To Brace Or Not To Brace

By Lance LeClere, M.D.

LCDR MC, United States Navy

Orthopaedic Sports Medicine and Shoulder Surgery

Naval Medical Center, San Diego, California

Note: this article first appeared in InMotion, published by the American Orthopaedic Society for Sports Medicine and is available as a free resource

Key Points:

  • Use of prophylactic (or “preventive”) knee braces is common in youth football
  • Evidence for effectiveness in reducing the severity of MCL injuries for some position players such as linemen, linebackers, and tight ends is fairly solid
  • There is no evidence that knee braces can reduce the incidence of ACL tears

Anterior cruciate ligament (ACL), medial collateral ligament (MCL), and other ligament football knee braceinjuries of the knee can be devastating for football players and may result in significant loss of playing time and/or require surgical treatment. As player safety and injury prevention continue to be a priority, many players and parents wonder if a knee brace can help prevent major football injuries. Several factors come under consideration when trying to decide whether a player should wear a knee brace:

  • Effectiveness in preventing an injury
  • Play hindrance
  • Added weight
  • Unnatural feel
  • Cost
  • Practicality of routine use
  • Possibility of increases in injuries in the hip or ankle

Prophylactic knee bracing or using a knee brace to prevent injury in football is controversial, with no clearcut answer from quality studies. Some studies suggest that prophylactic knee bracing helps prevent MCL injuries in “high risk positions” such as offensive and defensive linemen, linebackers, and tight ends and may decrease the severity of injuries when they do occur.1 However, there is no strong evidence to suggest that the rate of ACL injuries is decreased by routine use of knee braces.1 Two published review articles on prophylactic bracing for prevention of knee injuries in football players concluded that data was not clear enough to make a recommendation for or against prophylactic bracing.1,2

Widespread, routine use of prophylactic knee braces is not supported by available evidence or professional society recommendations. However, each player must consider individual factors such as position, level of competition, comfort, and cost when deciding if prophylactic bracing is advisable. As always, open dialogue among players, parents, coaches, athletic trainers, and team physicians is encouraged. 


  1. Salata, MJ, Gibbs AE, Sekiya JK. The Effectiveness of Prophylactic Knee Bracing in American Football:?A Systematic Review. Sports Health. 2010; 2(5): 375-379.
  2. Pietrosimone BG, Grindstaff TL, et al. A Systematic Review of Prophylactic Braces in the Prevention?of Knee Ligament Injuries in Collegiate Football Players. J Athl Train. 2008;43: 409-415.


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“Injuries Are The Result Of Coaching Incompetence.” Radio CaptainU Interviews Raymond Verheijen, Dutch soccer coach.

Summary By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Verheijen is an outspoken critic of many soccer coaches and often places the blame for athletes’ injuries on what he believes is improper player management and training from the coaches
  • He believes many injuries are the result of overtraining, fatigue, or ramping training intensity too quickly
  • This is an extremely entertaining podcast, well worth listening, but does lack some evidence so take it with a grain of salt

We are often asked by injured athletes to try and pinpoint the cause of injuries. Sometimes it’s pretty simple: a fall to the ground, or a hard tackle produces a bone fracture. But many times it’s not possible to accurately come up with a root cause to the injury. Take for example a noncontact ACL tear. We often say that it was just bad luck. But was it really? Raymond Verheijen believes that many injuries are due to improper training that results in muscle fatigue and susceptibility to injury. He goes as far as calling these injuries the result of “coaching incompetence”.

He believes that a disproportionate number of injuries especially in soccer occur at certain times in the season cycle: in the preseason after a time off from training; in the immediate return to sport after an injury layoff; and during a run of frequent games with limited recovery time.

We do have supportive scientific data for a number of his statements. For example, we do know that in some sports such as football there are higher numbers of injuries in the preseason two-a-days than there might be in the remainder of the season, and there is good evidence that in soccer there is an increased incidence of injury late in matches. The evidence is supportive but so far not completely definitive. One area where Verheijen gets it wrong is his belief that fatigue leads to slower nerve conduction velocity (meaning it takes longer for a nerve signal to reach the muscle). This does not happen, the most likely reasons fatigue affects performance are likely from loss of mental sharpness and possibly loss of muscle strength.

So take this interview with a grain of salt but it’s a really great discussion. I commend Captain U’s founder Avi Stopper for leading a balanced interview. It’s a controversial topic that will definitely make you think.

Posted in CaptainU, Coaches, Performance, Training | Leave a comment

The “Ten Percent” Rule For Runners: Fact or Fiction?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Common advice for runners returning from injury or other layoff is to increase weekly mileage by 10%
  • While I find that to be a generally good starting point, some runners are able to increase mileage faster and others must go even more slowly
  • From the orthopedic sports medicine standpoint, I often tailor return to running programs based upon the athlete’s unique injury situation

I often see young athletes with lower extremity stress fractures from running. We go through various treatments to allow the injury to heal, including preliminary running on an AlterG antigravity treadmill. After appropriate healing it becomes time to start overland running. ahs_White-TEAM-xc_4476

We generally recommend that the athlete follow the 10 percent rule, one of the most widely known in running. It does not specify a starting distance but says you should increase your mileage no more than 10 percent a week. The idea is that this is a safe way to increase your distance without risking re-injury. For example, we may recommend a novice young runner to go a total of 4.5 miles in the first week, and then if still pain free increase by about 10% to 5 miles total in the second week.

The interesting thing I find with this “rule”, like many others, is that athletes will often “cheat”. The higher the level runner, the faster they are likely to increase their mileage. And at the other end of the spectrum some athletes will have a recurrence of discomfort and we need to back off and go even slower.

So where did the “ten percent” rule come from? New York Times columnist Gina Kolata wrote a nice piece on the history of the 10% rule. She writes that there is one good scientific study on the subject. Conducted by researchers at the University of Groningen in the Netherlands.

They investigated the 10 percent rule because it is so popular and seemed to make sense with its gradual increase in effort. The study involved 532 novice runners whose average age was 40 and who wanted to train for a four-mile race held every year in the small town of Groningen.

Half the participants were assigned to a training program that increased their running time by 10 percent a week over 11 weeks, ending at 90 minutes a week. The others had an eight-week program that ended at 95 minutes a week. Everyone warmed up before each run by walking for five minutes. And everyone ran just three days a week.

It turns out they had almost the same injury rates – about 1 in 5 runners.

From a practical standpoint running is actually a fairly complicated thing to do, and then to stick with it. The “ten percent rule” might be more fiction than fact but I still find it a good starting point. The key I think is to then adapt the progression to the particular needs of the young runner.

“Nobody found out if it works or what is the basis of it,” wrote one of the Dutch researchers. And that is the way it often goes in exercise science. People “hear something, they read something,” he said, “and then it’s like a religion.”



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The Heat Is Still On. Pay Close Watch For Heat Illness In Football

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • It’s still hot and humid. Young athletes are still very susceptible to heat illness in football. Be on the lookout for signs and take immediate action
  • Allow rest breaks with the helmet removed as often as possible
  • Recognize signs of heat illness and take immediate action if heat illness is suspected

It’s September now but the heat is definitely still on, it’s still summer. The combination of heat and humidity seen in some parts of the country can be particularly dangerous.

In the past decade, 31 football players have died of heat-related illnesses in the United States, according to an annual study by the National Center for Catastrophic Sport Injury Research at the University of North Carolina. Fifty-two players have died since 1995. Forty-one of those deaths occurred at the high school level. 8d931587-cc6e-5987-bdb8-293ffad7fd4a.image

They are all especially tragic, experts say, because each one was 100 percent preventable.

We ask that coaches and trainers pay particular attention to signs of heat illness in July and August when preseason training typically starts but the current weather conditions in September are potentially dangerous too. Don’t let down your guard just because the boys have had a few weeks to acclimate and school has started.

Follow The NATA’s Recommendations

The National Athletic Trainer’s Association has published excellent guidelines on heat illness in young football players.  Here’s what they write on their website:

“The NATA’s Age Specific Task Force recommends that all young players be permitted to remove their helmets during rest breaks during both practices and games, as well as in-between periods and at halftime. With the football helmet on at all times in hot and humid weather, the body core temperature can increase to a greater extent and may play a role in the development of an exertional heat illness. Combining proper hydration, rest and the removal of the helmet for a period of time assists in the reduction of core body temperature and reduces the risk of developing a heat illness.”

Have a plan of action for preventing heat illness, recognize signs of heat illness, and take early action if heat illness is suspected

I’m a huge believer that most preventive strategies must have a clear plan of attack put in place before the start of the season. Even if you haven’t done that you can still take steps now to make sure the few remaining hot and humid weeks are as safe as possible.

  • I’m hoping you have a plan in place from the preseason to put appropriate rest breaks in for the players, with helmets off as recommended by the NATA.
  • Recognize signs of heat illness, as we’ve outlined in several previous blog posts. The NATA and other reputable organizations also have resources available to help coaches and parents recognize heat illness.
    • Decreased performance
    • Fatigue
    • Skin that ranges from pale or sweaty to cool and clammy.  If the skin is hot it’s a red flag!
    • Possibly irritable
    • Nausea
    • Headache
    • Light-headedness
    • May have difficulty paying attention or following directions.

Take immediate action if mild heat illness is suspected

    • Get the athlete off the field and let him lie down in a cool, shaded place.
    • Elevate the legs above the level of the head.
    • Provide a sports drink (not carbonated, no caffeine).
    • Remove helmet, pads, and any tight fitting clothing and remove socks.
    • If the player doesn’t start to feel better within 10-15 minutes, seek medical help.
    • Prevent future dehydration with a good hydration strategy.
    • Heat stroke (a much more severe form of heat illness, in which the athlete’s core temperature rises dangerously high and body system shut down takes place) is a medical emergency. These athletes may be unresponsive and look in serious trouble. For coaches and parents who are not expected to be medically trained, your best course of action is to call 911 or local emergency personnel immediately. Remove the athlete’s pads and helmet, start cooling immediately and as well as you can with ice packs to the neck, armpits, and groin.
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Everyone’s Sore This Week. Is That OK?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Muscle soreness is very common when you start a new exercise, or are coming off a period of rest
  • Most muscle soreness is manageable with simple steps such as active recovery, hydration, proper nutrition, massage, and rest
  • Seek professional medical evaluation for anything that you would describe as persistent pain

It seems this week that every young athlete coming in to the office is sore. Legs sore, arms sore, back sore, sore all over. What’s going on here? Is it okay to be sore and just play through the soreness? Is there anything that can be done to reduce the soreness? When is it time to stop and take a break? sore calf

First of all, you want to make sure it’s muscle soreness and not a joint issue, or a muscle tear. If there was a definite injury event (such as a hard tackle, fall to ground, etc.), if there was a feeling of a “pop”, if there was rapid onset of swelling, or if you are having what you would describe as significant pain then you’ll need a visit to a physician.

If none of those apply to you, and if you have generalized muscle soreness or fatigue you most likely have a common condition called Delayed Onset Muscle Soreness (DOMS).

DOMS happens when you subject your body to a new physical activity, one that your body wasn’t accustomed to doing. Essentially you’ve switched up your workout and surprised your body with something totally new. If you were taking a month off in July and then started aggressive two a day camp in August, your body is doing something new. If you’re an experienced runner who typically runs 3-5 miles on flat terrain and you switch to aggressive hill sprints you’re doing something new. The exact process behind DOMS is not completely understood, but from the athlete’s point of view you’re going to be sore.

Generally it will be okay to continue training through the soreness, as long as you’re not in significant pain and as long as your performance is reasonable. At this time of year many young athletes won’t have a good option- you’ll need to do what’s required of players trying out for a fall sport team.

But there are some things you can do to minimize the soreness. Pay close attention to hydration, proper nutrition, and get as much rest as possible. Massage can also help speed recovery time. If your coach is knowledgeable then he/she has likely put some active recovery time in to the preseason workouts. On those especially bothersome days it would be better to do a light run or stationary bike; something low intensity that will help with blood flow to the muscle and assist the muscle to recover.

At the end of the day you might not have many options, you’ll need to go along with the coach’s plan for the team. In a good program, you should be sore, and then not sore. And then you should be sore again if you add intensity or change up an exercise. In other words, constant pain does not necessarily equal maximum muscle gain. If you’re a young athlete and you’re in pain all the time I’d recommend that you seek professional evaluation from a sports medicine physician. Otherwise, do your best to hang in there. Eventually the two a days will be over!

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Establish a Preseason “Chain Of Command” About Youth Sports Injuries

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent survey was published by Safe Kids Worldwide highlighting important aspects of the culture surrounding youth sports injuries
  • Youth coaches at club and high school levels must be properly educated in basic injury recognition
  • It’s very important to have a discussion with parents prior to the club season to establish a decision process for dealing with on-field injuries

There are some really great points exposed in this recent survey from Safe Kids Worldwide regarding the culture of youth sports injuries. Here are the most relevant points I took away from the survey: Screen Shot 2014-08-19 at 11.37.00 AM

  • Survey was comprised of 1,000 young athletes (seventh through 10th grade), 1,000 coaches and 1,000 parents
  • 42% of players report that they have hidden or downplayed an injury during a game so they could keep playing; 62% say they know someone else who has done so.
  • 54% say they have played injured and 70% of those kids say they told a coach or parent that they were hurt. Top reasons given for playing injured: it wasn’t that bad (18%); couldn’t let the team down (13%); didn’t want to be benched (12%).
  • 33% say they have been injured as a result of dirty play from an opponent; 28% agree that it is normal to commit hard fouls and play rough to “send a message” during a game.
  • 53% of coaches say they have felt pressure from a parent or player to put an athlete back in a game if the child has been injured.
  • 80% of parents favored their child’s youth sports coach receiving certification or at least training in injury recognition
  • But less than half of coaches responded that they had received any injury training

The numbers above are interesting but what I’d really like to point out to you are that the numbers of players with injuries dealt with on the field of play by the coach and parent who do not end up seeing a physician are staggeringly large. We know with good certainty that there are about 1.2 million visits annually to the Emergency Room for youth sports related injuries; we also know with good certainty that about another 2 million visits take place annually to the pediatrician or sports medicine specialist for youth sports injuries. But the real number that is underpublicized is that at least 3 times that number are dealt with each year by the coach without involving a physician. That’s about 10 million injury incidents annually.

Many of those 10 million are really minor bumps, bruises, etc. What if they’re not? And will you as a coach know if it’s something that should be looked at by a skilled professional?

In the preseason it’s really important for the coach and parents of club teams to have an open and honest discussion to lay down some ground rules, what I like to refer to as a “chain of command”. First, the coach must be educated in basic injury recognition. Then, there needs to be a clear understanding that if the coach feels a child should not return to play due to injury that the coach is backed on his/her decision without pressure from parents or players to have the child continue playing. At the high school level there needs to be an understanding that the ATC (or if available the team physician) has the last word on play or no play for injured athletes during a game, and the coach should not have authority to override the professional opinion of the ATC.

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

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

Are You An Expert Performer? Radio CaptainU Interviews Joe Baker, Pioneering Canadian Researcher.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Expert Performance refers to individuals that perform at the absolute highest levels
  • The most important factor in expert performance is training related, and more important than genetics according to Baker
  • Other interesting factors in expert performance are birthdate, being left handed, and emphasis on multiple sports or physical activities at the youngest ages

How does someone get to be the very best at something? These individuals are called “expert performers” by Canadian researcher and noted authority Joe Baker. Is someone just born this way, can it somehow be trained, is there a spectrum of performance through which someone can move from novice to expert?

Well it turns out that all of us can take heart, expert performers can be made and are not necessarily created that way from birth. Certainly there are genetic and environmental factors that will play a crucial role in performance but many individuals can dramatically improve their sports performance, regardless of genetics.

The number one factor in expert performers is training, a person’s ability to take on hard training seems to be a critical factor in success. So to a certain extent hard work, determination, and response to adversity are possibly more important than genetics. Specific training indicators are often age dependent. In the earliest age groups research supports sport enjoyment and basic skill acquisition in multiple sports or physical activity as a very important factor. Later on, emphasis shifts more to sport specificity and seeing results from the hard work.

Another factor they identified is birthdate, called the “relative age effect”. Essentially, when you are young and playing in age group sports, those kids born immediately after the cutoff date for the sport will have a definite advantage in the early going. This factor seems to become less prevalent in adolescence but it’s definitely a factor in the youngest age groups.

A very interesting finding was handedness, apparently a disproportionate number of expert performers are left handed.

Baker’s research is very interesting, but one caution I’d offer is that most of the research on expert performers is done retrospectively, meaning that the researchers identify expert performers and then generally look back in their past to find factors possibly responsible for their development. The problem with any of these retrospective studies is that they might not be predictive. In other words, it’s currently not possible to say to someone “if you do the things that these expert performers do then you’ll definitely become one yourself”. Certainly you’ll improve your performance by following the principles of expert performers so you probably have nothing to lose by trying these things. Go get to work!

Posted in CaptainU, Performance | Leave a comment

The Crucial Importance Of Good Football Helmet Fit

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Proper football helmet fitting is a very important step in reducing risk of injuries such as concussions, facial lacerations, and facial fractures
  • Many high school football players will release air from the air bladders in their helmets during the season to improve comfort, however, this leads to a loose helmet that protects poorly
  • Ideally, helmet fit needs to be checked weekly, especially for air bladder type helmets
  • Steps: if possible, select the best STAR rated helmet you can afford, next you need to follow the manufacturer’s fitting steps, and finally you need to maintain the fit at weekly intervals

This week’s post is short and sweet: make sure your football helmet is properly fitted and that you keep it that way throughout the season.

It’s a simple enough thing, at the start of the season get the best helmet you can and then make sure it’s properly fitted for you.  Following generally well accepted guidelines for helmet fitting will mean that your head does not move around within the helmet, and this will mean fewer chances to get a cut on the skin from excessive movement, it will protect better against facial injuries, and it will reduce the chance of a concussion. OLYMPUS DIGITAL CAMERA

I would recommend that if you have a choice of helmet, that you use the STAR ratings from Virginia Tech and choose the best rated helmet you can afford. Then, make sure the helmet is properly fitted. If you are purchasing from a retail store then the sales representative should be properly trained to fit you; if you are doing this with a team then one of your coaches will be trained to do this. As a parent it might be good to familiarize yourself with the fitting process. USA Football’s informational page is an excellent resource.

During the season many players will modify the helmet fit because they feel more comfortable with a looser fit. I will commonly see players release air from air bladders, excessively loosen chinstraps, or remove padding to loosen the fit. You might be tempted to do this but resist that temptation and keep the fit snug and correct! Consult your coach or athletic trainer regularly to check your helmet. It’s a small price to pay for a big improvement in safety.

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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