NCAA Concussion Statement Has Great Points For High School Athletes Too

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The NCAA recently released a concussion guideline that presents clear definitions and processes for collegiate athletes in all sports
  • The vast majority of concussions will not have a loss of consciousness
  • In my opinion it would be helpful at the high school level for athletes to have preseason baseline concussion testing; suspected concussion in-season would be compared to the baseline
  • Return to classroom function can also require individual decision making, and students with pre-existing conditions such as ADHD, migraines, or depression may require extended assistance to successfully return to academics

I hope that someday soon we won’t have to write as many posts and articles about concussion. But for now we still need to improve awareness about recognition, treatment, and long term effects from concussion. girls soccer header

In an attempt to bring a comprehensive and clear set of processes around sport related concussion for men and women in all sports, the NCAA recently released their “Diagnosis and Management of Sport Related Concussion Guidelines”. There are a number of excellent points raised in the guideline, many of which bear repeating as they are applicable in youth sports too.

One of the most important points is that our current understanding of concussion is evolving based upon available scientific evidence and consensus statements authored by concussion experts. As we gain more knowledge it’s become clear that the vast majority of concussions occur in awake individuals who do not lose consciousness. Furthermore, the symptoms of concussion often clear up very rapidly. In fact at the high school level I find that most of our concussed athletes have returned to their baseline level of cognitive and neurologic function within about 15 minutes from the concussion event. At the high school level it would be very helpful for the head trainer to have a preseason discussion with the parents and coaching staff about this important point.

A second important point is that in the NCAA they will require baseline concussion testing in the preseason for all athletes.  The baseline testing could be computer based or paper based but the point is that the athlete with a suspected concussion would undergo the same testing as they had in the preseason and would be compared for differences, thus supporting the diagnosis of concussion. A return to baseline values on the testing would be required for the athlete to start a return to play process. This will be difficult to implement at the high school level due to cost and a number of logistical issues. However, I believe the rationale is clear and if a high school is able to have some form of preseason cognitive testing for their athletes then I believe they should do it.

Finally, the NCAA guidelines highlight the need for a stepwise progression not just for return to play, but also a return to academics. They refer to this as “return to learn”. Great phrase. Some students will have concurrent conditions such as ADHD, migraines, or depression that will contribute to a potentially slower recovery from concussion. The take home point here is that young athletes must have an individualized approach to return from concussion and that medical professionals may need to work with school administrators and counselors to ensure the best environment for the student to return to normal function.

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Hockey Helmet Ratings Coming Soon from Virginia Tech

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Independent and objective scientific analysis is adding to our knowledge of football helmet safety
  • The researchers at Virginia Tech will next analyze ice hockey helmets and then in the coming years look at baseball, softball, and lacrosse
  • I would predict that the evidence will be used by parents to demand the safest equipment for their kids

Whenever possible we like to base our medical decisions on high-quality scientific evidence.  The issue of concussion safety can become emotionally charged, which makes it even more necessary to seek out unbiased opinion when making recommendations on equipment, rules changes, sideline treatment of professional athletes, etc. 23HELMET-articleLarge

And so it is with helmet design. In football, we’ve come a very long way from the early days of leather “helmets”, and professional hockey in the relatively recent past didn’t even require helmets. Technical change requires buy-in from the players, who often have strong feelings about the traditions or culture of the game that may run counter to the proposed technical changes.

This is where objective analysis really helps. In football helmet design, the collaboration between Virginia Tech University and Wake Forest University School of Biomedical Engineering and Sciences has produced the Virginia Tech STAR Helmet Rating System. I find the testing methodology to be sound and well thought-out, utilizing linear and rotational testing. We will undoubtedly learn more about the exact risk factors for concussion but for now the Virginia Tech system is a big step in the right direction.

After football, one of the sports with the highest concussion risks is ice hockey. It is also a sport with a rapidly growing youth participation rate in the U.S., so it makes sense that science and industry take a close look at making the concussion risk as low as we possibly can. This article in the New York Times reports on a recent announcement by the researchers at Virginia Tech that they’ll be applying the STAR testing to hockey helmets. A hockey helmet rating will be published later this year.

Ideally, we should see similar testing by other independent researchers, and also look at external helmet padding such as the Shockstrip and Guardian Cap. The external padding makes some sense but in my opinion we simply don’t have the independent research to endorse use from the medical standpoint. The Virginia Tech researchers will look at baseball helmets, softball helmets, and lacrosse helmets using similar methodology over the next few years.

Design engineers have made enormous improvements in automobile safety over the last several years, and without question we can improve sports helmet safety too. My prediction is that the scientific evidence will compel parents to demand the best protection for their kids. It may take quite a bit of time and it may be expensive, but change is coming and all our young athletes will benefit.



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

Hamstring Injuries: What To Do, What To Expect, What’s On The Horizon

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Hamstring injuries can take a long time to fully heal, ranging from 3 to 8 weeks for most young athletes
  • See a physician soon after injury if you heard or felt a “pop”
  • Full recovery is needed before return to sports in order to lower your chance of reinjury

Hamstring injuries are common in any sport involving sprinting, jumping, or rapid change of direction. In young growing athletes hamstring injuries can involve pulling the bone off the pelvis (an “avulsion”). Once growth slows down or stops hamstring injuries are more often found in the muscle, or in the tendon at the upper or lower end.  These injuries generally have a high rate of return to play, but can often take a long time to recover and also have a risk of reinjury. Some new treatments are on the horizon which have the chance to improve healing times and lower reinjury rates. OLYMPUS DIGITAL CAMERA

What’s The Story?

Athletes with hamstring injuries will typically have a sudden onset of pain in the back of the thigh during a sprint.  This often causes them to stop the run, putting their hand on the back of the thigh.

If you heard or felt a “pop” at the time of the initial injury I would strongly recommend that you see a sports medicine physician for early evaluation and treatment.  The dreaded “pop” may mean that you had a bone injury in the pelvis, or it could mean a serious tear in the hamstring muscle or tendon.

Fortunately, most injuries involve the hamstring muscle rather than the bone or tendon. The reason that’s a good thing is that the muscle has a very good blood supply and that is essential for healing any injury. The blood carries cells and other repair factors to the injury and will allow the body to heal the injury.

Treatment Guidelines

Everyone will respond differently, so discuss your particular situation with your doctor. In general, hamstring injuries in young athletes will not require surgery. An exception could be a bone avulsion that is significantly pulled away from the bone. Most often, the initial treatment is rest from sports, ice, an Ace wrap for compression, anti-inflammatory medication, and physical therapy. Crutches might be needed early on for pain relief. In teenagers and young adults a cortisone injection is sometimes done, and has been shown to shorten return to play times in specific circumstances. Discuss this carefully with your doctor.

Proper rehabilitation is incredibly important. Before returning to practice or competition, the athlete will need to go through a gradual rehabilitation program involving range of motion, strength, agility, power, and speed. A physical therapist is skilled in these techniques and can greatly improve the chances for successful recovery. Very important: you want to be completely recovered before returning to play. If you are not completely recovered you have a high chance of getting another (and often more severe) injury.

On the horizon: new treatments

Keep an eye on the news for use of “platelet rich plasma” or “PRP” during the upcoming NFL season with hamstring injuries. This is a safe treatment involving an injection of concentrated products from the athlete’s own blood. PRP has the potential to accelerate healing and without any illegal substances used. I would predict that PRP will become common for most athletes over the coming years, once we gather widespread evidence of its benefits. Other treatments further down the line would include implantation of stem cells with the potential to truly heal the injury with normal tissue. Stem cell research for muscle injuries is progressing, but in the very early stages.

When Can I Return To Play?

Once again, everyone is different so you’ll want to get individual guidance from your doctor and physical therapist. But in general, I will typically see young athletes take about 3 weeks to return to play after a mild injury, and about 8 weeks to return after a more significant injury. It takes a surprisingly long time! Bone avulsions are a completely different story, often taking several months for successful return.  Whatever the injury severity, make sure you are fully recovered before you attempt a return to play.





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ACL Surgery In The Growing Athlete: Save The Growth Plates

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent scientific study showed that young growing athletes with open growth plates can successfully undergo ACL surgery with no risk to bone growth, and high success rates for return to sports
  • Return to unrestricted sports took about 13 months on average in this study
  • I would encourage the young athlete to consider “all inside” ACL reconstruction to avoid possible damage to the growth plates

The ACL is a main stabilizing ligament in the knee, and most athletes with a torn ACL will require surgery to rebuild (otherwise known as “reconstruct”) the ACL if their goal is to return to jumping, cutting, sprinting, and pivoting sports. Unfortunately, we are seeing more ACL tears in very young athletes. While ACL surgery in adults is a fairly straightforward procedure with a high success rate, surgery in young athletes with open growth plates poses some challenges. Recent technical advances now make it possible for the surgeon to completely avoid the growth plates.gty_child_knee_injury_dm_111020_wmain

Let’s start with some definitions. Growth plates are areas of developing cartilage tissue near the ends of long bones. The growth plate regulates and helps determine the length and shape of the mature bone. The long bones of the body do not grow from the center outward. Instead, growth occurs at each end of the bone around the growth plate. When a child becomes full-grown, the growth plates harden into solid bone. The two main growth plates around the knee are in the upper tibia and lower femur. With commonly performed ACL surgery, the surgeon creates tunnels across these two main growth plates. The tunnels would then create risk of damaging the growth plates resulting in the potential for a change in length or angulation of the bone.

Over the last few years, technical advances in ACL surgery now make it possible for the surgeon to do the procedure without creating any tunnels across the open growth plates. This type of surgery is called an “all-inside ACL reconstruction”. A presentation at this week’s annual meeting of the American Orthopaedic Society for Sports Medicine showed excellent results with this type of surgery. The success rate in terms of stabilizing the knee and allowing unrestricted sport activity was very high, (93%), and there were no observed changes in bone growth.

This type of ACL surgery requires specialized surgeon training, and not all sports medicine surgeons will be skilled in the procedure. But I think it would be worth finding a surgeon trained in the procedure if you are considering the surgery for your growing son or daughter.

What Would I Do With My Son Or Daughter?

We are now at the point where it makes sense to perform all-inside surgery for the young athlete with open growth plates who needs ACL surgery. The main limiting factor is that there just aren’t many surgeons trained in the procedure. You’ll have the best chance of finding a surgeon trained in all-inside ACL reconstruction in children at sports medicine clinics run through major children’s hospitals in larger urban areas. If it were my son or daughter I would research a children’s hospital sports medicine clinic in a major metropolitan area and have the all-inside procedure from an experienced surgeon. Having said that, not everyone has access to these specialized centers. We also have many, many years of solid scientific evidence that it is possible to create tunnels across the growth plates with slight modifications to the standard adult operation, with very little risk to the growth plates. You’ll find those skilled surgeons all across the U.S. With a skilled surgeon and careful attention to rehabilitation, ACL reconstruction in young athletes with open growth plates should allow a very high chance of successful sports participation and minimal risk to bone growth.



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Sports Nutrition (Including The Wonders Of Chocolate Milk!) Radio CaptainU Interviews Nancy Clark, Internationally Renowned Sports Nutritionist.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • For serious athletes at any age, nutrition is an often overlooked but incredibly important component of athletic performance
  • Each body will react differently to food and fluid recommendations, it’s best to do a bit of experimenting in the preseason
  • She’s as much of a believer in low-fat chocolate milk as a recovery drink as I am!
  • Her book provides outstanding practical advice in one source for all athletes

Nancy Clark is an internationally renowned sports nutritionist based in Boston. Over the course of her career, she has counseled athletes of all ages and levels of ability. Her substantial experience forms the basis of what I’m sure you’ll find interesting and practical in this Radio CaptainU episode.

If you are interested in maximizing your athletic performance (that goes for parents and coaches as well as young athletes) then her book is a great place to look. The book is organized in easy to read and practical sections, and is now in its Fifth Edition, titled: “Nancy Clark’s Sports Nutrition Guidebook”.

She bases her recommendations on science, and generally avoids the fad-of-the-day hype often found in many fitness magazines or other media sources. There are several points in the book that I found particularly useful:

  • Chapter 9: Fueling Before Exercise contains suggestions for pregame food based on the starting time of your event.
  • Suggestions are also based on the type of sport, e.g. endurance vs. power sport
  • Suggestions also given for weight-class sports
  • Chapter 10: Fueling During and After Exercise has outstanding recommendations for many different situations, including tournaments and back to back events
  • She is a believer in low-fat chocolate milk as an excellent post-event recovery drink.  I really like this and have recommended it for years.
  • Every body behaves differently so the young athlete should experiment with different food and fluid combinations in the preseason
  • Carbohydrates are important for the athlete! Low carb diets are generally ineffective for the competing athlete. A low carb diet might be good for a 50-year-old attempting to lose body fat and weight, but a high-energy athlete absolutely needs carbs for performance.

Have a listen to this very engaging interview with Ms. Clark!

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Throw Like A Pro: Dr. James Andrews’ iOS App Hopes To Save Young Arms

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Renowned clinicians Dr. James Andrews and Dr. Kevin Wilk created an app called “Throw Like A Pro” to assist young pitchers in healthy pitching habits
  • Proper use of the app has the strong potential to correctly monitor pitching load across multiple teams and private training sessions, and reduce the chance for serious overuse injuries to the shoulder and elbow

This is heavy pitching season for a lot of talented young arms. In our part of the country, a number of outstanding Little League teams have fielded teams that have gone very deep into the annual Little League baseball championships. Not surprisingly, having at least one truly outstanding pitcher is a prerequisite for success.  Grant Lewis

Many of these young pitchers are talented for sure, but many also rely on multiple sources of coaching and game experience to advance quickly. It’s common for a player to be on an “official” Little League All-Star team and also take private pitching instruction. During the regular season there are likely travel teams too.

The result is often overpitching. We can have a Little League coach follow a pitch count and innings count, but that has no effect on the pitches thrown outside the coach’s watch.

For the player and the parents they find themselves in a tough situation. There is a feeling that success must be achieved as early as possible to have a chance at landing a pro contract or a college baseball offer, and if the young man doesn’t get that early success he’ll be left behind. “Everyone else is doing a league team, travel team, and private instruction, so I need to do it too.” Orthopedic surgeons often hear that explanation when a young pitcher sees us for an injured shoulder or elbow. From their side I can definitely see their point: the very best college programs are now recruiting in middle school.

But the toll extracted physically from the young pitcher can be substantial. We continue to see more serious shoulder and elbow injuries in young pitchers than we did 10 years ago and Dr. James Andrews estimates that 60% of those injuries are from overuse. And therefore they could be preventable.

Dr. Andrews believes very strongly in education for young athletes in hopes of preventing serious injury. He contributes his time, money, and expertise to the STOP Sports Injuries program and recently created an iOS app called “Throw Like A Pro” along with noted rehabilitation specialist Dr. Kevin Wilk.

If you’re the parent of a young pitcher I strongly encourage you to use the app. There are four components to the app: a pitch counter and rest calculator; pre-season prep guide including an exercise regimen; pre-game warmup; and educational component on pitching injuries. I find that the pitch counter and rest calculator are the most valuable parts. If a player and parent actually use this tool it will allow them to keep track of the arm reps across any number of teams or private coaching sessions.

I completely recognize that the pressures are higher than ever to perform better at younger ages. As a parent and young pitcher it might take some courage for you to take a close look and resist the trend to overpitching. But doing so has a very good chance of successfully enjoying the game and competing far longer than you otherwise might.





Posted in Baseball, Elbow, Prevention, Shoulder, Tips and Training | Leave a comment

CrossFit for Kids: Good Potential, Just Be Careful

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • CrossFit is a multi-joint high intensity exercise regimen with the potential to be an excellent total body training for the young athlete
  • Young athletes can participate in CrossFit as long as it is an age specific class, and there is very close supervision from the instructor to ensure perfect form
  • Performing age inappropriate activity, or doing “too much, too soon” can risk growth plate or tendon problems in the growing athlete

I see a lot of adults with various injuries from CrossFit and lately I’m starting to see a few young athletes with injuries from CrossFit too. It seems that CrossFit programs for teenagers and adolescents are becoming more popular, so it’s only natural that larger numbers of participants will lead to a few injuries no matter the sport or activity.  But on the adult side we really do see a lot of injuries, so I wonder whether there’s something intrinsically wrong with the training, or whether it’s a great regimen where some other factors lead to injury. crossfit-kids

What exactly is CrossFit? CrossFit is an exercise regimen typically performed in a group class setting that aims to use multiple joint full body functional movements to improve health and fitness. The programs are designed to be constantly varied, high intensity, and often with multiple repetitions. In the adult version, the individual is supposed to modify load and intensity if they have a particular injury, or are starting from a lower level of fitness.  And for the adults, I think that’s where the problem comes in: we see a lot of injuries from “too much, too soon”. The group class setting can make it very difficult for someone to cut back due to the fairly intense peer pressure.

On the kids and young athlete side, CrossFit has a similar program called CrossFit Kids. The goals of the program are admirable and on the face of it I like what I am seeing. “The CrossFit Kids program uses the template of randomized, functional exercises, performed at high intensity. Adjustments are made to accommodate the specific needs and requirements of children and teens.”

The template shown on the website is divided into appropriate age groups starting from preschool up to “varsity”, which typically refers to high school aged athletes. As the ages increase and the athlete’s skill level increases there is an emphasis on movements such as weighted lunges, barbell cleans, handstands, and plyometric activities. A young athlete absolutely must not enter into an adult class. If you do CrossFit make sure it’s in an age specific class for young bodies.

When performed with perfect form, I find the activities listed to be safe and effective ways to build overall fitness, and should translate to improved sport performance.  I also like the variety and changing routines. The risk is that the exercises absolutely must be performed with perfect form, and if they are not there is risk for creating conditions across the open growth plates of growing athletes such as Osgood-Schlatter syndrome at the knee, or Sever’s apophysitis at the heel. A group setting with other motivated athletes and instructor can be a lot of fun, and perhaps lead to a higher level of compliance with the program. Be careful of giving in to peer pressure to try loads and moves your body is not ready for. “Too much, too soon” can easily happen for kids and teenagers. And to be sure, these cautions apply to many different exercise regimens and sports for kids, not limited to CrossFit.

Overall, I feel the objectives and program plan for CrossFit kids has the potential to be an engaging and effective way to improve total body fitness for young athletes. For some kids the group setting in a warehouse is fun and motivational, and other kids may prefer training individually or in smaller groups. You may want to do a sample class to see how you feel about that. But the most important aspect in my opinion is the close supervision needed from the trainer/instructor to ensure perfect form from the students.  Other keys would be to make sure you are in an age appropriate session, and be wary of overextending yourself from peer pressure. For now I’ll give CrossFit Kids the benefit of a doubt. I’m hoping it doesn’t change my mind over the coming year.




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What Are The Psychological Things That Great Athletes Do? Radio CaptainU Interviews Scott Kaufman, Professor of Psychology at NYU.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Each athlete should focus on developing an individual or core skill, rather than constantly comparing themselves to their peers
  • Focused, deliberate practice in which you push yourself beyond your limits is very helpful in creating a core competency

Scott Kaufman is a very interesting expert, self deprecating, funny, and provides a number of outstanding insights into the mental side of athletic performance training. The talk generally focuses on training, and not specifically on in-game mentality. Kaufman’s background is in basketball, so many of the examples he provides are basketball focused. But I feel the concepts are applicable to most sports.

One of the first points he makes is for an individual to follow his/her own pathway and to approach development as a unique process. Put energy and time into a specific skill. He believes this is a good way for almost any athlete to create a core competency that will allow them to participate at the highest level possible.

Kaufman is a believer in deliberate practice, which is a type of practice where you are repetitively and intentionally pushing yourself beyond your limits. Even pushing through in small ways is a key component to advancing your skills.

He also advocates using mental imagery or visualization of success, and often using guidance from a mentor to help you with this.

The goals of this type of training is to develop a go-to set of skills, see yourself succeeding at this skill, and in turn this gives you the best chance to succeed when you do get into a game situation.

And finally, Kaufman closes with some interesting anecdotes about his pathway as a high school basketball player and his desire to make it to the NBA. He kept that in mind until he started playing high school basketball with a fellow named Kobe Bryant.

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Uruguay Deserves A Red Card For Concussion Management: US Youth Sports Must Do Better

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • During the World Cup the Uruguay team allowed a player with an obvious concussion to continue playing in the same game, risking permanent injury to the player
  • Youth Sports organizations in the US must take the lead and require proper concussion recognition for their coaches.
  • Youth Sports organizations must provide clear and consistent rules for return to play; a qualified physician’s clearance should be mandatory

In a group stage game last week, Uruguay’s Alvaro Pereira sustained a concussion. To debate whether he did or did not have a concussion is ludicrous- it’s a concussion even by 1950s definitions.  Take a look here, along with some commentary by Taylor Twellman: Álvaro Pereira

There’s quite a bit of debate about what professional soccer must do to provide an appropriate way for medical personnel to evaluate a concussion (or any other potentially serious injury, for that matter). Rules in professional soccer essentially penalize a team for evaluating a player with an injury. And disturbingly in the Uruguay scenario the player and coaching staff were allowed to overrule the doctor, and the referees allowed the player back on.

Professional soccer has many questions to ask and answer about how they want to address the issue of on-field injury evaluation. And from their atrocious approach there are actually lessons that we can apply to youth sports in the United States.  Let’s have a look.

Lessons For U.S. Youth Sports

The first take-away is that there must be a uniform process that strongly favors player safety.  No more guessing about who’s in charge. No more inconsistent education for coaches. I’ve spoken to many high ranking decision makers in youth sports over the years and it’s interesting to listen to the pushback we get when discussing our available programs for in-game or in-practice injury recognition and management. Common statements are “we can’t afford this”, “our board won’t support this”, “we can do this ourselves”, “we can’t force our coaches to do any more than we are already making them do”, etc. etc. etc.  The reality is that coaches do want the education and they expect that the service organizations to which they are paying fees to provide the education.  Our youth sports leagues must take the lead and require the proper education and support to ensure uniform application of player safety rules.  Leaving it to the discretion of local leagues or making it optional simply will not work.

The second lesson is specific to concussions. We can’t expect a concussed player to determine whether he/she is fit to play, and we can’t expect a coach without medical training to make a diagnosis of concussion. The coach must be educated enough to suspect a concussion, remove the player from play, and then let a qualified physician make the actual diagnosis.

And the final lesson is about return to play.  When a youth sports coach decides to remove a player from play due to suspected injury the rules of the league, the club, and the referee need to stand behind the coach. The reality is that the coach can often be pressured by the player, the parents, or teammates to allow an injured player to play. The safest thing to do- especially in a problematic issue like concussion- is for the league to require written clearance from a physician to determine return to play.

We are making progress with player safety in U.S. youth sports but we can do better. It will be a big step forward when our youth sports organizations take a stand for uniform requirements favoring player safety.

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When Can I Play Again After Meniscus Surgery?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Recovery is highly variable, but generally speaking most young athletes can return to sprinting, cutting, and jumping sports at about 6 weeks after partial meniscus removal surgery
  • Generally speaking, most young athletes will return to sprinting, cutting, and jumping sports at about 4 months after meniscus repair with stitches
  • Beware about claims to return fully to sports at 2 weeks after surgery- this is very rare
  • Success rates are very high with properly followed rehab

This weekend I watched Costa Rica defeat Uruguay in a World Cup game, with this huge upset made possible in part because star Uruguay striker Luis Suarez was unable to play due to recovery from recent knee meniscus surgery. Many sports commentators felt fairly certain Suarez would be ready to play, only about 3 weeks after his surgery. But most orthopedic surgeons would honestly tell you it would be unusual for a player that relies on speed, quickness, and the ability to turn on a dime to be fully ready that quickly.

So how long should it realistically take? A00358F02

The meniscus is a shock absorber in the knee, a horseshoe shaped structure situated between the two major knee joint bones. There are two menisci in each knee, and either meniscus can be torn in patterns generally like the ones shown in the photo (from OrthoInfo, the American Academy of Orthopaedic Surgeons).

If surgery is done for a torn meniscus it will most often be a partial removal, which is somewhat like trimming a hangnail from your toe.  It’s a relatively quick procedure (usually about 15-20 minutes) and weightbearing is allowed immediately after surgery. The second possible procedure is called a meniscus “repair” where stitches are placed in the meniscus to sew it back together. After a meniscus repair there is usually a period of partial weightbearing on crutches that lasts several weeks.

The type of surgery performed has a major influence on the speed of the rehabilitation. With the commonly performed partial meniscus removal there is an early emphasis on minimizing swelling and regaining motion. Comfortable walking generally takes about a week or two. The highly variable part is return of power, speed, and the ability to cut hard or pivot. This is the part that takes the longest time and will usually take 2-4 weeks. So if we add the weeks up it will be a minimum of 3 weeks and perhaps up to 6 weeks for full return to sprinting, cutting, and jumping.

With meniscus repair with stitches there could be 4-6 weeks on crutches, followed by regaining full walking ability, and finally getting the knee sport-ready with strength, power, and speed.  There is some overlap in the phases but when all the time is added up you’re looking at 3 to 4 months until the player is ready for unrestricted sprinting, cutting, and jumping.

In the discussion above I’ve focused on return to sprinting, cutting, and jumping. So the timeline for return to sports will depend on whether you need to do those things in your sport. If you are a cyclist or swimmer you should expect a faster return to your sport. Distance runners will generally return to full training faster than sprinters but likely longer than cyclists.

Circling back to World Cup soccer, Mr. Suarez is now coming up on four weeks after his surgery. If I were a betting man I would expect to see him in the starting lineup for Uruguay this week. Young athletes should expect a high chance of successful return with proper rehab and time after surgery.

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