Creating a Safe Playing Environment for Your Athletes

Author: NCSS Information Team

As a coach, you are ultimately responsible for the safety of your athletes. Creating a safe playing environment for your students can significantly reduce the number and severity of injuries during your practices and games. The National Center for Sports Safety has outlined a few guidelines to help you create a safe playing environment.

  • Develop an emergency action plan and make sure all of your assisting coaches are familiar with the emergency procedures.
  • Always have an accessible, working phone at practice and at games to ensure that emergency personnel can be contacted quickly in case of an emergency. Make sure that your first aid kit is with you at all practices and games. Always have water or sports drinks available for your athletes, giving them numerous breaks to prevent dehydration.
  • Examine your playing fields, courts and other surfaces before practice and games for potentially dangerous obstacles such as holes, loose tiles, buckled wood, wet spots and sharp objects.
  • Regularly check the players safety equipment before practice to make sure it is put on correctly and that nothing is cracked or missing pieces. If equipment is damaged, do not let the athlete use it.
  • Make sure to store unused equipment away from the playing field so that no one trips over it while playing.
  • Encourage your athletes to be aware of any unsafe playing conditions and report them to you.

Preventing Heat Exhaustion and Dehydration

Author: Amadeus Mason, M.D.

Heat-related illness and dehydration syndromes have always been concerns for coaches, athletes and their parents. Each year heat-related illness and dehydration syndromes affect thousands of athletes at all levels and continues to be among the leading causes of preventable sports injury and death.

What are we talking about? Heat-related illness and dehydration syndromes include heat rash, heat cramps, heat exhaustion and heat stroke. These should not be seen as individual entities but as part of a continuum. The earlier the intervention, the better the odds of averting a disastrous chain reaction.

How does this work? The skin is the key to the body’s ability to regulate its temperature (thermoregulation). Once the brain senses that there is an increase in temperature, it initiates thermoregulatory mechanisms. The skin is the main cooling organ. It maximizes heat loss by using radiation, convection, conduction and evaporation. Radiation – heat is directly lost to the atmosphere. Convection – heat loss is facilitated by moving air or water vapor. Conduction – heat loss by direct contact with a cooler body. Evaporation – heat is lost by turning liquid (sweat) into vapor (the skin’s major heat loss mechanism).

It’s not so much the heat, it’s the humidity. If the skin is so effective at cooling, why do athletes get into trouble? First, for any of the skin’s cooling mechanisms to work, there needs to be adequate skin exposure. The problem is the much-needed sports safety equipment does not facilitate optimal skin exposure. Secondly, the environment needs to be conducive for heat transfer from the body. The combination of high temperatures and humidity severely impair the cooling mechanisms, especially evaporation. It is often the environment that athletes are training and competing in. For morphologic and physiologic reasons children do not adapt as effectively when exposed to heat stress, making young athletes more susceptible to heat- related illness and dehydration syndromes.

What can you do?

Stay cool:
  • Work out in early morning or late evening.
  • Avoid the hottest times of the day.
  • Reduce the intensity and duration of your workout.
  • Take the time to get into shape before arriving at training camp. Know the climate you are going to and try to get acclimated before getting there.
  • Take frequent rests and remove your headgear. The head has an ideal body-mass to surface-area-ratio to maximize heat loss.
Stay hydrated:
  • Drink often and drink regularly.
  • Do not rely on thirst, by the time you are feeling thirsty, there is already a significant fluid deficit.
  • Drink more than just water. When you exert yourself, you lose electrolytes as well as fluid. Replacing the fluid alone (with just water) can lead to electrolyte imbalances. These imbalances can be life-threatening.
  • Monitor your urine, it should be the consistency of lemonade, not apple juice.
Stay healthy:
  • Eat and sleep well. Maintain a well-balanced diet. Replenish salt and rehydrate.
  • Avoid alcohol, soda, caffeine and other stimulants.
  • Gain or lose weight slowly, allowing your body time to acclimate to the change.
  • Sharp drops in weight after exertion can be an indicator of excessive fluid loss.
  • Know the warning signs of heatrelated illness and dehydration syndromes.
What to look for?
  • Confusion – cannot remember simple things,complete simple/routine tasks.
  • Irritability – a change in temperament.
  • Belligerence – easily frustrated, compounded by the confusion and irritability.
  • Light headedness
  • Incoordination
  • Fatigue – in excess of what would be anticipated. Paradoxical chills – goose bumps and shivering in the face of high environmental temperature (an ominous sign).
If you or some one else is exhibiting these symptoms:
  • Stop the activity immediately.
  • Move to a cool (shaded) area.
  • Get some fluid (water, sports drink, IV).
  • Contact a health professional or your sport safety certified coach.
So where do we go from here?
  • In hindsight, most cases of heat related-illness and dehydration syndromes could have been prevented and should have been predicted. With a working knowledge of heat-related illness and dehydration syndromes, a moderate level of suspicion and a little common sense, everyone can get through two-a-days safely (even in the dog days of August).
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Safety Checklist for the Parent

As a parent, you play an important role in the safety of your youth athlete.

These tips will be helpful as you strive for an injury-free season!

  • Be proactive about safety issues; learn about the risks posed by the sport your child plays.
  • Insist that coaches receive training in first-aid and injury prevention and bring a properly stocked first-aid kit to all games and practices.
  • Guard against overuse injuries; don’t let your child play the same sport year-round.
  • Demand safe fields and equipment, such as anchored goals and emergency telephones.
  • Ask about the weather policy of your child’s league or club; if it doesn’t have one, adopt your own.
  • Protect your child from the dangerous coach. Ask your club to run background checks on coaches.
  • Get your child’s league or club to set up a risk management committee.

Author: NCSS Information Team

It is not only important for coaches to be prepared in emergency situations, but for parents and friends to be prepared as well. The National Center for Sports Safety recommends that spectators carry a first aid kit of their own to games and practices. This kit should include the items listed below.

  • Sport Safety Training Injury Prevention and Care Handbook
  • Non-powdered Barrier Gloves
  • Resuscitation mask/face shield
  • Cold Pack
  • Bandage Strips
  • Patch Bandage
  • Elastic Fabric Flexible Bandage
  • Kling Roller Gauze
  • Eye Dressing Kit (Eye Patch and Clear Medical Tape)
  • Eyewash
  • Adhesive Tape
  • Antibiotic Ointment
  • Anti-septic wipes
  • Alcohol Wipes
  • Triangular Bandage for sling
  • Insect Sting Ointment
  • Hydrocortisone Cream
  • Sun Block (30) SPF
  • Insect Repellant
  • Scissors
  • Tweezers

Author: Lyle Micheli, MD-Children’s Hospital Boston

Asthma is a disabling lung disorder characterized by wheezing and shortness of breath that affects an estimated eight million Americans.

Most doctors and nurses are familiar with the diagnosis and treatment of asthma, but much less is known about exercise-induced asthma. As the name suggests, this condition is brought on only by exercise. If your child shows signs of being out of breath even after mild exertion, he should be checked out for exercise-induced asthma.

Exercise-Induced asthma tends to begin in childhood. When a child has Exercise-Induced Asthma, he soon learns that physical exertion causes discomfort, though he may not recognize the symptoms. He may start to avoid exercise and become withdrawn, solitary, and sedentary. Since these children can’t exercise without suffering an asthma attack, they often think they are “unathletic.” This problem can be compounded if the primary care physician doesn’t recognize the condition as exercise-induced asthma and parents attribute the child’s unwillingness to participate in sports and fitness to a lack of “drive” or competitive spirit. As a result, many children with undiagnosed exercise-induced asthma drop out of sports altogether. This leaves them at higher risk of becoming obese and of not developing good heart-lung and bone-muscle fitness.

As adults, Exercise-Induced Asthma sufferers may be more vulnerable to a host of diseases due to inactivity, including heart disease, lower-back pain and osteoporosis. Most children with exercise-induced asthma don’t know they have asthma, and therefore don’t seek treatment to improve their condition. But with proper diagnosis and treatment, their world can expand dramatically. Asthma is one condition for which drug treatment can be truly liberating.

The most common drug recommendation for exercise-induced asthma is pre-treatment with Albuterol, an inhaled medication typically used for quick-relief during an asthma attack. In the case of exercise-induced asthma, it is used before the child engages in a physical activity and before asthma symptoms occur. Two puffs taken 15 to 20 minutes before starting a physical activity or sport is usually recommended. How can kids with asthma and exercise-induced asthma safely and successfully participate in strenuous sports? Asthma itself is not reason to avoid exercise. The vast majority of people with asthma show no deterioration of lung function even after repeated asthma attacks. If medication is taken to prevent attacks during exercise, the capacity to exercise should be as great as in people without asthma.

Advice to young athletes with exercise-induced asthma

Perform a warm-up (15 minutes light intensity, followed by 15 minutes moderate-to-high intensity) before training or competitions

  • Avoid training in cool or dry weather conditions
  • Avoid training in areas such as forests or grass fields where there may be pollen
  • Avoid training in polluted air
  • Wear a face mask when training in cold weather conditions

While drugs are an essential treatment for exercise-induced asthma, so is physical training, which can dramatically improve resistance to attacks. Because running for more than six minutes may trigger an asthma attack, short-duration “interval training” regimens are the most effective for improving lung function. Most exercise programs for people with asthma stress a combination of running and rest, or running and walking. The intervals should be short: two minutes of running and four minutes of rest, building up to five minutes of running and 10 minutes of walking or rest.

Exercise Recommendations for Improved Lung Function

  • Warm up with a combination of running and rest, or running and walking.
  • Start with: Two minutes of running and four minutes of rest
  • Build up to: Five minutes of running and 10 minutes of walking/rest

Eventually, through a properly conducted exercise program, children with asthma will be able to increase their heart-lung endurance considerably. Several coaches have reported that children in their programs with asthma show fewer symptoms as the season progresses, but when the season is over and they get out of condition, there is a much higher incidence of asthma attacks. This fact reinforces the need for cardiovascular conditioning for children with asthma. One of the most important decisions for children with asthma and their parents is choosing the right sport. Outdoor endurance sports, such as soccer and cross-country skiing, are most likely to trigger an asthma attack. Particularly in a cold, dry environment, sports that mix short bursts of activity with rest periods, such as baseball, tennis, and sprints, are more suitable. Indoor swimming with its warmth and high humidity is perhaps the ideal sport for a child with asthma. A combination of conditioning, drugs, breathing exercises and the right sport will enable the vast majority of children with lung disorders like asthma to participate safely and successfully, and to receive all the physical benefits and pure enjoyment that sports offer.

Source: Adapted from The Sports Medicine Bible for Young Athletes by Lyle J. Micheli, M.D., Sports Medicine Director, Children’s Hospital Boston, with Mark Jenkins (Sourcebooks, Inc., 2001).

Coaches, Welcome to the AHSAA Sports First Aid Health & Safety Course

Complete your required Sports First Aid Health & Safety Course online from the National Center for Sports Safety, based in Alabama!
  • AHSAA PREPARE Sports Safety eLearning course satisfies the “AHSAA Sports First Aid Health & Safety for Coaches.”
  • It takes approximately 2.5 hours to complete online, but does not need to be completed at once–you can stop at the end of any module, save and return.
  • Purchase price of $85.
  • By using this course, you are helping to fund an Alabama-based nonprofit.
  • Coaches receive an AHSAA PREPARE certificate of completion upon successfully completing the course.
  • *Certificates should be filed with your school’s athletic director or principal and kept for your records.
AHSAA PREPARE Sports Safety Course
  • Click here to register and purchase the AHSAA PREPARE Sports Safety Course.
  • Already registered for the AHSAA PREPARE Course, click here to log back in.
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Fair Warning

Author: Dr. Richard P. Borkowski

Asking student-athletes and their parents to read, understand, and sign an informed consent form lowers injuries—and helps keep you out of court.

In 1982, a catastrophically injured high school football player at West Seattle (Wash.) High School was awarded $6.3 million when the school district was found liable for the injury. The athlete, Chris Thompson, was not warned about the dangers of lowering his head during a tackle. This now-famous case shook the athletic world.

Since then, the duty to warn athletes about the risks in their sport has remained a significant and misunderstood responsibility.

“You’re kidding!” a coach shouted during a workshop. “You mean I can get sued if I don’t tell my catcher he could injure his hand? Where do I turn in my resignation?”

For many coaches, warning athletes about potential injuries seems counter-intuitive. After all, everyone knows you can get hurt in athletics, right? So why do you need to spell out the details? The main reason for informing students about the potential risks of participation is that it actually lowers the chance of injuries. When people understand the risks, they are better able to avoid them. In addition, warning those in your charge demonstrates your credibility and shows you care.

You may also wish to inform students to reduce your liability. Most schools do this by requiring the athletes to sign an informed consent form. This form is a major tool in meeting your duty to warn participants, and it may be your best protection against a lawsuit.

While some schools choose, instead, to use a waiver form, informed consent forms offer more information and have less chance of being repudiated than waiver forms. Waivers are usually only short exculpatory statements—meaning they clear the coach and school of fault and guilt. The informed consent form, on the other hand, is both exculpatory and educational. The extra step of providing information on the risks is an important one because student-athletes under 18 years of age (in most states) cannot legally waive the negligence of a program if they are unaware of the risk.

However, there is not one “standard” informed consent form that works in all situations. These forms should be unique to your school and the sport. They should also be reviewed by your
institution’s lawyer before being used.

The Document

The objective of the informed consent form is to give the player knowledge, understanding, and appreciation about the values and potential problems of participation. Essentially, it is an agreement to participate.

To start, the heading on the form should be descriptive and in large print. All key words, such as “Warning,” “Attention,” “Please Read Carefully,” and “If you have any questions …” should be accentuated.

The form should do the following:

  • It should inform the player he or she is volunteering to participate. It should explain the values and potential injuries of participation so that the athlete can decide whether the risk of injury is worth the reward of participation.
  • It should explain that safety is a shared responsibility. The athlete should understand that he or she also has a responsibility for his or her own safety.
  • It should state that its signer understands the requirements of the activity. This could include the need to be properly conditioned, check equipment, and report all injuries.
  • It should be sport specific, mentioning the potential injuries in the sport.&

Toward the bottom of the form, the signer should be asked if he or she understands and accepts the risks of participation. For example, a sentence such as “I recognize that (the activity) can be a hazardous activity” should be included.

The most meaningful phrase is the notification that the player will not hold the school (including coach, administrators, board of education, etc.) responsible for any injuries that occur and that the signers assume full responsibility for their actions. Place this clause close to the area for signatures and the date.

Seek your school’s legal counsel in the final preparation of your informed consent form. They are the professionals and they will include the necessary legal terms, such as “I agree to hold harmless,” and/or “I release …”

The signing must be of free will; it cannot be coerced. In addition, both parents and athletes must sign it. Give a copy to the participant. Keep the original.

Don’t Hide It

A fellow coach bragged to me that he was already aware of his duty to warn and inform his players. “During equipment handout time,” he said, “I place the forms on the floor at the end of the equipment line. They put them on my desk after signing them!”

This is not the approach to take when it comes to informed consent forms. The idea is to make the distribution, reading, and signing of this form a significant event. The form should not be buried somewhere in the middle of a manual or handed out when you have two minutes to spare. In fact, the best idea is to hand out the form at a preseason parents meeting for both athletes and
parents. Ask parents and athletes if they understand all the points of the form. Ask them what other questions they have.

Check the Form

An in-line hockey rink seemed to be on the right track when it required each participant to complete an informed consent form. Its procedure was to give the captain of each team the forms to be signed. During the process of a lawsuit following a shoulder injury, it was found that neither the injured party nor any parent signed the consent forms. The captain signed them all! The lesson here is simple: Check the form. In this case, a prudent administrator would have taken the time to review the forms.

Signed informed consent forms do not mean coaches are relieved of their duties to maintain safe activities. Nor do they mean discussion on the topic is finished. Rather, they are a first step for getting the coaches and athletes on the same path toward a safe season.

Richard P. Borkowski, EdD, CAA, is a sport safety consultant based in Narberth, Pa. The former Director of Physical Education and Athletics at the Episcopal Academy in Merion, Pa., his most recent book is titled The School Sports Safety Handbook, published by LRP Publications, in Horsham, Pa.
http://www.momentummedia.com/articles/am/am1204/ovowarning.htm

Developing an Emergency Action Plan

Author: NCSS Information Team

Preparation is the key to responding to unexpected emergencies. While people talk about emergency action plans, it is imperative to get it in writing. You may think you’ve got everything covered in your head, but the best way to cover all the bases is to put it in print.

Every program and facility should have an Emergency Action Plan. This is the only way to be ready for potential emergencies. Although emergencies can occur anywhere, certain types of emergencies, such as specific natural disasters, are more likely in some locations than others. Emergencies not only include injuries, but illnesses such as heart attack, seizure, or stroke.

An Emergency Action Plan should include all relevant categories and emergencies. This plan should outline the responsibility of everyone that may be involved, and should cover the following areas:

Layout of the facility

Plan where EMS personnel will enter and exit the field. Have a designated place for all keys that open gates or doors to the playing service so that emergency services can come in or students may be evacuated. Decide on the location of rescue and first aid equipment and always have a working phone nearby with emergency telephone numbers posted.

Equipment

Make sure that your first aid kits are fully stocked and you have access to emergency equipment such as flashlights, fire extinguisher, etc. Also, make sure to have physical forms and medical release forms for your athletes easily accessible.

Support Personnel (within the facility)

Evaluate which support personnel will be with you at the practice or game. This could include coaches, athletic trainers, athletic officials, facility administrators, management personnel, teachers, school nurse/physician, athletic director, clerical personnel and maintenance personnel.

External Support Personnel

Provide posted telephone numbers for EMS personnel, police, fire, hazardous materials (Hazmat) team, Poison Control Center, hospitals, power and gas companies and health department. Staff Responsibilities Assign each staff member a duty. There should be a person(s) to provide care, a person(s) to control bystanders and supervise other athletes, a person(s) to meet EMS personnel, and a person(s) to transport the injured athlete when appropriate.

Communication

Make sure it is clear how and when to call 911 or the local emergency number. Create a chain of command within your facility support personnel. Make sure there is a person to contact the injured student’s family or guardian, and a person to deal with the media.

Follow-up

Decide who will be responsible for completing the appropriate documentation (accident and incident report, etc.) and refilling your first aid kits. Put together a team to evaluate the effectiveness of the Emergency Action Plan and conduct a staff debriefing.

It is vital to have strategies and procedures in place prior to a crisis. By developing an Emergency Action Plan, you will be prepared to handle emergency situations at your practices or games.

Signs of a Safe Weightroom

Author: Dr. Richard P. Borkowski

General Guidelines, Size and Color, Shapes, Subject Matter, General Rules and more.

Coaches and fitness instructors have a responsibility to present the benefits of weight training. They also have a duty to warn individuals about the potential dangers associated with participation.

Strategically placed and well designed signs are an inexpensive, simple and too often overlooked strategy to inform and, at the same time, warn weight room users. Signage may not insure a participant’s safety but it can lower the chance of injury. Well planned signs help us meet our duty to warn and inform while lowering the chance of injury. They also demonstrate your concern and credibility.

Consider the following game plan for your weight room.

General Guidelines

Ask yourself, would a sign or label improve safety? Where would they be most conspicuous?

  • Signs are to help, not to decorate and not to confuse.
  • Signs should be simple, short and clearly stated.
  • Signs are not replacements for good instruction and supervision.
  • Signs should be placed at the sight line of the majority of those who will be using the facility. This is usually between 5′ to 7′ high.
  • Labels should be placed so that the user can see them! I’ve seen labels placed behind seats, facing walls and on top of machines–all less effective examples!
  • Avoid multiple information signs. Listing 21 rules is a lecture, not a safety sign.
  • Keep signs as positive as possible. Signs that start with “Do Not” are generally ineffective.
  • Orientation should include pointing out the signage.
  • Replace all damaged, illegible or missing signs.
  • Manufacturers generally supply labels. They should address the possibility of injury or death if caution is not used.
Size and Color

Wall sign letters should be at least 2″ high. Key words, such as “Warning” or “Caution,” should be at the top and about two to three times the size of the other print. Remember to place contrasting colored strips on steps. A one to two inch wide strip is normal. Some colors grab attention better than others. For example:

  • A danger sign is usually white letters on a red background.
  • A warning sign is usually black letters on an orange background.
  • A caution sign is usually black letters on a yellow background. A general safety sign is usually white letters on a green background.
  • Borders should also be contrasting.
Shapes

Different shapes can be used to emphasize meaning. For example:

  • Rectangular signs generally mean information.
  • Triangle signs mean caution.
  • Eight sided signs mean danger.
  • A circular sign can be eye catching.
Subject Matter

Colors and shapes are important, but even more important is the information that these signs convey. Use only simple words, phrases or graphics that are easy to understand. Use only internationally accepted graphics. Remember that simple words are better than complex graphics. However, symbol signs may be more helpful to multi-cultured users than words. Sign subjects include: ?Information, such as “Replace weights to storage racks.”

  • Warnings, such as “Always use a spotter.”
  • Exit signs.
  • Rules of the Weight Room (see sidebar). Phone and emergency numbers.
  • Motivational signs.

Weight Training Rules

General Rules
  • Only students who have passed the instructional course may use the weight room.
  • The room may be used only with proper supervision.
  • Shirt and shoes are required.
  • Proper stretching, warm up and cool down are required.
  • No spectators allowed.
  • Never interfere with the exerciser.
Concerning Machine Weights
  • Read the information label before using.
  • Keep pins in the machines.
  • Avoid quick movements.
  • Never drop weight plates.
Concerning Free Weights
  • Spotters must be used.
  • Use collars.
  • Return all weight plates to racks

Chronic or Overuse Injuries in Sports

Author: Joseph Iero, M.D.

The most common disorders seen by sports orthopaedists as well as the general orthopedic are the overuse injuries. All active persons, from the elite athlete to the “weekend warrior,” are subject to these injuries that typically become chronic because they do not cause enough discomfort to cause the athlete to stop participating in their sport. The athlete will usually consult a trainer or coach initially, and if symptoms continue or worsen will look for medical advice. Many of these injuries are brought on by insufficient recovery time. Some are nagging injuries following an acute event, which never is allowed to heal. There are many overuse injuries of both the upper and lower extremities that can cause an athlete to perform at a lower level.

Chronic injuries of the upper extremity include: rotator cuff tendonitis, tennis elbow (lateral epicondylitis), golfer’s elbow (medial epicondylitis), DeQuervain’s tenosynovitis, cubital tunnel syndrome, and carpal tunnel syndrome. Although there are many more disorders, these are some of the more commonly seen problems. Rotator cuff tendonitis is associated with overhead activity- especially with throwing athletes. The rotator cuff is a broad flat tendon comprised of four muscles. Together, they keep the head of the humerus centrally located throughout the range of motion of the shoulder joint. Overlying the tendon is a bursa, or a fluid-making sac, which can become inflamed as well. Patients will commonly complain of pain with overhead activity, problems sleeping on the shoulder, and possibly weakness of the shoulder, secondary to the pain while using the shoulder. The initial treatment for this type of chronic shoulder pain is activity modification (stop performing exercises that cause the shoulder to hurt), anti-inflammatory medicines (if no contraindications), icing and other modalities, and a physical therapy program designed to first achieve painless motion, followed by strengthening of the arm. Once these have been accomplished, a gradual return to normal activity is allowed.

Tennis and golfer’s elbow are basically the same entity on opposite sides of the elbow. During a golfer’s downswing, the lag arm has stress placed on the inside, or medial aspect, of the elbow. Likewise, during a backhand, the tennis player will stress the lateral or outside of the elbow. This repetitive stress can cause multiple micro-traumatic events that can cause the origin of the forearm flexor muscles (golfer’s elbow) or wrist extensors (tennis elbow) to develop tears and degenerate. This degeneration can cause pain and loss of strength. Normally, symptoms will abate time by combining rest, stretching, anti-inflammatory medicines, and occasionally a strap used to offload the area. However, like the name implies, these can cause long-term pain and dysfunction. If all non-operative treatment fails, there are some procedures that can alleviate symptoms.

DeQuervain’s tenosynovitis is a problem in the first extensor compartment of the wrist, caused by repetitive lifting or extending the wrist. The initial treatment starts with icing; anti-inflammatories, stretching, and can include an injection and splinting. The lower extremities are also frequently involved. These injuries can range from “nagging” problems with tendonitis and bursitis to the more serious stress fracture. Most of the lower extremity problems are caused by the repetitive nature of running, jumping or dancing. There are multiple sites in the lower extremities that can be involved with a bursitis or tendonitis. The most common sites are: the lateral aspect of the hip (greater trochanteric bursitis), the front portion of the knee (patellar tendonitis or pes anserine bursitis), and the posterior ankle (Achilles tendonitis). The treatment for all of these is activity modification, icing regimens, stretching, anti-inflammatories, and physical therapy.

While overuse injuries can cause months of distress and lost playing time, they are not as serious as a stress fracture. Stress fractures are commonly seen in the foot, lower leg and the hip. These injuries require diagnosis and treatment by an orthopaedic surgeon. Often this diagnosis can be made with a combination of a history, physical exam and x-rays. Sometimes an additional test, such as a bone scan, is needed to secure the diagnosis. Stress fractures of the metatarsals are treated with modified weightbearing, casting, and sometimes surgery. These same treatments are needed in the treatment of the lower leg stress fractures. Stress fractures of the hip are serious, and can be an emergency. Patients commonly complain of groin and knee pain. This injury is rare, but is usually seen in people who log many miles, such as long distance runners and military recruits. When suspected clinically, X-rays along with a MRI or bone scan, are used to confirm the diagnosis. These fractures commonly need to be “pinned” or secured with internal devices such as screws. If not caught early, they may go on to move apart and can have a poor outcome, with hip arthritis being the result.

Keeping all of this in mind, overuse or chronic injuries are commonly diagnosed and usually require a period of rest, combined with therapy and medications. They may need a longer time to heal than the athlete would like, but most will resolve with little or no long-term problems. Occasionally, a seemingly innocuous injury can be serious. If an athlete has tried treating the injury and the problem persists, he or she should consult a physician.

Crisis Management Plan for Youth Sporting Events

Author: Jeff Konin, PhD, PT, ATC, University of South Florida

Medical emergencies are inevitably a part of all youth sporting events. Unlike at professional and most intercollegiate games where properly trained medical personnel are employed and on hand immediately, such situations are often handled impromptu at youth sporting events by those who happen to present at the event. In many cases it is the coach, in some cases a caring parent, and yet sometimes by luck of the draw a parent or fan also happens to be in the medical profession. Our children are all too valuable for us to allow for a randomized method of care when it comes to medical emergencies. Today, more kids than ever are participating in organized sports, and many of these at ages younger than we as parents could ever imagine. Did you really think that there would be organized soccer leagues for 3 year olds? Or what about t-ball for kids who have just barely mastered the developmental phase of walking? Either way, there is a large increase in participation that has not been matched by an increase in accessible medical care at these events.

It is probably unrealistic to expect that we will see the same type of medical coverage at youth sporting events that we see at professional events anytime soon. However, it is important that we prepare in an equally as important manner to be ready for medical emergencies. After all, it is the least we can do and we owe it to our children! The most secure method of managing a medical crisis at a youth sporting event is by establishing, disseminating, and implementing a standardized and well-designed crisis intervention plan. Standardized crisis intervention plans are utilized in high school and university settings, as well as professional sporting events. There is no reason that the same type of planning and implementation can’t be integrated into youth sporting events.

They key to reaching the goal of having a comfortable plan in place is a step-by-step process that is assessed on a regular basis to be sure the plan remains accurate. A good plan includes 1) identifying the roles of individuals involved with managing an on-site crisis, 2) having accessible and accurate communication information, 3) an algorithmic approach to the steps involved with medical emergency management, 4) standard methods for documenting an incident and 5) a plan for review of the events that occurred.

Step 1: Identifying the roles of individuals involved with managing an on-site crisis

Perhaps the single most important criteria to define when one plans for managing crisis and emergency circumstances is to be sure that people understand their roles. Handling an emergency requires a sense of calmness and urgency all at one time. This is a time for efficiency, organization and leadership. Define roles of people ahead of time. For example, you could establish a standing procedure that in any emergency circumstance the head coach of the home team is responsible for calling 911. If for some reason the home team head coach is the one who needs care, then a simple back up plan could be established as well on a regular basis. Other roles could be to keep other parents and fans calm, to clear an area of further potential danger, to establish a clear path for a rescue squad, and to stand by the road to meet the squad and direct them to the location. These are just a few examples of roles that can be established with minimal planning needed.

Step 2: Having accessible and accurate communication information

People care about loved ones. One of the worse situations you can find yourself in is trying to contact someone and deliver bad news about a loved one and not be able to reach them. Accurate and updated information for all players and coaches emergency information should be handy in a number of locations. Having such information in the pocket or folder of a single person is not good enough, as it is possible that the individual may not attend a game here and there and not realize they have the important information. Keep this information in a safe and accessible place, and be sure to constantly remind people to update as needed.

Step 3: An algorithmic approach to the steps involved with medical emergency management

Established consistent procedures always help people in times of crisis. They allow individuals to rely on what they know, and from what they know in a sense of “this is how we always do it”. Based upon your sport, facility location, and typical personnel available, you should develop a sequence-based chain of events to follow by. For example, things to include would be attending to an injured person, directing the home team head coach to call 911, keeping people around calm, etc….Individual facility and geographical locations will assist in determining additional steps needed for a complete approach.

Step 4: Standard methods for documenting an incident

Medical emergencies are serious events. And one can never underestimate the importance of information gathered related to the history of how an event was handled. Whether it be to assist a medical provider in diagnosing an injury based upon how someone was hit by a ball, or to provide factual information for potential legal action from any incident, detailed information of the events are important. A recorder should be identified as well with the sole responsibility of taking good notes for others to review at a later date. Preparation and training sessions can help here, demonstrating the types of information that are critical to document. A simple 10-minute video can be made showing an event, and having people write down their own description of the event. A review session can then follow to point out key components.

Step 5: A plan for review of the events that occurred

All good leaders spend time debriefing major decisions. When a medical emergency occurs at a youth sporting event, it typically happens very fast. Before you know it, the field is cleared and the injured person is rushed off to a hospital. It is so important to bring a group of key individuals together after such an event to review the circumstances. Read the documented notes that were taken, and determine what aspects were handled well, and what aspects could be improved upon for future emergencies. This is not designed to be a finger-pointing session, or one to strategize a cover-up of any wrongdoing. Open and honest dialogue that will benefit all future situations is a productive and meaningful way to operate.

With the largest number of participants, coaches, parents, venues, and variety of sports, youth sports pose the greatest threat to utilization of standardized procedures for handling medical emergencies. Nonetheless, adolescents and children deserve no less attention and medical care than more developed and funded levels of sports participants. The diversity of coaching involvement at the youth sport level further emphasizes the need for standardized approaches nationwide to handling medical situations. Be proactive: Implement a plan for the children!

Sports Training – How Much is Too Much?

Author: Lyle Micheli, M.D.

Kids are starting sports earlier and training harder. Incentives to win are growing, sometimes literally – I’ve seen trophies almost bigger than the little athletes who’ve won them! With higher stakes have come pressures to perform better by being fitter and more skilled. Usually, this is achieved through repetition, repetition, repetition – whether it is serving a tennis ball, pitching a baseball, or performing a figure-skating double axle.

In kids’ sports programs, fitness and skill development have to be balanced with the need to avoid overtraining. Overtraining is when the athlete is required to do too much – either physically or mentally, or both.

Parents need to be sensitive to changes in performance and attitude that suggest their kids are being pushed too hard. Such changes may be precursors of physical injury.

Signs of overtraining
  • Slower times in distance sports such as running, cycling, and swimming
  • Deterioration in execution of sports plays or routines such as those performed in figure skating and gymnastics
  • Decreased ability to achieve training goals
  • Lack of motivation to practice
  • Getting tired easily
  • Irritability and unwillingness to cooperate with teammates

Unfortunately, the tendency when a parent or coach is confronted with signs of overtraining is to push the child harder. But if overtraining is the culprit, any increase in training will only worsen the situation.

And as I have suggested, training too much may eventually lead to overuse injuries in which actual damage to the bones and soft tissues occurs because the body can’t recover from the repetitive physical demands placed on it by sport activity.

This raises an important question: How much is too much? Not a great deal of hard data is available on this subject. That’s because to find out exactly how much training is safe, we’d have to take large groups of kids and put them through grueling sports drills and wait there with our clipboards for them to collapse in pain. I don’t think we could find too many parents who’d be willing to turn over their kids for such tests! In the absence of data obtained from clinical studies, we need to formulate our guidelines based on observations made over the years by coaches and sports scientists.

How long can kids train?

As a general rule, children shouldn’t train for more than 18-20 hours a week. If a child is engaged in elite competition there may be pressures to train for longer – especially in the lead-up to a major event. Anytime a child trains for longer than this recommended length of time she must be monitored by a qualified sports doctor with expertise in young athletes. This is to make sure abnormalities in growth or maturation do not occur. Any joint pain lasting more than two weeks is justification for a visit to the sports doctor.

It’s also important to ensure restrictions against excessive sports activity are not exceeded. For instance, young baseball pitchers in America are not allowed to pitch more than seven innings a week. While this restriction is mostly adhered to in the game setting, it is pointless if kids are pressured by their coaches to throw excessively during practices (parents, too, need to remember that going to the park with their kid to “throw a few” needs to be counted as part of the number of pitches he makes). In general, young baseball players shouldn’t perform more than 300 “skilled throws” a week; any more than this and the risk of injury dramatically increases.

How much of an increase in training is safe?

Increasing the frequency, duration, or intensity of training too quickly is one of the main causes of injury. To prevent injuries caused by too-rapid increases in training, I am a strong believer in athletes following the “ten-percent rule.” The rule refers to the amount a young athlete’s training can be increased every week without risking injury. In other words, a child running 20 minutes at a time four times a week can probably safely run 22 minutes four times a week the week after, an increase of ten percent.

Most of the injuries I see in my clinic are the product of violations of the ten percent rule, when young athletes have their training regimen increased “too much, too soon.

Too much too soon” scenarios
  • The football player, who, after a summer of inactivity, goes straight into a fall pre-season training camp.
  • The swimmer who normally trains at 5000 yards per day but then is asked to swim 8000 yards a day for three consecutive days.
  • The dancer who does 12 hours of classes per week and then suddenly is training six hours per day, six days a week at a summer dance program.
  • The gymnast, who, in the weeks before a major event, doubles her training time.
How hard should kids train?

When young athletes are growing the emphasis should be on developing athletic technique. Although power or speed are important qualities in sports, stressing them to children at the expense of technique can lead to injuries. Once good technique is mastered, power and speed can be introduced.

It is important for you to safeguard your children against being overtrained. The danger of this happening is especially acute if your child is an elite athlete or one engaged in a very competitive sports environment. Perhaps the most effective measure any parent can take is to make sure his child’s coach is certified. Another is to look out for the signs of overtraining, as described above, as well as the early signs of injuries themselves. A strength training program is an important component of any injury prevention program for athletes – kids included.

In many cases, I believe, kids drop out of sports because of low-grade pain that is actually the early stage of an overuse injury. The pain is never diagnosed as an early-stage overuse injury because the child simply quits the program. What this may do is prejudice a child against physical activity and exercise for life. The same is true for mental stress in sports.

Given the state of fitness in this country, overtraining children has the opposite effect of what we want, which is to instill in our young people a love of exercise that will stay with them through life, and inspire them to stay fit and healthy long after their youth sports days are done.

Dr. Micheli co-founded and is director of the world’s first sports medicine clinic for children, located at Boston Children’s Hospital. He is also the chairperson of the Massachusetts Governor’s Committee on Physical Fitness and Sports, and a past president of the American College of Sports Medicine.

Basic Weight Training & Conditioning for Children

Author: Vincent M. Burke, MPT, BS, CSCS,*DPT
Infinity Fitness & Sports Institute/ Infinity Rehabilitation and Sports Medicine

Over the past ten years there has been a paradigm shift from the three-sport athlete to the one sport athlete. Training for one sport has now become a constant year round process. Because of this, problems arise because the body never really rests and therefore athletes are acquiring overuse syndromes resulting in injuries or even shortened careers, most of which, can be been prevented.

The vigorous training techniques at schools, local gyms and/ or claimed sport specific training facilities have caught the attention of coaches, athletic directors, athletic trainers, physical therapists, parents and athletes to train functionally, sport specifically and/or “structure” power training i.e. lifting logs, throwing kegs, rolling tires. Other training techniques being used are bounding from one direction to another, jumping off platforms with weights, running with sport cords and parachutes. All of these training techniques are effective and fun; however, are they safe and developmentally appropriate for the junior athlete (prior to high school)? Safe training is more than just using the proper technique and /or appropriate supervision. Safety is also considering if the athlete is really prepared mentally and physically to perform these high mass lifts and/or the ballistic and speed training resistive exercises.

As a Master prepared Physical Therapist, Certified Strength and Conditioning Specialist and Doctoring student with 20 years of experience in training and treating athletes of all levels and sports, I am seeing younger and younger athletes in my clinic. This is typically due to overuse syndromes and poorly structured programs which have inadequate supervision and poor choice of exercise prescription. I concur with most of the innovative and fun exercises that the training industry has researched and designed to enhance athletic performance. However, before one engages in such vigorous exercises, much time should be spent on “Basic Training”.

I define “Basic Training” as first, educating the athlete in the arena of exercise; teaching them the purpose and proper form and technique with all aspects of exercise. This includes but is not limited to basic anatomy of the body and its function, injury prevention, posture, balance, coordination, spine and shoulder stabilization, body alignment during exercise, breathing, foot/body wear, hydration, basic nutrition, and to always have an attitude of “I CAN” just to name a few. We as personal trainers and coaches alike cannot force physiology and/or the development of a child, but we can guide and encourage athletic development within safe and appropriate parameters of training. I also believe that “no pain, no gain” is a poor methodology of getting results. With this mindset, it can be very harmful and costly to the young athlete. I find that athletes at such a young age need to work on less “sport-specific” exercises and focus more on developing their level of athleticism as a whole, not just focusing on speed, agility and/or quickness as an example. The human body, like any other creature, needs to develop under stress and strain, but with whom, when, where, how and what are the most vital questions to be answered before a child trains. Our children exercising need proper guidance and instruction as they do at home and school, i.e. how to answer the phone, when to say please and thank you, how to add and subtract. If parents, coaches and personal trainers say we need to train them so young, then we need to educate them on how to exercise and prevent injuries and put the “performance” word out of the equation. Remember a young athlete cannot perform if he/she is not healthy. Having the Basic Training as a prerequisite before the “sport” and training is important. It will not only give a lifetime of prevention, but a better performing athlete in the long run.

For parents seeking personal trainers in facilities, here are some tips to help choose who and what is best for your child. Personal trainers should:
  • Bachelor’s Degree in movement science
  • Be certified from a reputable organization that has specific guidelines for training children which is endorsed by the medical arena.
  • Be C.P.R. and First Aid Certified
  • Have experience with weight training and conditioning specifically for children
  • Conduct exercises in a safe environment with small groups of children that are of similar age and ability
Some safe weight training and conditioning guidelines for children:
  • Start when the child is entering sports
  • Always have qualified supervision
  • Always get clearance from a medical doctor
  • Always hydrate plenty before you train and after
  • Have sun block on at all times if outdoors
  • Have proper foot/body wear
  • Always have a baseline physical assessment prior to starting the program.
  • Always have goals of the personal trainer and athlete that are explained and agreed upon prior to starting
  • Always revisit the goals and set new realistic goals
  • Always warm up the body so one feels a slight sweat
  • Always active stretch after warming up and static stretch after exercise
  • Never eat heavy before exercising
  • Always report any pain or discomfort with any activity
  • Perform some kind of cardiovascular exercise 3 times per week Perform two to three sets of 10-16 repetitions per exercise
  • Perform a full body routine two-three X per week with 48-72 hours of rest in between
  • A must exercise prescription at first is teaching / training “athletic” posture, balance, coordination, spine and shoulder stabilization
  • No maximum lifts
  • No bodybuilding
  • No power lifting
  • No long distance running

Common and safe equipment used for children are sticks, balls, body weight, bands, cones, hoops, balancing equipment, mats, trampolines and hydraulic equipment.

At first, the fitness goals should be to educate and inform, assess abilities and set goals then to train and condition the basics of athletics focusing on each system of the body; cardiovascular, muscular, skeletal and nervous systems all which feed off of each other which will help the child be a better athlete who will later in their athletic career perform better in sports and in everyday life activities.

Lightning: The Uncontrollable in Sports Medicine

Author: Barbara J. Morris, MS, ATC, CSCS
USF HEALTH, SMART INSTITUTE

In the world of sports medicine major emphasis is place on prevention. Are the athletes conditioned properly? Has the rehabilitation process brought them back to an appropriate level to return to competition? Has hydration been appropriately delivered and monitored? The sports medicine professional can directly monitor and to an extent control most of these arenas. When speaking of control in the sports medicine realm the big uncontrollable is LIGHTNING.

According to the National Athletic Trainers’ Position Statement on Lightning, it is one of the top 3 causes of weather related deaths. It kills approximately100 people yearly and is responsible for approximately 500 injuries. Lightning can strike far from where it is raining, sometimes in clear skies. According to the National Severe Storm Laboratory, (NSSL) lightning can and does strike as far as 10 miles away from the rain. The adage goes, “If you can see it (lightning), flee it, and if you can hear it (thunder), clear it. If not using some sort of lightning detection device the 30-30 rule should be implemented. That rule is; when the “flash to bang” count approaches 30 seconds all individuals should be in the appointed shelter. The NSSL states that safe structures are any buildings normally occupied or frequently used by people. (Buildings with plumbing and/or electrical wiring that acts to ground the building). If no building is available any vehicle with a hard metal roof and windows rolled up is better than the outdoors. (DO NOT TOUCH THE SIDES OF THE VEHICLE). If a safe structure is not available one should seek a thick grove of small trees surrounded by taller trees or a dry ditch. The lightning position should be assumed immediately. If an individual should feel the hair stand on their skin tingle they should assume the lightning safe position; which is crouched on the ground, weight on the balls of their feet, feet together, head down, with the ears covered. The idea is to have the least amount of surface area as possible in contact with the ground and to be as compact as possible.

Once activity has been suspended, NSSL recommends a minimum of 30 minutes should pass prior to resuming activity. This should be strictly adhered to.

It is imperative that the activity coordinators have a lightning safe policy in place with an emergency action plan in the event of a strike. Individuals who have been struck do not carry a charge therefore life support measures can be initiated immediately.

The key to controlling the uncontrollable is rational quick decision making as the weather begins to deteriorate. Keeping in mind that lightning can come from blue skies. Monitoring of the weather service is very helpful when conducting outdoor events and having all staff trained appropriately so the emergency action plan becomes second nature.

References

  • National Lightning Safety Institute, 891 North Hoover, PO Box 778, Louisvill Colorado, 80027. www.lightingsafety.com
  • National Severe Storms Laboratory, NOAA, 1313 Hally Circle, Norman, OK 73069
  • Walsh, KM, et.al, National Athletic Trainers’ Association Position Statement: Lightning Safety for Athletics and Recreation. Journal of Athletic Training, 35 (4): 471-477, 2000.
  • Holle, Rl. Lopez, RE. Howard, KW. Vavrek, J. Allsopp. J. Safety in the Presence of Lightning. Semin Neurol. 15: 375-380, 1995.
  • Pictures: Lightning Research Laboratory University of FL, www.lightning.ece.ufl.edu

The New Scourge of Kids Sports

Author: Dr. Lyle Micheli

I am a passionate advocate of children’s sports, but I’m not so gung-ho that I can’t recognize the profound changes taking place in children’s sports, and the problems these changes have created – in particular, the rise of “overuse” injuries.

Overuse injuries were once virtually unknown in young athletes. All that changed with the emergence of organized sports and their emphasis on repetitive coaching drills, as well as the recent trend toward sports specialization in young athletes. Patellar pain syndrome – an alignment problem in the knee caused by overtraining – is today the number-one diagnosis in my clinic, even though it had never been seen in kids until the growth in organized sports. Talk of stress fractures, tendinitis, and bursitis is no longer confined to pro athletes; today it can be heard in high school locker rooms.

Certain overuse sports injuries, such as Little League elbow, which refers to shear damage to the growth cartilage in the elbow joint caused by repetitive whipping motions of the arm, are seen exclusively in child athletes because of the softness of their growing bones and relative tightness of their ligaments and tendons during growth spurts.

Other overuse sports injuries seen mostly in children include osteochondritis dissecans of the knee and ankle (repetitive grinding together of bones in those joints causes damage to the growing surface cartilage and may result in pieces of dead bone and cartilage dropping into the joint and wreaking havoc), Osgood Schlatter’s syndrome (inflammation at the point where the tendon connects the kneecap to the very top of the shinbone) and os calcis apophysitis (inflammation at the point where the Achilles tendon attaches to the heel).

Unlike acute sports injuries such as sprains, strains, bruises, and breaks, which the Consumer Products Safety Commission tells us result in four million emergency room visits every year, the exact prevalence of overuse injuries is difficult to ascertain. That’s because the symptoms of overuse injuries develop over time, and do not require immediate emergency care. Suffice it to say overuse injuries in kids sports are so common that pediatric sports medicine clinics such as the one at Boston Children’s Hospital have opened to respond to the problem, and, as seen above, we’ve had to come up with medical names for them.

One of the most disturbing aspects of overuse injuries is their insidiousness. Often kids won’t admit to being sore – they just drop out of sports, often for life. When they go undetected, the damage to a growing child’s hard and soft tissues can be permanent. Evidence suggests that overuse injuries sustained in childhood may continue to cause problems in later life – arthritis, for instance.

As overtraining is the most common cause of overuse injury, the most effective way to prevent overuse injuries is to ensure kids are being coached by qualified personnel. The National Center for Sports Safety has just introduced a sports safety course called PREPARE that I helped develop. The course is available online at www.SportsSafety.org and covers important topics ranging from blisters and sprains to life-threatening head and neck injuries. PREPARE gives coaches and parents the knowledge and confidence to respond to emergencies until professional help arrives. I urge you to have the coaches in your local youth sports take this course. Another important measure is to make sure kids have a proper pre-season physical every year to rule out underlying conditions that might predispose them to overuse injury – anatomical abnormalities such as knock knees, flat feet, and swayback, for instance. Finally, if kids want to participate in strenuous sports, they should be fit enough to do so – a properly-performed pre-season physical should rule out fitness deficiencies, and recommend an exercise program.

Every day I see happy, healthy, confident youngsters with a glint in their eye that tells me they’re hooked on sports for life. By reducing overuse injuries we can make sports a safer and even more rewarding environment for their young participants.

Dr. Micheli co-founded and is director of the world’s first sports medicine clinic for children, located at Boston Children’s Hospital. He is also the chairperson of the Massachusetts Governor’s Committee on Physical Fitness and Sports, and a past president of the American College of Sports Medicine

Repetitive Stress Injuries or Something More…Thinking Outside the Box

By Chris A. Gillespie, MEd, ATC, LAT

We have all heard of repetitive stress injuries. These injuries are those such as rotator cuff impingement syndrome, shin splints, iliotibial band syndrome, bursitis, tendonitis, and so many other long-term, overuse problems. We spend hours upon hours visiting with our medical experts. We invest thousands of dollars in new shoes and other gadgets that will make our pain less. Yet, if the real truth be known, we do all of these things in order to allow us to continue to play or run or ride without missing any time!

Unfortunately in the athletic world and environment in which we live, there is much less repetitive stress injury than we have diagnosed through the years. I believe that we have to start looking at the real possibility that instead of repetitive stress injuries, many times we are dealing with “cumulative stress injuries.” The difference: Repetitive stress is doing the same motion over and over again such as throwing a baseball or running on the same side of the road each day over a long period of time. Cumulative stress, as I describe it, is having a repetitive stress injury and continuing to work through it day after day. In other words, we are dealing with repetitive stress on top of repetitive stress.

Cumulative stress is having shin splints and running through it for weeks only to develop stress fractures. It’s being an elite little league pitcher and playing recreational league ball and travel ball at the same time – having pitch count rules in each of those leagues yet, ignoring the fact that a kid has reached his or her maximum number of pitches in EACH league. Therefore, the cumulative effect on that young arm is double that of someone who pitches in only one league!

You might say that it’s a matter of semantics – just using different words. I disagree! It’s a matter of ignoring the facts that you have at your disposal. It’s a matter of dismissing an injury to the point of pushing through to a totally new level of distress on a body part. It’s an epidemic and unfortunately, it has no end unless we do something about it.

It won’t be as simple as just “not running” or “not throwing” as much. This is going to take a total shift in how we view overuse problems. We will have to investigate the rules and demands of the sports in which we participate. This will cause us to take a step back and ask one simple question: Is this what is best for the athlete’s health and welfare? I believe if you really look at this, you’ll find, as I have, that we need to change the way we do things and evaluate the reality of the situation we are in – what we are doing with repetitive stress injuries is NOT working. It’s time we started treating these injuries for what they truly are … cumulative “self-induced” trauma!

It’s a choice that we all have to make. Train, rest, recover, and get better OR don’t rest, don’t recover and get worse!

Looking for Relief…Pitching, Pitch Counts, and What to Look For

By Brian Boyls-White

Around the country, youth baseball is underway. Whether you are just starting your season or your season is reaching the half-way point, you may look around and notice your teammates and friends suffering from shoulder and elbow injuries. You and your parents may simply chalk up these injuries to the rigors of the season, but with education and a proactive approach many shoulder and elbow injuries in today’s youth athletes could be reduced.

Of these upper extremity overuse injuries, four injuries are more common in today’s youth baseball athletes:

  1. Little League Shoulder
  2. Little League Elbow
  3. Olecranon Stress Fractures
  4. Ulnar Neuritis

In order to minimize time lost due to these injuries, athletes, parents, and coaches alike need to be aware of these conditions and their corresponding signs and symptoms. As with any of these injuries, it is important to follow-up with your treating physician, and follow his or her instructions for treatment in order to prevent any set-backs.

Little League Shoulder

An overuse injury caused by repetitive (too often and too much) throwing, associated with poor throwing/pitching technique and little active rest of the shoulder. This repetitive action (throwing/pitching) causes changes at the growth plate level in the bones of the shoulder. As changes occur and if allowed to continue, these athletes will naturally change the biomechanics of the shoulder, and subsequently alter their throwing mechanics.

Signs and Symptoms
  • Gradual and progressive symptoms increase, usually associated with no specific injury or mechanism
  • Shoulder pain while throwing – Pain may carry over into activities of daily living if allowed to continue
  • Shoulder soreness lasting a few days after throwing
  • A thrower reporting feeling slower and less command/control of the ball
  • In general, swelling around the shoulder
  • In general, tenderness around the shoulder
Little League Elbow

An overuse injury caused by repetitive (too often and too much) throwing, associated with poor throwing/pitching technique and little active rest of the elbow. This repetitive action on the elbow causes changes at the growth plate level in the bones of the elbow. Changes in elbow and shoulder biomechanics and in throwing mechanics can stress other structures in the elbow including ulnar collateral joint (UCL) of the elbow, and the ulnar nerve.

Signs and Symptoms
  • Gradual and progressive symptoms increase, usually with no specific injury or mechanism
  • Pain when palpating the medial epicondyle (bump on the inner arm at the elbow)
  • Pain may be achy and/or deep diffuse and/or sharp in feeling around the elbow
  • Swelling over the medial epicondyle
  • A possible decrease in range of motion of the elbow
Olecranon Stress Fracture

An overuse injury caused by repetitive (too often and too much) stress to the bony posterior elbow. These changes in the bony posterior elbow (micro-fracturing, stress reactions, stress fractures, fracturing) occur due to repetitive deceleration/absorption at the posterior elbow during the follow through phase of throwing.

Signs and Symptoms
  • Diffuse achy pain in the posterior elbow
  • Pain increases while throwing, but can remain during periods of rest
  • Potential swelling around the posterior elbow
  • A reluctant decrease in elbow extension -Forceful extension can increase pain in the elbow
Ulnar Neuritis

An overuse injury caused by repetitive (too often and too much) stress to the ulnar nerve. This repetitive stress can be attributed to poor throwing/pitching mechanics and unnecessary changes to the elbow and shoulder.  While throwing, repetitive bending of the elbow can stretch the nerve, or even cause the nerve to slip in and out of place.

Signs and Symptoms
  • Numbness and/or tingling going down the forearm and into the hand
  • Pain along the inside part of the elbow
  • Weakness in the forearm and hand reported by the athlete
  • A thrower reporting feeling slower and less command/control of the ball
Factors Leading to Injury
  • Poor throwing and mechanics (education/teaching/coaching)
  • Poor muscular endurance/strength of the body, and especially the shoulder
  • Poor warm-up prior to throwing/pitching, and/or poor warm-up before coming in to throw/pitch
  • A lack of cool-downs following practice and games
  • Throwing for speed/velocity and not for control and finesse
  • Throwing/pitching in excess (going over, or not keeping to a throwers/pitch count)
  • Playing in multiple games in the same day, whether it be the same team/league and/or different teams/different leagues
  • Playing in multiple games in the same day as a pitcher and/or catcher and then inserted back into the lineup at another position
  • Playing in multiple leagues/teams during the same season
  • Throwing/pitching year round with no active rest
  • Playing in ‘Showcase’ games
Return to Play: Treatment and Rehabilitation for Overuse Injuries

As with treatment and recovery for many overuse injuries, throwing overuse injuries include active rest, therapy and rehabilitation, and a proper throwing progression. As following with most injuries, active rest is usually the first step to returning back to play. This step is important, as to allow the anatomical structures to return to their pre-injured health. During active rest, it is not uncommon to follow-up with your physician periodically over time in order to evaluate changes during the healing process. While resting, some physicians may start you on a course of therapy/rehabilitation, and/or allow you to do other activity excluding throwing or overhead activities.

It is important to adhere to the treatment plan, as deviating can cause delays in the healing process or set-backs. Once rehabilitation begins, your therapist may conduct a postural screening, and evaluate range of motion and strengthen in order to create your own rehabilitation program. As you progress through your exercises, you may notice your exercises becoming harder than when you first began therapy. As you continue to progress with your rehabilitation, it is not uncommon to see similarities between your rehabilitation exercises (sports specific exercises), and your previous activity.

Again, it is important to keep to your rehabilitation program, and not return to activity unless specially instructed too by your physician or therapists. Once cleared by your physician to resume activities, it is important to get clarification with regards to specific return to play guidelines. Most return to play guidelines for shoulder or elbow injuries include a systematic return to play throwing progression before a full-return to play is granted.  Day-by-day and week-by-week, a proper throwing progression incorporates throwing biomechanics re-education and will steadily take the athlete through an increase and decrease in throwing quantity, distance and intensity while monitoring any changes in their signs and symptoms.

During all phases of throwing progression, the athlete should continue to be sign and symptom free, while mastering control and correct shoulder mechanics. As such, during your throwing progression, it is important to communicate to the therapist, coach, and parent on how you are feeling. Once you progress through all stages of your throwing progression, and complete your rehabilitation program, you may have a final follow-up with your physician in order to get full clearance to return to full play. While it may seem like a long rehabilitation process, it is important to follow each step specifically, as not to have any set-backs or re-injuries during the course of returning to play.

Injury Prevention

Overhead athletes such as those who participate in baseball, softball and volleyball players should investigate shoulder injury prevention programs in order to avoid time lost due to injury. Programs such as the ‘Throwers Ten’ and ‘Advanced Throwers Ten,’ programs were created in order to strengthen the shoulder (rotator cuff and scapula stabilizers) during overhead movement activity demands. Your local orthopedic physician, physical therapy group or athletic trainer can also help in creating and progressing your program.

Aside from implementing a shoulder injury prevention program, and monitoring how your athletes are feeling each day, coaches, parents and athletes should adhere to the rules outlined by Little League or USA Baseball in order to prevent shoulder or elbow injuries. As a league or coach, talking with your parents before the start of the season is a great way to educate parents with regards to signs and symptoms to be on the lookout for, and for spreading injury prevention information. Prior to the first practice, coaches should talk with their team (athletes and parents) about how important it is stay healthy, the importance of shoulder injury prevention programs are, and reporting how each player is feeling day-to-day.

Pitch Count

In order to help minimize overuse injuries and maximize safety in today’s young throwers, USA Baseball and Little League Baseball have recommended and implemented rules to limit the amount of pitching during a game and/or practice. While their recommendations differ a little bit, they both agree that a pitch/throwers count is needed in order to maximize safety and limit any unnecessary time loss due to injury. Below are the most up-to-date (4/26/2013) rules with regards to pitch/throw counts.

Be sure to check with your local little league organization as for any updates in rules, pitching and pitch counts. Coaches should be aware and adhere to these rules in order to keep your athletes in the game for innings to come.

Runner’s Knee

Dr. Jose J. Echenique

WHAT IS RUNNER’S KNEE?

Patellofemoral pain syndrome is pain in the “front” of the knee and around the knee cap. It is often seen in runners, hence its alternate name “runner’s knee”. However, it is commonly seen in non-runners as well. The pain may be exacerbated after a run, when using stairs (especially going downstairs) or when getting up after sitting with the knee bent for a prolonged period of time (ie. stepping out of the car).

The cause of runner’s knees is unknown but it is believed to have to do with “incorrect tracking” of the patella (knee cap) on the trochlea (the grove of the femur). This may place abnormal stress on the undersurface of the patella that may lead to pain.

The good news is that there are simple exercises that are often very effective in relieving the symptoms of runner’s knee. It is believed that they do so by strengthening the muscles that help the patella track appropriately, thereby decreasing the stress on the cartilage.

Exercises aimed at quadriceps strengthening and stretching, and hamstring stretching for 1 month may be all that is needed. Other tips that may accelerate recovery is to try to keep the knee straight when sitting and avoid running, squatting or using stairs if possible while in the rehab period.

If the pain does not resolve, or if there are other symptoms like clicking, catching, locking, instability or history of an injury, it may be worthwhile to see a sports medicine orthopedist.

Dangers, Prevention and Treatment of Concussions

James Sedlis, MD

A concussion is defined as a temporary impairment of neurological function caused from head trauma. It has been estimated that 1.2 million sports related concussions occur every year.  It is a clinical diagnosis made by having characteristic neurological and physical symptoms commonly including confusion, dizziness, headaches, nausea, foggy feeling, visual problems and trouble concentrating.

Exercise and cognitive activity place increased demand on the areas of the brain healing, which potentially delays recover. The risk of a second, more serious concussion is greatly increased when someone is still symptomatic from a first concussion. Second impact syndrome (SIS) is a condition in which the brain irreversible swells after suffering a new head injury before symptoms from an earlier one have subsided.  The death rate from SIS is 50% and those who survive the disability is almost 100%.  Youth are especially vulnerable as all documented cases occurred in people younger than 20 except in boxing.

With repeated head injuries the number of functional brain cells may diminish with time to a level where recovery is adversely affected. Chronic traumatic encephalopathy (CTE) has gotten a lot of press lately due to the unfortunate premature death of many professional athletes. CTE is a progressive degenerative disease, which can only be diagnosed by autopsy and occurs in individuals with a history of multiple concussions and other forms of head injury.

How can head trauma be avoided? Be smart! Follow the safety rules and the rules of the sport. Use the right protective equipment (should be fitted and maintained properly in order to provide the expected protection) such as a helmet when playing any sports or engaging in an activity at risk for potential head injury. There is no football helmet, or mouth guard that can prevent a concussion. Helmets are designed to prevent against skull fractures, cerebral bleeding, while mouth guards are to avoid oral injuries. The data is mixed on the use of headbands/head gear in soccer. Perhaps any protective effect is offset by more aggressive play by the athlete. Coaches and athletes should maintain appropriate conditioning for participation in sports. Better skill development can also decrease the frequency of concussions. Life is a contact sport so make the home safe to prevent accidental injuries. Wear a seat belt every time you drive or ride in a motor vehicle and make sure that any children are fitted properly for their safety/booster seat, or seat belt (according to the child’s height, weight, and age).

Concussions are a serious injury, and return to activity afterwards is an important consideration.  Do not return to play with a known or suspected concussion until you have been evaluated and given permission by an appropriate health care professional. Treatment consists of a team approach utilizing the most up-to-date medical therapies, clinical interviews, neurocognitive testing, rest, physical therapy, medications if symptoms persist and re-examinations. At the present time we do not have enough knowledge to know how many sub-concussion head blows or concussions are too many and when should an athlete stop playing contact sports. What is important is to carefully manage each concussion by someone with experience.

WARM UP, COOL DOWN AND BE FLEXIBLE

By William C. Cottrell, M.D.

An effective fitness program is more than aerobic training and strength building. To really reap the benefits of exercise, you need to add flexibility training to the mix.

Stretching can help your body get ready for exercise. It is also an essential part of recovering from aerobic activity. All exercise sessions should end with stretching – and not just for the mental relaxation benefits. The more flexible you are, the less likely you are to be injured during exercise.

Warm Up

A good warm up prepares your body for more intense activity. It gets your blood flowing, raises your muscle temperature, and increases your breathing rate. Warming up gives your body time to adjust to the demands of exercise. This can improve your performance and help you get the results you want.

The simplest way to warm up is to do an aerobic activity at an easy pace. If cycling is what you plan to do, then start out slowly in a low gear.

How long you spend warming up will depend on your fitness level. If you are newer to exercise, your body (and your mental resolve!) will respond better with a longer warm up.

Adding stretches to your warm up may improve your exercise performance. Once your muscles are warm, spend a few minutes on stretching. Since the goal of your warm up is to increase your heart rate and get you ready for more intense work, choose stretches that can be done standing up. Floor stretches are best for your cool down segment.

Cool Down

Just as a warm up prepares your body for exercise, an effective cool down gives your body time to recover.

Your cool down begins as you gradually decrease your intensity level at the end of your aerobic exercise session. For example, if you have been walking at a quick pace, begin cooling down by slowing your steps and taking your arms out of the movement. Walk at a comfortable pace until your breathing and heart rate have returned to normal.

Once you are breathing easily, stretch while your muscles are still warm.

Flexibility Exercises

Stretching is too often neglected by exercisers pressed to fit workouts into their busy schedules. This common mistake can reduce the effectiveness of exercise because better flexibility results in better fitness.

By increasing your flexibility you can improve your ability to move around. You will have less muscle tension and your posture will likely improve. Most importantly, stretching after each workout reduces your risk for injury.

Get the most out of your flexibility training by following these simple guidelines:

  • Always warm up before your stretch. Stretching cold muscles can cause injury
  • Stretch slowly and gently. Breathe into your stretch to avoid muscle tension. Relax and hold each stretch 10 to 30 seconds
  • Do not bounce your stretches. Ballistic (bouncy) stretching can cause injury
  • Stretching should not hurt. If you feel pain, take the stretch easier, breathe deeply and relax into it

Dental Injuries in Youth Sports

by Jennifer Kramer

Dental injuries are different than routine dental problems.  Routine dental problems are things such as, cavities, toothaches, teeth grinding, tooth erosion, etc.  Dental injuries on the other hand can happen while playing sports and be caused by a fall, a hit to the mouth, jarring of the teeth against one another, and numerous other ways.  Dental injuries fall into three categories, dislocations, subluxations, or fractures and need immediate attention by a dentist.

Tooth Dislocation

A dislocated tooth is a tooth that has been knocked out of socket.  The care of a dislocated tooth varies depending on whether the tooth is a baby (primary) tooth or a permanent tooth.

Baby (primary) tooth dislocation:

This is the most common injury to the baby (primary) teeth.  It often occurs to the front teeth as they are the most exposed.  The important thing to keep in mind is to prevent any damage from happening to the permanent teeth that have not begun to come in.  With that in mind, if the baby (primary) tooth is completely knocked out DO NOT put it back into the gums.  Putting the tooth back into the gums may damage the permanent tooth underneath.

Permanent Tooth Dislocation:

This is a dental emergency that requires immediate treatment by a dentist. The survival of the dislocated tooth depends greatly on the amount of time it is left out of the socket.  The tooth should be placed back into the tooth socket as soon as possible, ideally within 15 minutes and up to one hour (or longer if stored in cold milk). At least 85 percent of teeth that are put back in the tooth socket within five minutes survive.

Because of the importance of replacing the tooth quickly, the child, parent, or another adult can (and should) attempt to reimplant the tooth. The following steps are recommended:

  • Handle the tooth carefully by the top (crown)
  • Make sure there is no dirt or debris on the tooth.  This can be done by gently rinsing the tooth with saline or tap water.  DO NOT sterilize or scrub the tooth for any reason.
  • Carefully reinsert the tooth by hand back into the socket.
  • Have the child bite down on a clean towel to keep the tooth securely in place.
  • The child should be immediately seen by a dentist.

In some cases it may not be possible to reinsert the tooth in the gums.  If this happens the tooth should be stored in a container of cold milk. If cold milk is not immediately available then place the tooth in a container of the child’s saliva. Do not store the tooth in water or saline. This will reduce the survival chances of the reimplanted tooth. The child should immediately see a dentist or other healthcare provider as soon as possible to reimplant the tooth. The chance the tooth will survive is reduced the longer the tooth is out of the mouth.

Tooth Subluxations (loose tooth/teeth)

A subluxed tooth is a tooth that has been loosened but has not come out of the socket.  This is also a dental emergency that needs immediate care.  Most subluxed teeth can be repositioned and monitored over time, but in some cases it might be necessary to use stitches or splints to hold a tooth in place.

Fractured Tooth

Fractured Baby (Primary) Teeth

Children with fractured (broken) baby teeth should see a dentist immediately.  The dentist will examine the tooth for any damage to the nerves or blood vessels. Treatment may include smoothing the rough edges of the tooth, repairing it with a tooth-colored resin material, leaving the tooth in place, or removing it.

Fractured Permanent teeth

Fractured (broken) permanent teeth can usually be repaired. It is best that the child is seen by a dentist immediately to rule any sensitivity/nerve issues.  It is possible to reattach fractured tooth fragments, therefore be sure to rinse them off and submerge them in tap water. If tooth fragments cannot be found or cannot be reattached, the tooth may be repaired with a material called composite resin, which can be matched to the color of the natural tooth.

Dental injuries can occur in most all sports.  The American Dental Association recommends wearing custom mouth guards for the following sports: acrobats, basketball, boxing, all hockey-related sports, football, gymnastics, handball, lacrosse, martial arts, racquetball, rugby, shot putting, skateboarding, skiing, skydiving, soccer, squash, surfing, volleyball, water polo, weightlifting, wrestling.  Before choosing and purchasing a mouth guard check out the Mouth Guard 101 for Sports article.

Cold Illness Recognition

by Brian Boyls-White

Read and learn the following cold illness injury below. 

Chilblain – a nonfreezing cold illness, chilblain develops a few hours after the skin is exposed to the cold. The person will appear to have red or swollen skin, which may be painful and tender to touch.  Other complaints may include itchy skin, achiness or possible numbness.  This person needs removed from the cold environment and warm-up naturally.  Do not rub the affected areas.  Remove all wet clothes and dry off gently. Cover with blankets. Chilblain is not considered a medical emergency, if recognized early and treated properly.

Frost Nip – an injury to the skin caused by prolonged exposure to cold weather.  The person’s skin will appear white and waxy, and may have a mottled appearance.  Pain and numbness is possible as exposure continues.  Treatment includes removing this person from the cold exposure, and warm-up naturally.  Do not rub the affected areas. Remove all wet clothes and dry off gently.  Cover with blankets.  Limiting cold exposure, recognizing sign and symptoms, and if properly treated early, this is not considered a medical emergency.

Frostbite (Superficial) – a thermal injury to the skin caused by prolonged exposure to cold weather.  The person’s skin will appear white or gray color, and may have a mottled appearance.  Deep layers of the skin will feel rubbery-hard with increased sensitivity to touch.  Treatment includes removing this person from the cold exposure, and warm-up naturally.  Do not rub the affected areas.  Remove all wet clothes and dry off gently.  Cover with blankets.  Depending on severity and exposure duration and exposure temperature, this will need to be seen in the emergency room.

Frostbite (Deep) – a thermal injury to the skin caused by prolonged exposure to cold weather.  The person’s skin will appear white in color.  The skin will feel wooden hard with numbness.  This is a medical emergency.  Treatment includes removing this person from the cold exposure, and warm-up naturally.  Do not rub the affected areas.  Remove all wet clothes and dry off gently.  Cover with blankets.  Get this person to the closest emergency room for further evaluation and treatment.

Hypothermia – a decrease in core body temperature, below 95° F, is associated with different sign and symptoms according to severity, and is categorized as mild, moderate and severe.

Mild Hypothermia – core body temperature measured as 99-95° F, these people will shiver and have a cold sensation.  The skin may have goose bumps.  The person may report numbness in the hands and feet, and may report chest pains.  This is not yet a medical emergency if treated quickly.  Remove this person from the cold environment.  Have them remove all wet clothes.  Use blankets and towels to gently dry off.  Put new clothes on following.  These people should warm-up naturally, and without any extreme external stimulation (rubbing, hot fluids, etc.).

Moderate Hypothermia – core body temperature measured as 95-90° F, these people may have some of the symptoms of mild hypothermia as well as intense/violent shaking/shivering.  These people may stumbling movements, difficulty speaking, and have slow and labored breathing and heart rate.  As they progress they may have difficult remembering things and chest pain.  This is a serious medical emergency, and they need treatment quickly.  Remove this person from the cold environment.  Have them remove all wet clothes.  Use blankets and towels to gently dry off.  Put new clothes on following.  These people should warm-up naturally, and without any extreme external stimulation (rubbing, hot fluids, etc.).  They should be transported to the closest emergency room as soon as possible, and when safe.

Severe Hypothermia – core body temperature measured as 90-75° F, these people may have some of the symptoms of moderate hypothermia, however there shaking/shivering will stop.  The skin will appear a puffy bluish/purplish.  Difficulty or inability to walk or talk continues to progress.  The persons thought process, and talking skills will seem incoherent and irrational.  They will have poor muscular control, with muscles very ridged.  The heart and respiratory rate will seem very erratic.  As they progress, they may weave in and out of consciousness.  Death is common if not treated immediately.  This is a very serious medical emergency, and they need treatment quickly.  Remove this person from the cold environment.  Have them remove all wet clothes.  Use blankets and towels to gently dry off.  Put new clothes on following.  These people should warm-up naturally, and without any extreme external stimulation (rubbing, hot fluids, etc.).  They should be transported to the closest emergency room as soon as possible, and when safe.