Sideline Sports Doc: Why We Do What We Do

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

It’s mid-July and in the heat of the month we’re taking it a bit easy with this week’s post. ESPN Sports Med WeeklyHere’s a link to a recent interview I did with my colleague Dr. Brian Cole and Steve Kashul his co-host of ESPN Radio’s Sports Medicine Weekly. Have a listen to the podcast here.

In the interview I discuss with Brian and Steve the key aspects of the problem as it now stands:

  • Most youth sports coaches receive little or no formal training in the main injury areas common to their sport
  • There’s a significant risk and negative impact on the young player’s health due to the lack of proper training
  • Any training method should cover basic injury evaluation, application of RICE, and the main injury topics specific to each sport (this means knee, ankle, shoulder, etc.- not just concussion!)
  • Our method is sport specific, presented as eBook, mp3 audio, and online course to address multiple learning styles
  • No one else does this! We hope your sport organization will be one of the ones working with us to help make your sport safer and better for your young athletes


Posted in Sideline Sports Doc Miscellaneous | 1 Comment

The “Wild West” Of Concussion Treatment

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • If you have been diagnosed with a concussion and you are having continued symptoms after the concussion event you should be under care from a qualified neurologist or concussion specialist physician
  • Seek guidance from your specialist before starting any concussion recovery treatment
  • Many different types of concussion treatments are available; some are marketed with little scientific support. Be cautious and consult your doctor first.

For this week’s post I’d like to point you to a recent New York Times article highlighting concussion hyperbaricthe explosion of various treatments reported to treat concussion. It’s an excellent read if you have interest in concussion treatments. One company CEO quoted in the article refers to the expanding number of varied treaments as the “Wild West”, with so many methods now available. It seems that the public’s awareness combined with several research studies have contributed to a ripe market for companies developing methods to treat concussion. Some of these will likely turn out to be very useful but the article also sounds a note of caution when considering some of the treatments.

Let’s be clear that the companies and treatments mentioned are being used to treat someone with continuing sypmtoms from a concussion or multiple concussions. Post-concussive symptoms can be incredibly difficult for the individual to deal with since these symptoms can affect just about every aspect of your life. The treatments mentioned here are not used to diagnose a concussion.

Some interesting areas to consider from this article are that many highly touted possible treatments for concussion might eventually prove to be minimally beneficial. It often takes quite a bit of time and rigorous scientific testing to prove the worthiness of a medical treatment and sometimes initially promising results are shown to be less effective when studied carefully.

If you or your child are having continued symptoms after a concussion it’s very important for you to be under the care of a neurologist or other physician with specific expertise in treatment for post-concussive symptoms. Proper treatment will often require the input of many different types of practitioners, with the overall care directed by your specialist.

Be very cautious before starting any treatment with a shorter track record. Make sure to consult your concussion specialist for recommendations specifically tailored to your situation.


Posted in Concussions, Sports Science, Treatment | 1 Comment

The Importance of the High School Preparticipation Physical Exam

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • The Preparticipation Physical Exam (PPE) is a very important part of preseason high school sports readiness
  • The real purpose of the NFL Combine is to do preparticipation physical exams on the athletes entering the NFL draft
  • A high school PPE is designed to ensure the safety of the athlete, and to identify areas where rehab may be necessary prior to the season


We are now roughly 6 weeks before most high school football programs will start summer two-a-days or other intensive preseason training. This means that you should have already completed your clearance physical exam from your doctor, commonly called a “preparticipation physical exam” or “PPE”. Many high school students attempt to skip this important step but doing so could place your season- or your long-term health- at risk. PPE

Just about every NFL fan is somewhat familiar with the “NFL Combine” held each spring prior to the NFL draft. This event is now a mind-numbing televised display of 40-yard dash times, shuttle runs, bench press reps, etc. But how many of you know the real purpose of the NFL Combine?

Well, the real purpose of the NFL Combine is to provide medical exams for the players entering the NFL draft- it is their preparticipation physical exam. The NFL Combine is properly called the National Invitational Camp and the first camp was held in 1982. The need for the camp arose out of a need from team executives and medical staff to determine the physical health of the players entering the draft. Prior to 1982 there was no standardized way to assess player health coming out of college. The Combine was a way to do very detailed health assessments including possible heart and lung ailments, concussion history, and of course orthopedic history. Team medical staff will assign clearance classifications or grades to athletes that often attempt to predict future risk or effects on performance. Many millions of dollars ride on these assessments.

For the high school athlete the purpose of the PPE is a bit less detailed than the assessments at the NFL Combine but no less important. The main objective is to detect possible life threatening or disabling conditions, detect conditions that might predispose the athlete to illness or injury, and to fulfill possible legal requirements from the individual State governing organizations. From a practical standpoint it also gives the physician a chance to work with the athlete in those last few weeks prior to the start of their season to do necessary rehab or training.

Each state high school association has its own rules for conducting the PPE. Your school will typically send out notifications to athletes at least 2 months in advance of the fall school year. Some states may require that a licensed physician perform a comprehensive exam each year, other states require a comprehensive exam at the start of freshman year and then focused updates in the following years. There are some controversies regarding the use of special tests such as baseline concussion tests (for example the King-Devick test or ImPACT test), or baseline EKGs, but there’s one thing we can all agree on: don’t skip your PPE. It’s there to make your season as successful as possible.

Posted in Parents, Prevention, Sports Science | Leave a comment

Why Ankle Sprains Need Rehab

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:


  • Significant swelling, any bruising, or inability to bear weight might indicate a more severe ankle injury. Get an evaluation from an orthopedic surgeon or sports medicine physician for the proper diagnosis
  • Many ankle sprains are undertreated, meaning that they are not properly rehabilitated
  • Good rehab with a physical therapist for more significant ankle injuries can get you back to sports faster and decrease chances for another injury


Last week we wrote about baseball and softball sliding injuries. There are a number of different kinds of injuries that can occur from sliding but by far the most common injury is an ankle sprain. SwollenAnkle_2

An ankle sprain typically happens when the ankle rolls inward following landing from a jump, as in basketball or volleyball, or forceful contact with the bag in baseball or softball. This stretches the ligaments on the outside of the ankle. This is such a common type of athletic injury that it is often undertreated and the athlete can have a chronic problem. It’s important to adequately assess the injury and form a treatment plan that will ensure a prompt and safe return to sports and also ensure that an athlete will have no long-term problems.

Many ankle sprains in young athletes will be mild injuries with little to no swelling and only mild discomfort. These will often improve with RICE (rest, ice, compression, elevation) and allow the player to return to sports after a few days. But some injuries can result in a very swollen ankle, bruising, and difficulty weight bearing. In those instances it’s best to see a sports medicine physician or orthopedic surgeon for a proper diagnosis. This could be a growth plate injury, a bone fracture, or a more severe ankle sprain.

After being evaluated for any bone or excessive ligament damage, the treatment plan will be started. The first stage is to continue the ice, compression, and elevation to minimize the swelling. Sometimes taping or an ankle splint may be used to relieve the pain and reduce further swelling.

As the athlete can gradually bear weight to tolerance, it is also important to start range- of-motion and strengthening exercises. This is where I tend to recommend working with a skilled physical therapist. The therapist can usually start strengthening and coordination exercises that will get the athlete back in shape quickly. I also find that restoring balance is very important in restoring sport specific skills and in reducing the chance for a repeat injury. You’ll be doing a lot of “homework” too, such as work with elastic bands for strength and alphabet writing with the toes for motion. You might find some of these exercises a bit boring but they work!

When an athlete comes to the office with multiple past sprains we often find that they did not go through the proper rehabilitation in their previous sprains. Good rehab is the missing link in these cases. Cutting corners can lead to ongoing issues that make you susceptible to repeated injuries. The right rehab will get you back to playing faster and should decrease chances of reinjury later on.





Posted in Ankle, Baseball, Basketball, Soccer, Softball | Leave a comment

Tips For Preventing Baseball Sliding Injuries

By Daryl Osbahr, M.D.

Level One Orthopedics at Orlando Health

Note: the following post is from the STOP Sports Injuries Blog and appeared on July 24, 2014

While baseball is commonly known as a non-contact sport, the risk of collision is certainly not minimal. Some are due to contact with the ball, bat, or another player, but it is easy to forget that a base can cause injuries. Help young baseball players avoid sliding injuries with these tips from Dr. Daryl Osbahr. 

As the Assistant Team Physician for the Washington Nationals, a member of the USA baseballtournamentBaseball Medical & Safety Committee, and a member of the STOP Sports Injuries Outreach & Education Committee, I work with players, parents, coaches and athletic trainers to reinforce the importance of proper baseball sliding technique. Here are some helpful tips that you can apply in your own life or teach to your children to help avoid a serious injury:

  • Always take time to stretch and warm up properly. This will help you avoid lower body ligament injuries while maintaining flexibility and strength.
  • It is important that proper sliding technique is taught and practiced before using an actual base.
  • Always practice with a sliding bag first. Once the player has learned the correct technique, gradually move to a breakaway base and then, if your league requires it, to a standard, anchored base.
  • Players under the age of 10 should not be taught to slide.
  • When coming into home plate, the baserunner should attempt to slide safely in order to avoid a collision with the catcher.
  • The obstruction rule should always be taught and observed. It is dangerous to get in the way of the runner or block the base without possession of the ball because it could cause serious injury to both the baserunner and the fielder.
  • If league rules allow it, use separate bases for the runner and the fielder to help prevent foot and ankle injuries.
  • Always wear the appropriate footwear. Your cleats should have enough traction to help avoid slippage, but not so much that they can get caught in the turf or injure another player.
  • Know what equipment your league (or your child’s league) is using, and be sure to have a thorough understanding of league rules.

In every situation, prevention is always the best treatment. Together, we can make sliding safer—but it takes an athlete’s entire influence circle to make a difference. The athlete, parents, coach, team personnel and doctors all need to be dedicated to preventing injuries together.

For information about Dr. Osbahr’s practice please visit:


Posted in Baseball, Softball | Leave a comment

Stress Fracture Can Stop Your Summer Running

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • A stress fracture is a type of overuse injury
  • Stress fractures often start with mild activity related pain that never disappears
  • Stress fractures will usually heal with proper treatment, allowing return to sports but the healing process can take a long time


Last week we wrote about an overuse/growth related injury called Osgood-Schlatter syndrome and this week I’d like to focus on another overuse injury: stress fractures.

Here’s a common scenario:

A high school distance runner started developing a slight ache in her inner leg towards the sore calfmiddle of spring track season. She thought very little of it and continued to train and compete. She iced down religiously after training, used a compression sleeve, and used a foam roller. The pain gradually intensified to the point where she needed to pop 3 or 4 ibuprofen pills before every race just to be able to finish. High school season ended, she took two weeks off from running and then went straight into summer training, now using hill runs in preparation for a marathon she wanted to run this July. But the pain worsened immediately on her first training run and bothered her with any amount of walking or even just weight bearing.

When this young woman came to see me the concern was for a stress fracture in her tibia, and we confirmed this with imaging. My suspicion is that she started with a shin splint syndrome but continued to power through the pain. The muscles and soft tissues were unable to support the running stress, the stress transferred to the bone instead, and a stress fracture in the bone was the result.

What is a stress fracture?

A stress fracture is a crack in a bone that results from overuse. It occurs when muscles become fatigued and are unable to absorb added shock. In the scenario above the suspected shin splints ultimately caused bone overload. Eventually, the bone gave out as well and developed a crack.

Stress fractures often are the result of increasing the amount or intensity of an activity too rapidly. They also can be caused by the impact of an unfamiliar surface (a tennis player who has switched surfaces from a soft clay court to a hard court); improper equipment (a runner using worn or less flexible shoes); and increased physical stress (a basketball player who has had a substantial increase in playing time).

Most stress fractures occur in the weightbearing bones of the lower leg and the foot. More than 50 percent of all stress fractures occur in the lower leg. The tibia, fibula, and metatarsal bones are common stress fracture sites.

In my experience runners are most susceptible to stress fracture. Other sports placing the young athlete at risk for stress fracture are tennis, gymnastics, and basketball. In all of these sports, the repetitive stress of the foot striking the ground can cause trauma. Without sufficient rest between workouts or competitions, an athlete is at risk for developing a stress fracture.

Symptoms of a Stress Fracture

Pain with activity is the most common complaint with a stress fracture. This pain typically subsides with rest. If your pain progresses to the point where simple walking is painful, you should see a sports physician. You should also see a sports physician if your pain returns immediately after a period of a few weeks rest. As you can see from the scenario at the top of this post there’s sometimes a progression from shin splints to stress fracture, so if you’re just not sure what you are dealing with then get professional evaluation from a sports physician early on.

How are stress fractures treated?

The most important treatment is rest. Athletes need to rest from the activity that caused the stress fracture, and engage in a pain-free activity during the six to eight weeks it takes most stress fractures to heal. If the activity that caused the stress fracture is resumed too quickly, larger, harder-to-heal stress fractures can develop. Re-injury also could lead to chronic problems where the stress fracture might never heal properly. In addition to rest, shoe inserts or braces may be used to help these injuries heal.


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Growing Pains or Osgood-Schlatter

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:


  • Overuse injuries related to growth spurts are common in certain sports, especially sports involving jumping, sprinting, and rapid changes of direction
  • Osgood-Schlatter syndrome is a very common growth related pain in the front of the knee
  • Osgood-Schlatter can be successfully treated by rest from the activities causing the pain, and allowing gradual return to sports


School’s out now for many kids, and I’m starting to see a lot of kids come through the office to get “tuned up” for summer activities. Typically we are now dealing with a number of nagging overuse injuries, and one extremely common type is pain in the front of the knee. Osgood Schlatter

Pain in adolescent athletes is often called “growing pain” but there are specific age ranges and sports that predispose a young athlete to pain.

“Osgood-Schlatter” syndrome (sometimes called Osgood-Schlatter disease) is one such specific problem. The young athlete can develop a painful lump below the kneecap particularly in children and adolescents experiencing growth spurts during puberty.

Osgood-Schlatter syndrome occurs most often in children who participate in sports that involve running, jumping and rapid changes of direction — such as soccer, basketball, figure skating and ballet.

While Osgood-Schlatter syndrome is more common in boys, the gender gap is narrowing as more girls become involved with sports. Age ranges differ by sex because girls experience puberty earlier than boys. Osgood-Schlatter syndrome typically occurs in boys ages 13 to 14 and girls ages 11 to 12. The condition usually resolves on its own, once the child’s bones stop growing.

Some kids will have only mild pain while performing certain activities, especially running and jumping. For others, the pain is nearly constant and debilitating.

Osgood-Schlatter syndrome usually occurs in just one knee, but sometimes it develops in both knees. The discomfort can last from weeks to months and may recur until the young athlete is finished growing.

How do you treat Osgood-Schlatter’s?

Activity modification is the main treatment for Osgood-Schlatter’s. For those kids that end up in my office we will typically spend a long time carefully analyzing sports, activities, and time spent on each. Treatment generally means cutting back substantially on jumping and sprinting sports until the pain is gone, and then gradually restarting those sports. Other conservative treatment measures include ice, stretching, controlled strengthening, physical therapy, simple over-the- counter pain medicines, and a patellar strap. In more severe cases, a short period of casting or bracing may be recommended.

The good news is that Osgood-Schlatter doesn’t last forever. The hard part is cutting back on activities that cause the symptoms. The symptoms of Osgood-Schlatter’s almost always improve with rest and also usually subside when the athlete finishes growth. In rare cases, a fragment of bone may not unite to the underlying tibia and symptoms may persist into adulthood.

Although extremely rare, an athlete who continues to play vigorous sports with persistent pain from Osgood- Schlatter’s may develop a complete fracture through the growth plate at the top of the tibia. Usually, however, the only long-term consequence of Osgood-Schlatter’s is a residual bump on the front of the knee that does not interfere significantly with sports.


Posted in Knee | Leave a comment

Yoga Catching On With Young Athletes

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Participation in yoga is increasing amongst all age groups in the United States
  • When done correctly, yoga has many benefits for young athletes in improving core strength, flexibility, and psychological benefits
  • Some poses may need to be avoided or modified if the athlete has some pre-existing medical conditions, such as avoiding lunges if you have Osgood-Schlatter syndrome


This week we’ll continue the discussion of sports and activities outside of team sports. Last week we looked at some aspects of dance, and this week focus on yoga. kids yoga

Various estimates of yoga participation in the United States appear to show increases in all age groups. It’s generally believed that the percentage of U.S. adults who said they practice yoga increased from 5.1 percent in 2002 to 9.5 percent in 2012, according to one survey conducted by the National Institutes of Health and the Centers for Disease Control and Prevention. Yoga participation amongst kids is also on the rise: the percentage of children ages 4 to 17 who do yoga increased from 2.3 percent in 2007 to 3.1 percent in 2012.

I’m generally a yoga fan, although there’s quite a bit of commercialism surrounding mainstream yoga. Yoga encourages balance, strength, proper

posture, improved breathing, control, and awareness of one’s body, and has potential mental benefits as well. We are seeing some more injuries than we did several years ago, but with a few simple guidelines, many of these injuries can be prevented or limited. Additionally, when working with an experienced instructor, yoga may be helpful for injury recovery from numerous orthopaedic conditions such as common strains and sprains.

There are several types or disciplines of yoga. Not every form is friendly for beginners and some can be quite strenuous. Depending on your athleticism, fitness, flexibility, and conditioning as well as pre-existing medical conditions, you should choose a style that fits you well. You should also communicate your goals and needs with the instructor before embarking on a new program.

Injuries can be avoided by knowing your limitations. If you have pre-existing medical problems or extremity injuries, consult your physician or orthopaedic surgeon prior to starting or renewing a yoga program. Discuss any pre-existing conditions with the yoga instructor before starting a class. They may want you to avoid certain poses or positions.

Typically, injuries occur when participants attempt a challenging pose or posture without having the initial capability, flexibility, or strength to perform that maneuver or when the pose is performed improperly. In yoga,

it is better to do a portion of the maneuver perfectly than to push from poor alignment into a full pose.

Two common areas for potential problems are with pre-existing conditions such as Osgood-Schlatter syndrome in the knee or Sever’s syndrome in the heel. If a young athlete has these conditions you’ll likely need to modify or avoid some poses, such as avoiding lunges.

With proper techniques and guidance yoga can be extremely rewarding both physically and mentally. Following this straightforward advice, injuries are unusual and the disciplines can be quite beneficial for core and postural strength, balance, and flexibility.


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

Keep Moving When You Dance

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Dance classes are very popular amongst adolescent girls, but a recent study shows that only about one third of a typical dance class involves moderate to vigorous physical activity
  • Several organized sports practices as well as dance activity might be improved to encourage larger amounts of movement based activity


You would think that dance equals movement, right?

Many prominent national health and medical associations recommend that children and ballet classadolescents participate in at least 60 minutes of moderate to vigorous physical activity on most days of the week. There are multiple physical and psychological benefits of that type of activity, however, several studies have shown that in general only 42% of children and 8% of adolescents are meeting these guidelines. It’s no secret that starting at the youngest ages we’ve become a much more sedentary society.

The emphasis has shifted away from the schools to provide physical activity, and these days a considerable amount of physical activity among adolescents occurs after school in structured or organized programs such as sports teams or dance lessons. Dance is particularly popular among girls, which means it has the potential to make up the gap in physical activity typically seen in adolescent girls. Dance has many health benefits such as muscle and bone strengthening, increased flexibility, improvements in balance and spatial awareness, and enhanced cognitive functioning.

A recent published study attempts to put some objective data behind the amount of physical activity typically found in dance class. New research shows that over all, the level of physical activity in children’s’ and teenagers’ dance classes is surprisingly low. On average, students spend only about one-third of their class time in moderate to vigorous physical activity.

The study used accelerometers to measure activity. Accelerometers can underestimate actual activity since they measure arm or upper body movement, but still the amount of activity the kids spent actually moving is quite low. In fairness to the dance instructors, their dance classes are usually designed around teaching dance skills and are not the type of dance class found in an aerobics studio. Dance instructors in dance studios are there to promote an art form, which is a great idea.

But the takeaway lesson is that many types of sport or dance activity don’t actually involve a lot of activity. In my experience this is certainly not limited to dance. If you observe many types of organized sports practices you’ll find a lot of kids standing around as instructions are yelled at them, or as drills are done in a sequential one v one design.

As a coach or instructor you’ve got a great opportunity to structure your sessions around more movement, which will usually lead to a better, fitter young athlete. And as parents spend some time observing the sessions and if necessary encourage more vigorous activities.



Posted in Dance, Sports Science | Leave a comment

Exercise For Your Vision Might Save Your Brain

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University


Key Points:

  • Published research from the University of Cincinnati shows that visual field training has the potential to significantly reduce concussion rates in college football
  • This very early research needs to be repeated for applicability in youth and high school football as well as other sports, but may have promise


I do hope that someday we’ll have a tighter handle on reducing concussion risk so we won’t have to write about it quite so much, but until then I’ll continue to highlight some developments in science that could benefit young athletes. This week I’d like to focus on an interesting preliminary study from the University of Cincinnati showing that training for improved peripheral vision has the potential to decrease the incidence of concussions in football. W_EagleVisiontraining

Peripheral vision training has become commonplace as a performance enhancement tool for some sports. Training athletes for better peripheral vision reportedly improves a batter’s ability to hit a baseball, a tennis player to return a serve, a quarterback to see receivers, and other sport specific tasks. Fighter pilots and NASA astronauts use peripheral vision training to improve their critical job performance.

Is it possible that improving peripheral vision might somehow allow an athlete to avoid the serious hits that lead to a concussion? Would improved peripheral vision decrease the blind side hits that lead to an unexpected jarring of the head and neck? Researchers working with the University of Cincinnati football team conducted a study to find out.

From 2006 to 2009, the University of Cincinnati football team averaged about nine concussions a year. From 2010 to this most recent season, the team’s average concussion rate has dropped below two a year. Researchers attribute the large decrease in concussions to peripheral vision training for the players using a Dynavision light board on its football players.

The theory behind the improvement is that improved peripheral vision allowed the players to avoid the most vulnerable positions that would typically result in an unexpected impact. By seeing and sensing the impact before it happens the player is in a better position to protect himself from the hit and thus have a chance to avoid a concussion. You can read the study here.

My initial take on this study is that it is promising, especially for collegiate football, it makes sense, and certainly can’t hurt. We will of course need additional research to prove that the vision training caused the decrease in concussions, but this small study is very interesting. It’s also hard to say how applicable the training would be in reducing concussions in sports with different concussion mechanisms, such as soccer where many concussions occur in head to head impact while trying to head the ball. It would also need some data in younger age groups, and cost is likely to be an issue for high schools.

So more research is needed, but visual training is catching on in sports at the youth level, in college and beyond. The hope is that by seeing the field of play in a different light, more athletes will avoid a concussion that takes them out of play.


Posted in Concussions, Football | Leave a comment