Yes, Sometimes You Really Should See A Doctor

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Very broadly speaking, see a physician if you have a nagging physical ailment that you’re just not sure about
  • For acute injuries on the field of play there are some “red flag” situations that I outline below that often need immediate evaluation
  • And finally, for ongoing problems you’ll need to be on the lookout for decreases in sport performance or chronic painful movements. These may indicate an underlying physical problem. Proper evaluation and treatment can often shorten the recovery time and improve performance while still allowing modified play during healing.

One of the most common questions I’m asked by friends or by parents of players at events girlsbasketballconcussionis “do we need to go see a doctor”? This isn’t always easy to answer, as some simple injuries don’t need to be seen by a professional, and in other instances waiting too long to see a doctor can result in making a simple injury a potentially permanent problem. So let’s look at a few scenarios.

First: See A Physician If You Have Something You’re Just Not Sure About

I’ll start off with a very broad statement: go see a physician if you’re just not sure about something. This could literally be anything from a headache that doesn’t go away, a lingering cough, or even vague nagging joint pain. Many things are treatable, and it all starts with a diagnosis from a skilled clinician.

Second: Some On-Field Injuries Will Need Immediate Evaluation

Sideline Sports Doc is in the business of teaching coaches how to perform basic on-field evaluation of injuries. We teach about what we call The SAFE Method, which involves an assessment of the Story, Appearance, Feel, and Effort. In each of these categories are some red flags that would signal the need for immediate attention. For example, in Story, if there are complaints of significant pain, you’d be wise to see a physician immediately. Under the Appearance category you’d look for things such as immediate bruising or swelling. If either of those happens in the first minute or two, you’ll likely need to go to the local emergency room. With Feel we are asking you to press lightly on the injured area, and if this produces considerable pain with light touch that warrants immediate evaluation. And finally with Effort you’ll check for the ability of the injured athlete to move the injured area on their own. If this effort is painful or if they are unable to move the area at all then get to a physician urgently.

Third: Ongoing Pain, Discomfort, or Poor Sport Performance Could Benefit From Proper Evaluation And Treatment

This is sometimes a tricky decision. The young athlete often hides ongoing or nagging injuries from their parents or coaches out of fear that something will be discovered that keeps them out of play for an extended time. And they might be right. But more often than not, proper diagnosis will allow some treatment that can actually shorten the recovery time and at the same time allow for continued modified activity. After physician evaluation there might be treatments such as short term medication, bracing, physical therapy, or working with an athletic trainer that can really help. My advice is that if you have discomfort or pain that causes you to come out of a practice or game then you should see a sports physician. And similarly if you are noticing decreases in performance that’s not corrected by proper form or training, it could mean there’s an underlying physical problem. Good evaluation, proper treatment, and perhaps a short time off can make a huge difference in the long run.

Posted in Coaches, Parents, Treatment | Leave a comment

Basketball: ankle bracing and balance training reduce ankle sprain risk

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Basketball players are at risk for ankle sprains, knee ACL injury, and general lower extremity injury
  • Using lace-up ankle braces and/or performing balance training can reduce the risk of ankle sprains and general lower extremity injury
  • Unfortunately, there is no currently proven training method that reduces the risk of ACL injury in basketball players
  • Basketball players should strongly consider using lace-up ankle braces for practices and games, and consider balance training programs too

I wrote recently on the effectiveness of the FIFA 11+ program to reduce the incidence of a basketball rolledankle2_3wide variety of lower extremity injuries in soccer, including ACL tears. That program works for soccer players, coaches should require it.

Does an equivalent program exist to reduce injuries in basketball players? Possible strategies that have been used for basketball players include ankle bracing, ankle taping, balance training, and jump/landing training.

A recent pooled analysis of published studies shows that the results for lowering injury rates in general lower extremity injuries and ankle sprains is very good, but unfortunately the training programs have not shown a reduction in ACL injuries.

Basketball movements place unique demands on the player, including a much higher percentage of vertical movements than soccer players, and higher percentages of lateral movements compared to volleyball. Balance, strength, or neuromuscular education programs would need to account for the specific movements required in basketball. It’s possible that the current ACL training programs for basketball do not fully train the athlete for these movements, future programs might show better results with modifications. It’s also possible that the current studies simply did not study enough athletes to show a statistical difference.

Ankle sprain reduction: braces and balance training work

Several well-designed studies have shown the effectiveness of lace-up ankle braces in reducing incidence of ankle sprains. The effect is particularly strong for an athlete who has had prior sprains, in reducing the chance for yet another sprain. Other studies have shown that using an ankle brace does not “weaken” the ankle. With this in mind, the easiest intervention for a basketball player would be to use a lace up ankle brace for practices and games. If you do happen to get a sprain with a brace on, my feeling is that the sprain is less severe than it would be without a brace.

Other strategies involve balance training. These programs typically involve training a few times per week for 8 to 12 weeks and have also shown effectiveness in reducing the incidence of ankle sprains. The programs have only one drawback: they are only effective if you actually do the training! Some coaches may not want to devote time to the training, and compliance amongst young athletes can be low.

Your best strategy then is to use a lace up ankle brace for sure, and also utilize the balance training programs if possible. It appears that these strategies will certainly lower your risk of ankle sprains, and it doesn’t appear that there are any negative effects from either strategy. We still need good training programs to reduce ACL injury risk though. I have a feeling we are close on that front and need some larger studies to prove effectiveness.

Until then, lace up your ankle brace and have a good season!

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

Don’t Let An Injury Stop You From Exercising

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Being injured doesn’t always mean you need to completely stop all exercise or sport activity.
  • Don’t be afraid to have a discussion with your doctor, physical therapist, or athletic trainer about modifications or alternate activity during your healing
  • With proper guidance you will likely be able to continue some type of physical activity and you might even be able to use the recovery as an opportunity to correct some pre-existing issues and come back to your sport even better

Injuries are often viewed as some kind of exercise or training death-sentence. The reality isArm Cast  often the opposite of that. When done properly, an injury will usually allow the injured athlete to continue some type of physical activity during their healing from injury, and when viewed psychologically the injury can offer the athlete a chance to come back better than before the injury.

Let me start with a typical example. A 12-year-old soccer player came in to my office this week with a wrist injury to his non-dominant arm. We found that he had a common wrist fracture called a “torus fracture”, treatable in a short arm cast for about 4 weeks. His initial reaction was that he would not be able to do anything at all with the cast on. But we drilled down into his activities and found many places where he could participate.

“Can I play soccer?” Well, yes and no. With padding we found that his coach would allow him to participate in practices, but unfortunately his league rules would not allow competitive play. But still it was something. “Can I go running?” Yes for sure. More progress. “There is a basketball tryout for my school team coming up in a couple of weeks, can I do that?” Actually yes, if the coach and school will allow it. He found that he could dribble and shoot without difficulty, and the school allowed it with padding. The point is that we went from “I can’t do anything” to “there’s actually quite a bit I can do.”

If you have an injury requiring some type of treatment for proper healing I’d recommend that you discuss alternative exercise carefully with your doctor, physical therapist, or athletic trainer. They will usually be able to work with you to find some activities you can safely do while your injury properly heals. Physical therapists and athletic trainers are highly skilled in recommending alternative activities- use their expertise!

Here are some other common examples:

  • If you had an ankle sprain requiring you to take time off running you might be able to use the elliptical trainer, bike, or do weight training
  • If you have an ankle injury being treated in a walking boot there might still be things you can do. Basketball players can shoot free throws, golfers may be able to chip and putt.
  • With a back injury you might not be able to do squats or Olympic lifts but it might be possible to do a flat bench press using lighter dumbbells.
  • And for serious injuries requiring surgery you will likely be able to do things in your recovery to make you even better when you return to your sport. For example many teenage girls who have an ACL tear treated with surgery might have had some problems with their landing mechanics on a jump that contributed to their injury risk. Proper rehabilitation after surgery should include jump training to improve mechanics and actually make this part of your body movement better than before your injury.

No one wants to be injured and for sure each injury will need to be addressed individually. If you are injured don’t be afraid to have specific discussions with your doctor or other members of your recovery team. You’ll probably be pleased to hear there are many things you can do to stay active during your healing.

Posted in Parents, Performance, Tips and Training | Leave a comment

5 Cool Technologies That Will Impact Youth Sports and Health

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • For this week a bit of a departure: I’m going to highlight some cool new technology that will be coming soon for use by you or the young athlete
  • Many of the technologies represent radical departures from the way we do things but whether “radical” means “better” is still tbd
  1. This temporary tattoo senses through your skin. A “biostamp” is a means of measuring many body functions completely unobtrusively. For the athlete I see this as a way of measuring critical environmental functions, especially body temperature, heart rate, and respiratory rate to warn the athlete of impending heat illness. This is a near-term product likely to become part of the next wave of wearable technology.biostamp620-1432239290871
  2. Will athletes take a concussion pill to save their brains? Harvard researchers have developed an experimental treatment that helps restore normal brain structure and function in mice that have sustained severe concussions. The treatment could lead to a drug that treats and reverses the effects from traumatic brain injuries, like those seen in boxers, football players and soldiers. A drug that can reverse brain damage caused by concussion would be enormously helpful. If you are a football playing mouse you’re in luck J. For the rest of us this promising treatment is likely several years away.
  3. Can this online avatar replace a face-to-face visit with a psychologist? Her name is Ellie and she’s always available to talk. There is unfortunately a steep rise in issues such as autism spectrum disorders, add/adhd, and even depression in adolescents. For young people today computer and handheld monitors are ubiquitous. Could low cost easy 24/7 access to a “therapist” improve mental health? Exercise and sports are often prescribed for at-risk young people.
  4. You’ll be able to feel virtual reality for sports and fitness training. Computer feedback is used extensively in sports training, especially sports involving highly technical movements. What’s been missing it the “feel” a person gets from actually making contact with an object, such as a golf club or a ball. Expect this to change rapidly with new haptic technology that is portable.
  5. This robot wins rock-paper-scissors 100% of the time. Ok this has absolutely nothing to do with youth sports, health, or fitness but it is nevertheless cool. Japanese researchers have created a robot that can play Rock Paper Scissors better than any human, every time. The robot doesn’t actually play by the rules: it uses a high-speed camera and electronic reflexes that are faster than a human’s to identify the opponent’s hand shape and then play the corresponding winning move.
Posted in In the News, Sports Science, Sports Technology | Leave a comment

Sport Specialization Can Increase Injury Risk Regardless of Hours and Months Played

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent scientific article suggests that single sport specialization in young athletes increases injury risk, regardless of the number of hours played- this is a new and important finding
  • The risk of injury increases considerably if the young athlete plays a single sport for more than 8 months out of the year, or more than 16 hours per week
  • Some highly technical sport movements also increase the risk of injury, such as baseball pitching, the tennis kick serve, or technically repetitive sports such as gymnastics, dance, swimming, and diving
  • If a young athlete does choose single sport specialization it would be wise to limit participation to a maximum of 8 months out of the year and 16 hours per week

This week I’d like to point you to a recent publication of an interesting scientific article about Sport Specialization, published in the journal Sports Health. The most interesting finding from the study is in the first bullet point above: early sport specialization is in and of itself a risk for injury in the young athlete, regardless of the number of hours played per week or months played per year.6-17-09-7 XATHLETES

My take on this is that it’s interesting and also perplexing. Why would sport specialization lead to an increased injury risk even if the number of hours played per week or months played per year is a reasonable or modest amount? There is some speculation about the reasons but no clear answers yet. The younger the athlete the greater the risk due to the presence of open bone growth plates, and some highly specialized repetitive sport movements could also reasonably increase risk- I get that. But we need more research in this area, which is likely to come in the next several years. The study I reference above is a pooled retrospective clinical review, so it can be difficult to take absolute recommendations from this but we can at least be reasonable.

In the meantime each family needs to assess their own child’s goals, ambitions, and risks for themselves. The 16-hour per week maximum really shouldn’t be that hard to do but I think the harder part will be the maximum 8 months of dedicated sport participation per calendar year. There’s a lot of pressure now for single sport athletes to play year round and in fact that’s generally viewed as a badge of honor by most of the parents I talk to.

When kids come to see the orthopedic surgeon it means they’ve already had a problem so our perspective is a bit skewed. On the plus side the super-elite sports world is full of athletes that will tell you they played multiple sports until somewhere in their mid-teen years and that’s a formula that leads to success competitively as well as from a health standpoint. I’d strongly encourage you to employ sport diversification and participation limits in your own kids’ lives.

Posted in Parents, Sports Science, Tips and Training | Leave a comment

When Can I Return 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

We’ve written previously about the timing of ACL surgery for high school age athletes, and in ACL hop testthe 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.

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 Knee, Sports Science | Leave a comment

Save Your Hamstrings? Save Your ACL? Use The FIFA 11+ !

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The FIFA 11+ warmup program results in reductions to all soccer related injuries by an incredible 30% to 70%
  • The program works for males and females, across multiple age groups
  • You must consistently use the program at least 2 times per week, all season
  • The head coach is in an excellent position to improve player health by requiring this warmup program

I listened recently to a presentation by Holly Silvers, one of the creators of the PEP FIFA 11warmup program for soccer that ultimately evolved into the FIFA 11+ program. I was astounded by what I heard- using the program consistently, at least 2 times per week produced reductions in all soccer related injuries by 30% to 70%.

For context, I’ve only seen those types of health-related reductions if a drug is involved, for example using statins to reduce LDL cholesterol or using insulin for a diabetic to reduce blood sugar. But for a physical intervention to reduce injury rates by this amount is really unheard of. I think other than the 11+ program you could only reduce injury rates this much by staying in bed all day.

The links at the bottom of this page will take you to FIFA’s F-Marc site where you can download the program, as well as see some supporting scientific information. Please review it critically yourself and I believe you’ll come to the same conclusion: this program works.

At Sideline Sports Doc we’ve been preaching the benefits of injury reduction for years now, so let’s review a few of these areas. Each of these can be achieved through use of the FIFA 11+:

  • Reduce injuries to the groin, hamstrings, knees, legs, ankles by 30% to 70% for males and females, across multiple age groups
  • Reduced injuries means you keep players in your squad longer
  • The program also improves soccer specific performance
  • Fewer injuries means lower health related costs. In many parts of the United States a severe ankle sprain will cost in excess of $3000 to diagnose and treat. These costs will often be borne by the parents through high-deductible insurance plans. If you’re a parent, wouldn’t you rather have a healthy child, and keep that money for something else?

Like any safety and preventive measure, this program is only good if you actually use it, consistently through the season, at least 2 times per week. The person in the best position to implement the program and positively influence player health is the head coach. Take a stand for player health by letting your players know that you are going to be doing the program all year, let them know that you are doing it because you really care about their health, safety, and performance.

Your players look up to you as their coach, and if you set the example they will do the program. Save a hamstring, save an ACL. Use the FIFA 11+.

The FIFA 11+ Program

FIFA Medical Assessment And Research Centre (F-MARC)

Comprehensive review article on results of the 11+ program

Posted in Ankle, Hamstring, Hip, Knee, Prevention, Soccer | Leave a comment

Sideline Tips: Safe Steps In The Return To Play Decision

By Dev Mishra, MD

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


And Bert R. Mandelbaum, MD DHL (hon)

Santa Monica Orthopaedic and Sports Medicine Group and Sports Foundation

Team Physician LA Galaxy, US Soccer, Pepperdine University

Member FIFA and CONCACAF Medical Committee and F-MARC

Assistant Medical Director Major League Soccer


Key Points:

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

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

Returning to play prematurely can lead to a more serious injury. In our clinical practices over the last 25+ years we see one or two kids each week with a significant injury that started out as some kind of minor injury. For whatever reason they kept playing and that minor injury turned into something more significant.

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

If you think a kid’s not really ready, it’s better to sit them – maybe lose them for a few days – rather than to let them get back in before they’re ready and lose them for weeks or months. An injured player is likely not an effective player, plus there is risk of making a minor injury a major one.

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

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

When Players Insist They Are Ready To Play

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

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

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

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

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

In-game: do a functional test

In most soccer injury situations you’ll be dealing with injuries to the lower extremities – hip, knee, ankle, foot.

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

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


Posted in Basketball, Coaches, Football, Lacrosse, Soccer, Tips and Training | Leave a comment

Helmets Off Makes Heads Cooler

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Coaches need to maintain awareness of possible heat illness during the early days of September, when air temperatures can be high
  • Sweating through exposed skin is one of the body’s most effective ways to reduce the risk of heat illness, but football helmets and protective equipment limit the amount of exposed skin
  • Removing the helmet when not involved in play can be an effective way to vent off heat and reduce heat illness risk

Youth and high school football practices are now in high gear, and end-of-summer air temperatures can be very high. This means that there’s still a considerable risk of dehydration and heat illness, especially when practicing in pads and helmets. football-player-kneeling-with-helmet-off

Heat illness isn’t just an issue for teams practicing in 100-degree days, it can occur even in 80-degree temperature. Many studies have shown that even at lower air temperature a young athlete’s internal body temperature can exceed 100 degrees (98.6 degrees is generally considered “normal”) and can reach as high as 104 degrees. When a body temperature gets that high there is the risk of problems with mental status, cramping, and a severe medical emergency called heat stroke.

One of the body’s methods of dealing with excessive heat is by cooling through sweat of exposed skin. Arms, legs, neck, head- any of these areas can essentially vent off heat and help regulate body temperature. The problem is that with football clothing and equipment there can be very limited skin exposure to release the heat.

Most youth coaches know the benefits of water breaks and keeping up with hydration. USA Football has a number of excellent tips on hydration for young players, and this section on “hydration myths” is interesting.

One under-utilized method of cooling for football players is helmet removal. The surface area of the head and neck are about 10% of the available skin surface area, so that means the head and neck are good possible sources to vent off excess heat.

If you’re standing on the sidelines not involved in play on the field- take your helmet off and hold it in your hands. That will help with cooling and you’re ready to go immediately if called on to the field. For non-contact days coaches should consider no helmet drills, and for walk through days consider no helmets and no pads, or just shoulder pads only.

Coaches have learned a lot about the importance of proper hydration and heat awareness, so keep up the good work with water breaks, ice and fluid available at practice, and misters from garden hoses.

Good attention to details of heat and hydration along with appropriate use of helmets and safety equipment can go a long way to decreasing risk of heat illness. At least in theory heat illness is totally preventable.

Posted in Football, Heat Illness, Prevention | Leave a comment

Why I Hold My Breath On Kickoffs

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Football kickoffs are the plays most likely to result in serious injury to players
  • The NFL, NCAA, and high school federations recognize this and have taken a number of steps to make kickoffs safer

Yes that’s right, I literally hold my breath on kickoffs when I’m standing on the sidelines. football kickoffFrom a fan’s standpoint there are few plays in football that are as exciting or have the same momentum creating potential. If the return man breaks a big gain, then the receiving team has the edge. If the coverage team pins the returner deep, then they have the advantage. Even at the high school level I’m surprised how many guys love to run down the field and hit somebody on a kickoff.

So why am I holding my breath and why am I surprised that guys want to do this? Because there is no play in football that results in more serious injuries than the kickoff.

A widely referenced study in 2009 highlighted the problem. The study authors evaluated a number of aspects of high school football injuries during the 2005-06 seasons including type of play (e.g. kickoff, punt, routine downs), place on field (e.g. middle of field vs. periphery of field), and time during the game. Injuries were categorized as mild, moderate, severe, and concussion.

During kickoff and punts a greater proportion of severe injuries occurred compared to all other phases of play. Thirty-three percent of injuries occurring during kickoff and punt were severe and 20 percent were concussions. Forty-four percent of the severe injuries were fractures.

The NFL, NCAA, and high school federations have certainly taken notice. No one wants another injury on a kickoff such as the ones sustained by Eric LeGrand or Kevin Everett. The NFL made the three man wedge illegal, limited the run-up distance for tacklers, and moved the kicking spot to the 35 yard line from the 30 yard line. As a result about half of NFL kickoffs are now touchbacks and it appears that injuries on kickoffs are down.

At the high school level several measures have also been enacted into rules designed to improve kickoff safety. First, at least four members of the kicking team must be on each side of the kicker, and, second, other than the kicker, no members of the kicking team may be more than five yards behind the kicking team’s free-kick line. Additionally, if one player is more than five yards behind the restraining line and any other player kicks the ball, it is a penalty. These changes are designed to reduce injuries by balancing the kicking team’s formation and to limit the speed achieved by the tacklers. The changes make a lot of sense to me but we don’t yet have data to prove effectiveness.

There is still a tendency- perpetuated by media coverage- to dwell on the negative aspects of youth sports and especially sports injuries. But from what I can see the NFL down to the youth football leagues are taking positive steps in improving player safety while still trying to preserve the traditions of the game. To be sure there is a long way to go but I am starting to think I might be able to breathe again on kickoffs some time soon.


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