Science Or Magic After Injury?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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



Posted in Science, Therapy, Treatment | Leave a comment

Returning To Sports After ACL Surgery

By Geoffrey Abrams, M.D.

Assistant Professor of Orthopedic Surgery, Stanford University

And Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

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

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

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

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

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

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

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

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

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







Posted in Basketball, Football, Hockey, Knee, Skiing, Soccer, Treatment | Leave a comment

Timing Your ACL Surgery

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Young athletes will typically need 9 to 12 months to successfully return to sports. Pick your most important upcoming events and work backwards for at least 9 months. That’s the latest you should have your surgery.
  • The first 2 to 3 weeks after ACL surgery are hard. Try to have surgery during a school break. If you must have surgery when school is in session you’ll probably need to significantly reduce your workload.

I think I really jinxed everyone’s luck last week by writing about ACL tears in skiers because this week I saw a huge number of young skiers with ACL tears, almost all of whom will require ACL surgery. With that in mind I’d like to devote this week’s post to a couple of important issues regarding timing of surgery for the high school athlete, and in next week’s post we’ll discuss issues about returning to your sport. allograft ACL

First of all, you’ll need a really skilled surgeon, and even better than that would be a surgeon who truly understands the needs of the athlete who wishes to return to sports after surgery. If you don’t have a surgeon already, I’d recommend that you check out the physician finder at the American Orthopaedic Society for Sports Medicine.

Key Point #1: It will take at least nine months to successfully return to your sport

This is one of the main sticking points we often have in discussing the timing of surgery with our young patients and their parents. The sports media has gotten us accustomed to professional athletes returning to their sport at six months after surgery and sometimes as early as four months after surgery. We’ll discuss return to sport in more detail next week but for now I’ll give you one very strong statement: in my 20 years of doing ACL surgery I’ve never seen a high school aged athlete successfully come back to a cutting, pivoting, or power based sport in less than 9 months.

The key word there is “successfully”. Sure, some athletes attempt a return to sport at about 6 months, usually against the advice of their physical therapist or surgeon. But invariably something goes wrong. Their sport performance is bad, the knee becomes painful or swollen, or perhaps they have a reinjury to the knee.

The young athlete’s knee requires a minimum of about 9 months after surgery to really be ready to return to sports, and ideally 12 months. Key point #1 then is to look out over your sports horizon, pick the event or season that’s most important for you and go backwards at least 9 months. That is the latest you should have your knee surgery.

Key Point #2: If you have surgery while school is in session you’re going to miss a good amount of school

ACL surgery can be very successful but the first 2 or 3 weeks after surgery are tough. You’ll typically have a cooling unit hooked up to your knee for most of the day, sometimes you’ll also have a machine that moves your knee back and forth called a “CPM”. When you’re attached to these things it’s not particularly easy to haul yourself into your school. Additionally you’ll be on crutches and probably pretty loopy from pain medication.

For most of our high school athletes the ideal thing is to have surgery when you are on a reasonably long break, e.g. winter break, spring break, or summer. If you need to have surgery during school (see Key Point #1 above) then you may want to speak to your teachers and school officials to arrange a reduced schedule for about 3 weeks.

It’s really easy to get into the mode of thinking “I have to have my surgery right now”, but for all high school athletes having ACL surgery I’d strongly encourage you to think about the points above, discuss them carefully with your family, your surgeon, and your school.



Posted in Basketball, Football, Hockey, Knee, Skiing, Soccer, Treatment | Leave a comment

Skiers Must Check Bindings To Reduce Knee Injury Risk

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Lack of binding release is correlated with knee injury in most age groups
  • Bindings must be professionally adjusted at the minimum at the start of the ski season, and more often if you are a high-frequency skier
  • Get yourself in good skiing condition prior to the start of your ski season

In Northern California mountains it is snowing, ski resorts are open for business, and this week we started seeing the first real flow of patients with skiing related injuries in the office. We revisit an important topic today: skiers, check your bindings for proper release to reduce your knee injury risk. warren-miller-fall-2007-film-tour-schedule

Skis, boots, and bindings have changed dramatically over the last 40 years. It was believed that the main injury risk for skiers were fractures of the leg or ankle, and over time the design of skis, boots, and bindings has evolved to significantly reduce the risk of equipment related fractures. But an interesting thing then happened: as the risk of fractures went down the risk of knee ligament injuries went up. ACL tears in particular are estimated to occur in 70,000 skiers per year. There are several factors that lead up to the “why” but I would anecdotally say that in the clinic I do hear some common themes in the injured patient. It was an end of day run with less than ideal conditions, and the patient’s legs were fatigued. And from the equipment standpoint we often hear that the bindings didn’t release.

Like most medical issues, the exact causes for knee injury in skiers is not black and white. For the scientifically inclined amongst you I would recommend you have a look at this excellent review study in the open source Orthopedic Journal of Sports Medicine. You can view the full text here. There are a few nice take-aways from the article. Younger skiers (less than 20 years old) reported that their binding did release at time of injury in 53.7% of the injuries but across all age groups the bindings released in only about 24.6% of all injuries. This study along with several others does not prove that the lack of binding release caused the knee injury but certainly it suggests a correlation. Furthermore, the lack of binding release seems to be more dangerous in some injury mechanisms like the “phantom foot” (happens when the skier falls backwards).

The experience from our orthopedic sports medicine clinic might be a bit different in other parts of the country but at least from what we are seeing I can suggest some simple tactics to reduce your chance of injuries this ski season.

  • Get yourself into good skiing shape! My bias especially for young athletes is to avoid heavy weights and focus on power, core strength, and coordination. Click here for a simple set of exercises that utilizes body weight activities and can be done indoors or out. These are good for all age groups up to adults.
  • Absolutely make sure your bindings are professionally adjusted, for novice skiers at the start of the ski season and for high-frequency skiers at a minimum a monthly check. You might also consider the Knee Binding, a new type of binding that allows for a binding release prior to the theoretic strain point leading to ACL tears.
  • Finally, know your conditions! Resist the temptation to ski in bad snow, especially slush. You’re just asking for trouble.
Posted in Skiing | Leave a comment

Burnout: When The Reasons Aren’t Physical

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Pressure from parents, peers, or coaches can sometimes lead young athletes to quit organized sports due to “burnout”
  • We need to be on the lookout for signs of burnout and seek help early
  • Signs may include lack of enthusiasm for sports, recurring physical ailments, and generally declining sport performance

Last week I wrote about the things a high school athlete should be doing between sports seasons, and this week’s topic is a follow-on to last week’s post. This is admittedly a bit of a “downer” topic, especially since it’s Christmas time and I should probably be writing about something cheery and uplifting. But I couldn’t get over the fact that I saw three promising young athletes who came to my office this week with what could best be described as a general failure to perform. burnout teenager

For sure they came in to the office with specific complaints. In fact they were perfect textbook complaints of the types of symptoms we would expect with some sports injuries. The “history” helps a physician focus thinking on the type of problem and helps to direct the physical exam. And that’s usually where things start going sideways. The exams were nearly normal. The parents of course are concerned; insist that there must be something we are missing. An MRI is ordered, which comes back totally clean.

Invariably, this leads to a somewhat awkward conversation. The good news is that your joint is structurally normal. The unfortunate news is that there are other factors likely contributing to your pain and poor performance. At these times I often have to request a brief private conversation with the young athlete with the parents out of the room. It’s usually then that I hear the underlying factors: the kid feels pressured by their parents, sometimes pressured by their peers, often conflicted about whether they want to keep putting in the time and effort needed to live up to those expectations. This is burnout.

Studies have shown that about 70% of kids quit organized sports by the age of 13. I wouldn’t have too much problem with that if some type of lifetime fitness activity replaced the organized sport, but too often the opposite happens. Inactivity, poor nutrition, a potential for out-of-school trouble, and a general decline in physical health.

Organized sports activity has numerous positive benefits, and in the absence of organized sports some type of regular fitness activity is critical. As parents, coaches, and healthcare practitioners we need to be on the lookout for burnout. If a previously enthusiastic and willing sports participant starts withdrawing, looking for reasons not to attend practice or games, has recurring physical ailments, or generally looks uninterested then it could be a sign of burnout. Of course there could be very legitimate reasons for the problems but the point is that we need to really care about the kid and have the courage to have the tough conversations sometimes. If you have concerns, discuss them with the young athlete and get professional help from your pediatrician or sports medicine specialist.





Posted in Parents, Performance, Psychology | Leave a comment

Fall Sports Are Done: What You Must Do Now

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The time between the end of your fall sport and the start of your spring sport is an important time to do some “maintenance” on your body
  • Take some time off, see a sports medicine specialist if you have nagging issues, and start a conditioning program before spring practices start

There are quite a few high school athletes who have just finished a fall sport and will then group strength traininghave a short time off before practice starts for their spring sport. This is a pretty short amount of down time for the young athlete. And this in turn can lead to an increased risk of injury with possible decrease in sport performance. Ideally, you’d want some time off between sports in which you can do a bit of maintenance work for your body. Here are 3 things I think every young competitive athlete must do in their off-season.

1.You need to take some time off from intense training.

It’s critical for coaches, parents, and players to realize that there needs to be a balance between work and rest. Over training is a huge risk for injury, especially with growing young athletes. You need to be willing to take off at least a few weeks or maybe even a month from intense exercise each year in order to allow your body to rest.

2. See a sports medicine specialist if you have nagging injuries.

Athletes of all ages will commonly put up with injuries towards the end of the season, especially if your team happens to be playing well. If you have ongoing pain or an injury that just hasn’t healed with simple treatment, the off-season is the time to seek specialist care. After a proper diagnosis is made, a plan can be put in place to get you back to peak performance.

3. Start a proper preseason conditioning program prior to your next sport.

Properly designed preseason strength and conditioning programs can dramatically decrease the risk of injuries. “Fitness” needs to begin prior to the 1st day of practice. Many scientific studies have shown that the majority of injuries occur in the 1st few weeks of a sport season, often times due to inadequate preseason preparation. No matter which sport you play it is important to focus on general conditioning and core stability, as well as overall cardiovascular fitness. Cross training during the off-season is especially important if you happen to participate in a predominantly one-sided sport in the spring, such as baseball.

How rapidly can you advance your off-season training? Most sports medicine specialists recommend that young athletes follow a simple 10% rule: don’t increase your weight load, training activity, mileage, or pace by more than 10% each week. This will allow your body an adequate period of time to rest, rebuild and recover after any training session.

Right now it’s snowing, raining, or just downright unpleasant weather in many parts of the country. Use this time to take care of some things you may have neglected during your fall sports season. Do your best on your homework. Help your mom with chores around the house. And take care of your body.


Posted in Performance, Prevention | Leave a comment

Arthroscopic Surgery For FAI In Young Athletes

By Marc Safran, M.D.

Professor of Orthopedic Surgery, Stanford University

And Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • FAI surgery is sometimes necessary to return the athlete to sports participation
  • Results from FAI surgery are generally excellent, with 95% of athletes returning to sport at about 4-6 months after surgery

Last week we wrote about a condition called “femoroacetabular impingement”, commonly referred to as “FAI”. The hip is a ball-and-socket type of joint. FAI is a condition where the femoral head (the ball), acetabulum (the socket), or both do not fit normally in place due to an alteration in the shape of the femoral head or rim of the acetabulum. The result is increased contact (impingement) as the hip is placed through a range of motion. ch1_image_020

Patients with FAI often complain of pain in the groin with sports activity, after prolonged sitting or even with walking. Many athletes often describe pain in the groin with deep flexion or rotation of the hip during activity. Occasionally, a popping or clicking in the front of the hip is described.

We diagnose FAI through a careful evaluation of your description of the pain, an examination of the hip and pelvis, along with an assessment of your sports participation. Imaging studies typically begin with x-rays, which are very useful to look at the shape of the bone and any bone spurs. We will usually also do a special type of MRI scan called an “arthrogram MRI” in which some dye is injected into the hip joint to highlight the soft tissue structures.

The first step in treating the problem is usually done without surgery. Rest from the sport or activity causing the pain combined with anti-inflammatory treatment can get the pain under better control. Physical therapy to correct weakness or imbalance in the hip and core musculature is done. The nonsurgical approach can be successful in some cases.

But in many cases where the bone overgrowth is simply too much, the impingement will continue to cause pain when the young athlete attempts to return to sports. In those cases, arthroscopic surgery can be done.

The emphasis with arthroscopic surgery is to tailor the procedure to the exact type of problem in each hip. For young athletes we have a strong preference for performing the most conservative procedure that results in restoration of as close to normal anatomy as possible. This typically includes removal of the impinging bone spurs to restore the natural shape of the ball and socket, repairing the ring of tissue around the socket (called the labrum), and tightening loose ligaments.

The surgery is done as a come-and-go procedure, meaning that there is no overnight stay in the hospital. The specific recovery will be different for each person depending on the type of repair, but for the typical FAI surgery you can expect to be on crutches and in a hip brace for two weeks after surgery. We recommend that physical therapy start early (as early as week 1) and generally continue through week 12 – 24.

A review of our results from FAI surgery across all age groups showed that 95% of athletes (all levels – including recreational, high school, college, and professional / Olympic) successfully returned to sports with excellent pain relief, function, and performance. The physical therapist or performance specialist will have the athlete go through a series of tests to determine readiness for return to sport, and return can be expected at 4 to 6 months after surgery, depending on the type of sport.



Posted in Football, Hip, Hockey, Soccer | Leave a comment

Hip and Groin Injuries in Young Athletes

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

And Marc Safran, M.D.

Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Muscle strains are the most common hip and groin injuries in young athletes and will typically improve with simple measures
  • An “avulsion fracture” can occur in the growing athlete, and can also result in excellent healing without surgery
  • Femoroacetabular impingement (FAI) can be a source of hip pain in older adolescents and teenagers. This condition often requires surgery, with typically excellent outcomes.

Hip and groin injuries are fairly common in young athletes, and the type of injury is often influenced by the age of the young athlete. In the very young player, hip and groin injuries tend to be mild tendon or muscle strains. In the 11-17 year old age group a large percentage will also be tendon or muscle strains but a type of fracture through one of the growth plates around the hip and pelvis can also occur. In older players, stress fractures, athletic pubalgia (also known as sports hernia or core muscle injury), FAI, and hamstring tears can happen. 7050567_orig

Muscle strains can happen in any of the muscles crossing the hip joint but we tend to see the highest number of muscle strains in the group of muscles in front of the hip called the “hip flexors”. A hip flexor can be strained when it contracts forcefully, especially when the leg is fully extended or prevented from moving. Kicking and sprinting are the most common movements that cause strained hip flexors.

The athlete will typically feel soreness or pain in the front of the hip along with a sense of weakness. If pain is significant or you are having difficulty putting weight on the leg see a sports medicine physician soon. For most mild strains, there will generally be a good recovery with initial rest and ice, followed by stretching and strengthening, and eventually gradual return to sports. Some athletes find that a compression wrap is helpful in recovery.

A more serious injury sometimes confused with a hip flexor strain is called an “avulsion fracture”. In the young athlete the bones are growing through areas called growth plates. The growth plates are a site of weakness and occasionally a tendon attaching to the growth plate can pull off a piece of bone attached to the tendon. This injury is typically accompanied by a “pop” at the time of injury, can be quite painful, and can be very difficult to put weight on the leg. If you experienced a “pop” and are having a lot of pain and difficulty walking on that leg, then we recommend you see your pediatrician or a sports medicine physician quickly for proper evaluation. These injuries will usually have a full recovery without surgery if they are treated correctly from the start.

We are becoming more aware of a condition called “femoroacetabular impingement”, sometimes simply referred to as “FAI”. FAI typically affects the older adolescent or teenage athlete. FAI is a condition in which abnormal bone growth on the femur (the large bone in the upper leg) and / or the acetabulum (the socket part of the pelvis) repetitively contacts each other.

Sports involving forceful rotation place the athlete at risk of developing pain from FAI. Golf, football, baseball, volleyball, soccer, hockey, lacrosse, field hockey, martial arts, and tennis are the sports most likely to aggravate the FAI.

For reasons not completely understood, some people develop excessive bone growth at the top of the femur and/or around the edge of the hip socket. These people are not born with FAI but it appears to develop early in life with growth. The movement that aggravates FAI is deep bending, or a forceful rotation of the core, including the hips. The longer that repetitive rotational movement occurs over a period of years, the more irritated the area becomes, the more pain can be felt because of bone bumping into bone, leading to damage of other, non-bony, tissues.

FAI requires careful evaluation by a sports medicine specialist with expertise in hip injuries. The pain may decrease with a period of rest and rehabilitation but unfortunately surgery is often needed for return to sports. The good news is that arthroscopic surgery for FAI is becoming much more common, and with very high success rates. In next week’s post we will outline the basics of FAI surgery.




Posted in Football, Hamstring, Hip, Hockey, Soccer | Leave a comment

The “High Ankle Sprain” vs. The Common Ankle Sprain- What’s The Difference?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • High ankle sprains happen with body rotation, such as being tackled with the foot planted at the same time as changing direction
  • Most mild and moderate high ankle sprains are treated without surgery
  • Expect return to play to take longer than common ankle sprains- typically 6 to 12 weeks for young athletes, depending on the sport

We’ve recently written about the usefulness of ankle bracing in reducing the risk of football high ankle sprain - Version 2common ankle sprains with basketball. But there is a different type of ankle sprain, commonly called a “high ankle sprain” that behaves differently. What is the difference between a common ankle sprain and a high ankle sprain? And why do athletes with a high ankle sprain seem to be out for a longer period of time? The explanations center on the anatomy of the ankle and the different ligaments injured in a common vs. high ankle sprain.

The common ankle sprain involves injury to a ligament on the outside of the ankle called the “ATFL”, which stands for the anterior talofibular ligament. This ligament runs between the end of the fibula to the talus on the outside of the ankle. It is one of the primary stabilizers of the ankle and is frequently injured when an athlete “rolls” the ankle. Athletes frequently will have pain, swelling, and even bruising in more severe sprains. These symptoms can be experienced on the outside of the foot, just below the ankle joint.

In the high ankle sprain, however, a different ligament is injured, called the “syndesmosis”. The syndesmosis is a tough sheet of tissue that lies between the tibia and fibula and holds these two bones together. In normal walking and running the syndesmosis is preventing the tibia and fibula from being pulled apart. The high ankle sprain typically occurs with rotation of the body around the planted foot, such as with a player being tackled at the same time he is making a cut or direction change. This is very different from the rolling that results in a common ankle sprain.

The high ankle sprain can be mild, moderate, or severe, similar in grading to the common ankle sprain. Severe high ankle sprains will cause a widening of the space between the tibia and fibula. The severe high ankle sprain will usually need surgery to repair the proper space between the bones. Most mild high ankle sprains can be treated without surgery. We will typically place the leg in a boot with some weight support with crutches. As healing progresses the boot and crutches are stopped, and physical therapy started.

Return to play after high ankle sprains almost always takes longer than return after a common ankle sprain. The reasons for this are not known. With adolescent athletes I find that return to full sport participation will take 6 to 12 weeks, depending on the sport and the position. Physical therapy is very helpful to help the athlete regain strength, agility, power, and confidence. I send all my young athletes to physical therapy after high ankle sprains. The good news about these injuries is that they tend to be “one and done” events and tend not to happen over and over. If they are treated correctly, keep your spirits up, you’ll almost always get back to normal activity but just expect it to take a bit of time.



Posted in Ankle, Basketball, Football, Soccer | Leave a comment

Heel Pain In Young Athletes: Calcaneal Apophysitis or “Sever’s Disease”

By Amol Saxena, DPM

Fellow, American Academy of Podiatric Sports Medicine

Fellow, American College of Foot & Ankle Surgeons

Palo Alto, CA

Key Points:

  • Heel pain in young athletes is a very common condition in young growing athletes
  • Most often this is a condition called “Sever’s Disease”, and can be managed with heel cushioning, proper shoe wear, and activity modification Severs-Disease-1

Heel pain is one of the most common complaints in young athletes. This generally occurs during the early portion of the growth phase around 8-10 years old, and can recur towards the end of growth (14-16 years old). Symptoms are typically in the back portion of the heel, can occur in one heel or both, usually having a gradual onset. The heel bone’s growth plate is in this area, which is immature soft bone and cartilage. A “tug of war” occurs in this region from the foot growing longer and the leg bones getting taller, which puts tension on this heel bone area known as the calcaneal apophysis. The inflammation is called calcaneal apophysitis or “Sever’s disease”.

Activities with more impact and running aggravate the pain, which can be a throbbing, aching discomfort. Thin and hard soled shoes also can aggravate the condition. Cleated shoes can actually accentuate the tension on the area; grass cleats are worse as they can actually have a “negative” heel. Turf cleats are better due to the higher heel and more cushioning. Even if games are played on grass, turf shoes usually work better as symptoms are less.

In addition to using turf cleats for athletes in sports such as soccer, football, baseball, and field hockey, adding heel cushions can help. Stretching and icing may have temporary benefit. X-ray’s and other imaging usually are not helpful. Sometime inserts to help address other foot deformities can help, but usually just heel elevation is sufficient. The other key item in controlling symptoms is activity modification and even reduction.

Sometimes calcaneal apophysitis worsens and becomes a stress fracture. The symptoms become more constant and patients have swelling, it hurts to hop on the involved limb and to squeeze the heel. The treatment at this point is rest and immobilization in a boot. Other conditions that can occur in this area are an “avulsion” or displacement of the growth plate and bursitis in the back of the heel. An avulsion happens from a severe landing on the heel, whereas bursitis (aka “pump bump” or “Haglund’s”) is more of chronic condition due to a prominent portion of the heel.

Calcaneal apophysitis is generally self-limiting and resolves after 6-12 months. Maintaining cushioning, proper shoes and activity modification is key in controlling symptoms. It is really not a disease, but rather a common condition of active youth athletes and can be controlled while allowing the young athlete to continue sports activity.


Posted in Football, Prevention, Running, Soccer | Leave a comment