents | 1 Comment

We Need To Rethink Tackle Football For The Youngest Players

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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



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

The One Predictor Of Elite Level Performance In Football Is…

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Power. In multiple scientific studies, power is the one measureable predictor of elite level performance in football, rugby, soccer, and several other sports. Measured power is consistently higher for elite athletes compared to non-elite athletes in the same sport.
  • Power is essentially a combination of strength generated in the shortest amount of time, resulting in what might be called “explosiveness”
  • You can train power very effectively but with some cautions for the young, growing athlete

The NFL draft is taking place this week, with no other sport devoting so much money, time, and effort into trying to predict who will become the next superstar player.  Players take personality profiles, their backgrounds are dissected, endless interviews are conducted, and there is the famous NFL Combine where players are tested in 8 key physical tasks.  The purpose of all of that is to try and predict which player will help his team win and produce the greatest return for all of that money and effort.  Many scientific studies have been performed to attempt to figure out whether any measureable predictor plyo trainingof success exists. It turns out that one physical measurement stands out above all the others as the best predictor of elite level performance in so-called “anaerobic field and court sports”: power.

“Power” is defined as the amount of work done per unit of time, and it is measured in Watts.  A number of commercially available testing devices can measure lower extremity and upper extremity power, in a number of different sport specific tasks.  Power measurement is fairly accurate and repeatable, making it a very good tool to study athletes, along with other measurements such as 40-yard-sprint, vertical jump, and body size measurements.

The interesting thing about training for power is that it encompasses many different components of performance.  Weight training, sprinting, jumping, and agility are all components of proper power training. So in some respects training for power is the best way to make use of your own time and effort during training.

How do you train for power?  Most athletic trainers and strength/conditioning specialists point to plyometric training as the most effective way to train for power, although all trainers recommend that you begin with fundamental training in strength for several weeks before moving on to power training.  Plyometric training involves jumping and agility drills, such as box jumps, single leg hops, bounding jumps, etc. For example, a young athlete might spend 6-8 weeks on foundational strength training for key muscle groups in a properly supervised program emphasizing squats, walking lunges, multi-angle lunges, deadlifts, etc. Once the foundation of strength is created then the athlete moves on to explosive movement such as plyometric training.

Caution For The Young Athlete

Almost all of the scientific studies and training protocols are made for adults. Some cautions are needed for young athletes with growing bodies starting a power program.

  •  If you’re new to these exercises you absolutely must start with supervision from a trainer with skill and experience working with young athletes
  • Don’t start a plyometric program if you have any pre-existing joint pain, such as Osgood-Schlatter in the knee or Sever’s in the heel. Stop the training if you develop any joint pain during training.
  • If done correctly, strength and plyometric training can be safe and effective for young athletes

There are many, many factors that go in to “performance”, some of which are really impossible to predict.  But one physical factor under your control is power.  Train properly for power and you might just end up as the next Peyton Manning and not the next Ryan Leaf.



Posted in Football, Hockey, Soccer, Sports Science, Training | Leave a comment

Everything You Know About Fitness Is Wrong. Radio CaptainU Interviews Author Daniel Duane.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Men’s Journal author Daniel Duane provides an interesting and provocative commentary on “getting fit”, you can listen to the CaptainU podcast below. Some of his points are:
  • The gym is your enemy- best to work with free weights on the periphery of the gym and avoid the various machines highlighted in the middle
  • Five key lifting activities will provide the greatest return for your effort: squat, deadlift, pushup, pullup, bench press
  • You can lift and train far less often than you think, as long as you are smart about using the key lifts. 3 days a week, 45 to 60 minutes.
  • No matter the sport, ignore strength at your own peril
  • Once you start and continue with this type of training you’ll develop the freedom to train yourself for life

Daniel Duane wrote an outstanding article for Men’s Journal in 2010 highlighting his journey through the world of fitness and personal training. I highly recommend you listen to the podcast from CaptainU below, and for additional background read the original article from Men’s Journal.  The podcast is specifically focused on gaining muscle strength and in the article he covers other aspects of fitness.

One key aspect I’d like to point out for our young athletes that we’ve written about before: the young athlete must have proper form from the start in order to minimize the chances of injury to growing bones and joints.  While Mr. Duane believes a good personal trainer can be invaluable in teaching proper form, he also acknowledges that these really good trainers are hard to find. My best advice to you is to ask around in your youth sports community about excellent trainers, then do your research on specific qualifications and experience working with young athletes.  Enjoy the podcast!

Posted in CaptainU, Training | Leave a comment

Soccer Injury Prevention Programs Work. Do These Now To Get Ready For Fall Soccer.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A Belgian study of soccer players provides convincing evidence that all soccer related injuries can be reduced with a comprehensive strategy
  • Using a preventive training program such as FIFA 11+ or PEP program is important
  • Other factors such as postponing/rescheduling matches in poor weather conditions is also important
  • Injuries remain common and all coaches should have basic injury recognition training

For some reason we continue to debate the effectiveness of comprehensive injury reduction strategies in sports.  I say “for some reason” because common sense indicates that these strategies should work but still we search for proper scientifically based evidence of effectiveness.  A Belgian study published recently in the American Journal of Sports Medicine shows that a strategy employing the FIFA 11+ program, combined with awareness of referees to cancel matches in poor weather conditions lead to a conclusive reduction in all musculoskeletal injuries over a 10 year period. Screen Shot 2014-04-26 at 10.52.59 AM

In this study, the authors performed an extensive analysis of the Belgian national database of soccer related injuries in the 1999-2000 seasons and in the 2009-2010 seasons.  In the interim 10 years the Belgian soccer federation made mandatory the use of the FIFA 11+ training program and instructed referees to have a lower threshold of canceling games in poor weather conditions.

These measures led to a significant reduction of soccer-related injuries. Several interesting findings came from the study, such as the substantially higher rate of injuries earlier in the season; recreational players have a higher injury rate than professional players; and that the proportion of severe injuries was higher for female players and male youth players.

Steps We Can Take To Improve Injury Rates Further

The fact that injury rates are higher early in the season leads to the natural conclusion that preseason training improvements can further reduce the early season injury rates.  However, the added intensity of early season training (fighting for a place on the team, or for a spot in the first team) may create a unique situation.  But again common sense indicates that better preseason training can only help.  If you assume it will take about 12 weeks of good training for meaningful improvements you should start now to get ready for August tournaments. You can access the FIFA 11+ or the Santa Monica PEP program.

Awareness of weather conditions and canceling games is another important point.  In Belgium they focused on ice/snow conditions but in the U.S. the area I think we can pay better attention to is heat and humidity.  A combination of high temperature and high humidity, often found in many parts of the country in August are a setup for heat illness.

Finally, the authors noted that there were multiple factors leading to the higher severe injury rates for women and girls. One area they identified was that the female players did not have access to the same quality of medical support, often leading to delayed diagnosis of injury. We can make an impact in this area now by making sure the observers on the field – the coaches – are properly trained in basic injury recognition. You can learn these principles from our downloadable pdf and mp3 audio programs.

The debate is over. It’s time for all of us to recognize that a comprehensive set of training, management, and injury recognition can go a long way to improving the health of our players.



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

What To Do When You’re Injured: Introducing You To CaptainU

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopaedic Surgery, Stanford University

This month we’ll be starting collaboration with a great company called CaptainU. We’ll feature CaptainU podcasts periodically, on fitness and performance issues of importance to young athletes. I think you’ll find these podcasts relevant, interesting, and occasionally controversial- which makes for great listening!CaptainULogo

First, a few words about CaptainU.  This is a great service principally targeted at connecting young athletes seeking to play their sport in college, their parents, and college coaches.  Together CaptainU has built a substantial community of about 500,000 members. By way of a disclaimer neither Sideline Sports Doc nor I have any financial relationship with CaptainU but our family believed strongly in what the CaptainU service can do so we paid for CaptainU subscriptions for our sons when they were going through their college selection process.  We found the service extremely helpful for researching and communicating effectively with coaches, and their advice for the process of college recruiting was absolutely correct.  As a young athlete if you market yourself correctly to the best-fit colleges your chances of gaining a spot on a college team are actually quite good. Not only is their method effective but it’s actually fun! Their “Make The Team” eBook is available for free download from our website.

Several months back, CaptainU started a blog and series of podcasts delivering information on a variety of sports related topics relevant to high school aged athletes. I’ve had an opportunity to be on their show a couple of times now and as we get our work with CaptainU kick-started I’d like to feature a podcast I did with them titled: “What To Do When You’re Injured”.  You can access it here:

The podcast lasts about 30 minutes- perfect length for a drive to and from practice, or plugging in during a training run.  Here are some of the key points that we cover in detail:

  • Prevention starts with appropriate preseason conditioning
  • End of season injuries are common simply because the athlete has been exposed to more training and games, which makes a body vulnerable to injury
  • In-season injuries that are evaluated and treated properly by a trainer, physical therapist, or sports medicine physician can often be effectively treated at the same time the athlete can remain playing.
  • If you just can’t perform in the way you must to be effective in your sport because of a lingering injury you need to seek some help.
  • “Pain” is not normal for a young athlete. Almost all young athletes are capable of making a difference between “pain” and “soreness”. If you think you have pain, get help and get on the path to healing.
  • Communication with the coach also needs to start in the preseason, noting that the health of the athlete is critical to the team’s overall success.
  • An athlete should use the athletic trainer for school sports and their parents for club sports as an intermediary when it’s necessary to discuss an injury.  A clear line of communication with the coach is important, and timing of the discussion is important too (never right after a game!).
  • If you do have to take time off from your sport to rehab an injury you can almost always come back stronger and better than you were before.
Posted in CaptainU, Tips and Training | Leave a comment

Tiger’s Back: Could It Happen To A Young Athlete?

tiger's backBy Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopaedic Surgery, Stanford University

The Master’s Golf Tournament has a bit of a hollow feeling this year.  As I write this post it’s Saturday morning and the third round has yet to get underway, with no Tiger, no Phil, no Dustin…and about 20 other “big name” golfers also out of the picture.  For several of those golfers a balky back has led to decreases in performance, and in Tiger’s case it’s required surgery. For the young athletes we focus on, when is back pain something to really pay attention to, and could a serious injury requiring surgery happen in a young athlete?

Is it a “sore back” or is it “back pain”?

Many young athletes will have an occasional sore back as part of the normal process with a sport.  This is especially common in sports requiring twisting or torsion on the back such as gymnastics, golf, tennis, and lacrosse. In general, a sore back will involve mild to moderate discomfort and will tend to be located along the large strap muscles in the low or midback.  Soreness will generally resolve with simple treatment such as ice/heat, rest for a few days, and perhaps some anti-inflammatory medication such as Advil.

Red Flags that signal a possible serious injury

There are a few things to be on the lookout for that could signal that the problem is something more significant than simple muscle soreness.  Watch for these things and seek evaluation and treatment from a sports medicine physician soon:

  • Did the pain start with an injury associated with a “pop” or sudden sharp pain?  This could be a sign of a stress fracture, or rarely a disc injury.
  • Is it “pain” or “soreness”?  This is a tough call, as each of us will have a slightly different personal definition of “pain”.  But in my experience a young athlete definitely knows when something is “painful” vs. “sore”.  If the complaint is about “pain”, seek evaluation urgently.
  • Any numbness or tingling going down the legs or buttock?  This could be an injury to a disc or to the bone causing nerve irritation.  Proper early evaluation and treatment is important.
  • And if it’s soreness that’s lasted more than about 2 weeks, you’d be wise to seek proper evaluation.  In my medical practice this is a common reason for young athletes to seek care.  Back soreness that lasts more than about 2 weeks is uncommon and often means there’s an underlying cause.  I have seen a big jump in the number of young athletes with this scenario, and oftentimes we find that they have a condition called a “stress reaction” or even a “stress fracture” in one of the lower back vertebrae.  This condition can lead to a lifetime of low back problems if not treated, but can usually be fully rehabilitated without long-term consequences if treated properly.

With some sports it’s impossible to completely eliminate the stresses placed on the spine. If you have any of the “red flag” conditions I’ve outlined above then you should get some help from a sports medicine physician.  Any golfer would love to play like Tiger or Phil at their prime, but I don’t think any of us want their backs.





Posted in Back, In the News, Sideline Sports Doc Miscellaneous | Leave a comment