ANKLE SPRAIN: WHEN CAN I PLAY AGAIN

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Recovery and return to play after ankle sprains will vary depending on the severity of the injury, and the injured athlete’s unique healing response
  • Sport specific reconditioning after an ankle sprain often takes much longer than you think
  • For the common Grade 1 sprain, I typically see return to play with a brace at 1-2 weeks after injury
  • For the common Grade 2 sprain, I typically see return to play with a brace at 4-5 weeks after injury

There’s never a good time to be injured. As we come up to the end of many winter sports, SwollenAnkle_2players often have their eyes on championships or important tournaments. When an injury happens one of the most important questions the young athlete wants to know is “when can I play again?” Usually their point of reference is the newsfeed on some professional athlete’s injury, and the answer from the news media is almost always “2-3 weeks.” The reality, however, is that full recovery as I outline below can often take much longer than that. Let me outline the general phases for injury recovery, and finish with some rough timelines for return to play after ankle sprains.

Treating the Injury

The treatment phase involves the healing of the injured part. For an ankle sprain, this may involve a brace, sometimes crutches, and typically “RICE”: rest, ice, compression, and elevation. Ankle sprains are classified by physicians in “grades”, ranging from Grade 1 (mild) to Grade 3 (severe, with complete ligament tear).

Rehabilitating the Injury

Once the treatment for the injury has started, the next phase of recovery begins. This will often involve referral to a qualified physical therapist or working with your athletic trainer. The physical therapist and athletic trainer are highly trained in techniques to restore function of the injured ankle, develop a plan for sport-specific training, or suggest equipment modification such as bracing. For many injuries we’ve learned over the years that early involvement by an athletic trainer or physical therapist speeds up return to play.

Conditioning the Injured Athlete for Return to Play

Here’s the part that can take some time, often much longer than you initially realize. Let’s say you’ve had a significant ankle sprain. You were treated in a brace for 2-4 weeks, and then you started getting some movement skills back for another 2-4 weeks. Now we’re up to 4-8 weeks from the time of your injury, and you know what you haven’t been doing- practicing or playing sports. Getting yourself fit will take a few more weeks (or even months, if you’ve been out a long time). In this phase we will usually rely on the trainer to start sport specific conditioning drills designed to safely return you to play.

Putting it All Together- How Long Until You Can Play Again?

ssd.bannerI’ve broken the process into “phases” above, but the reality is that there’s a lot of overlap between the phases. For example, treatment and rehabilitation will be going on at the same time and will overlap, and rehabilitation and conditioning will also overlap. Additionally, each person responds differently to injury and healing. So each situation can vary quite a bit with the specifics of your injury, but here are some very rough guides based on real world experience from my orthopedic practice.

  • “Mild” or Grade 1 ankle sprain: Brace or Ace wrap for 3-5 days, Return to play with ankle brace 1-2 weeks
  • “Moderate” or Grade 2 ankle sprain: Brace 2 weeks, Rehab and conditioning 2 weeks, Full return to training 4-5 weeks after injury
  • “Severe” or Grade 3 ankle sprain: Boot or brace 3 weeks, Rehab and conditioning 4-6 weeks, Full return to training 7-9 weeks after injury
  • “High Ankle” or syndesmosis sprain (highly variable return times): Boot or cast 3 weeks, possibly crutches as well, Rehab and conditioning 6-12 weeks, Full return to training 9-15 weeks after injury

ACL SURGERY IN GROWING ADOLESCENT KIDS

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • We are seeing more ACL injuries in young growing athletes than we used to several decades ago, and more young athletes choose to have early ACL surgery
  • ACL surgery in a growing athlete requires special considerations to minimize chances of injury to the growth plates
  • With proper techniques, risk to the growth plates is low and success rates for surgery are very good although results are not as good as they are for adults after ACL surgery

An ACL tear in growing athletically active kids is a challenging issue to manage from a allograft ACLsurgeon’s standpoint. It appears that the number of young people sustaining ACL tears is on the rise, and in particular we are seeing more ACL injuries in kids who are not done with their growth.

As compared to kids who are still growing, teenagers who are done growing can be treated as adults when it comes to surgical decision making. Regardless of age, the main issue with a torn ACL is that the knee is typically unstable, making some sports and daily activities difficult. A knee with a torn ACL often gives way or buckles with activities.

Some surgeons will recommend that a young patient modify activity and possibly wear a brace until growth is finished, and then go through the ACL surgery. This is theoretically possible but it’s often very difficult to successfully manage a young person’s activity level, leading to quite a bit of unhappiness. This study showed that only 6% to 52% of young athletes were able to remain physically active to their desired level when managed without surgery, whereas 80% to 100% of young athletes managed surgically were able to successfully return to their desired level of activity. The surgical option tends to be much more appealing to most kids and parents.

The surgery for a torn ACL- called “ACL reconstruction”- involves building a new ligament by drilling tunnels in the tibia and femur, and then placing a new tissue called a “graft” in those tunnels. As the graft heals and matures it functions as the new ACL. In a young growing athlete the key consideration is that the areas of the bone where growth takes place, the “growth plates”, can theoretically be damaged by the surgery. This means that there’s a chance that either the leg length or the angulation of the leg could be altered by the surgery.

Considerable research has gone into the ways to minimize risk to the growth plates during surgery. Some techniques involve modifications to the tunnel positions to avoid crossing the growth plates. Other research has studied the effects of various types of ACL grafts on growth using conventional surgery techniques.

Not surprisingly, in this relatively new area of ACL research there is some controversy. The growth plate sparing techniques may have somewhat reduced stability compared to a conventional technique. And some graft choices may have a higher risk of damage to the growth plate. For example, a patellar tendon graft with bone plugs is commonly used in adults but there appears to be a higher risk of growth disturbance if the bone plug crosses the growth plate. Hamstring tendon grafts and conventional tunnel drilling technique seem to have the best combination of stability, excellent return to sport, and low risk of injury to the growth plates.

Some recently published studies have shown excellent functional results from the surgery with low rates of bone growth issues. This study of surgery on young people with open growth plates using conventional surgical technique and hamstring grafts showed about 15% of kids with some x-ray evidence of growth issues at 4 years, but none of the issues was limiting to the young athlete. Interestingly, this study showed that during the 4 year follow up period 16% of the kids retore the ACL, and 16% tore the ACL in the other knee. Success rates are quite a bit higher in adults.

ssd.bannerThis is a controversial area with a number of important considerations when deciding treatment pathways. My advice if you’re a parent of a young growing athlete with an ACL tear is to seek the opinion of highly experienced sports medicine surgeons, or possibly a pediatric sports medicine specialist to assist you in your decision.

HIP POINTERS

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • The term “hip pointer” refers to a bruise of the muscles and soft tissue attachments to the top of the pelvis bone, near the area where your shorts or pants would be
  • A hip pointer occurs from direct contact, such as from an opponent’s knee or fall to the court
  • Most hip pointers heal very well, with full recovery typically expected at about 3 weeks

In the last few weeks there have been several prominent NBA players sidelined for an Rockets v Clippersinjury called a “hip pointer”. We’ll see a fair number of these at all levels of basketball, including at the youth level.

What’s A “Hip Pointer”?

The term “hip pointer” has been used by sports medicine specialists for many decades, and in 1967 Dr. Martin E. Blazina from UCLA specifically noted that the phrase “hip pointer” should be used to describe a deep bruise to an area of the pelvis called the iliac crest (bone on the side of the body roughly near the top of your shorts or pants). So in actuality a hip pointer doesn’t really involve the hip, but the pelvis. Still we use the term somewhat broadly today. A hip pointer is an injury that occurs when there is direct contact to the iliac crest. This can occur by getting hit or falling onto your side and landing on a hard surface.

How the Injury Happens

The pelvic bone can see trauma during basketball if there is a direct blow from an opponent’s knee, or from a fall directly on to the basketball floor.

What’s The Story?

Hip pointers typically result in immediate, intense pain and localized tenderness over the iliac crest or pelvic bone. There will usually be significant bruising and swelling around the front, outside and inside of the hip. Due to the bleeding and swelling, movement of the hip will usually be limited and painful. Decreased range of motion and weakness are also typically seen. In young athletes I’ll typically get an x-ray to look for a fracture around the pelvis. One area particularly vulnerable in the growing athlete is the upper edge of the bone, where growth is still occurring.

Typical Treatment

Treatment starts with a proper diagnosis from a skilled sports medicine professional. These injures can be very uncomfortable, so crutches may be needed for the first several days, along with “RICE”: rest, ice, compression, and elevation. This will help to reduce inflammation and control the swelling. After the initial healing, the focus will shift to soft tissue mobilization. Soft tissue massage can help improve range of motion of the hip joint, further reduce swelling and prevent scar tissue. The athlete can then be progressed to range of motion, flexibility, strengthening, and sport specific exercises. For many young athletes I’ll prescribe physical therapy.

Time To Return To Play

Once pain free gait has been resumed sports specific training can be initiated. Fullssd.banner return to competition usually takes about 1-3 weeks for older teenagers, but may take longer in younger athletes, and longer still if there’s a fracture to the bone. After full healing, you should expect to be able to participate in full activity without restrictions.

Snowboarding Ankle Injuries

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Snowboarders tend to get more ankle injuries than skiers, and skiers tend to get more knee injuries than snowboarders
  • The “snowboarder’s fracture” is unique to ankle injuries in snowboarding
  • A fracture of the “lateral process of the talus” is sometimes missed on regular x-rays and it’s sometimes necessary to use specialized imaging to make a proper diagnosis
  • When treated early and properly this fracture will typically allow full return of sports participation but a missed diagnosis can result in significant problems

In this post I’m going to discuss a particular type of broken bone seen in snowboarding snowboardoften referred to as “the snowboarder’s fracture.” This particular fracture occurs in one of the ankle bones called “the talus”. A fracture in the lateral process of the talus is called the snowboarder’s fracture.

Patterns of injury are a bit different in snowboarding compared to skiing. Skiers tend to get more knee injuries than ankle injuries, and snowboarders tend to get more ankle injuries than knee injuries. One proposed reason for this difference is due to the less rigid boots used in snowboarding, which provide minimal protection to the ankle joint.

Most ankle injuries in snowboarding affect the lead leg. And about half of all ankle injuries in snowboarding are fractures. The “snowboarder’s fracture” occurs because of sudden upward movement of the foot, combined with the foot turning inwards. This injury typically occurs when landing from a jump. Pain is present on the outer side of the foot and ankle, and is often associated with swelling, bruising and significant tenderness to touch. Unfortunately, this injury is often missed, because regular X-rays don’t always show the fracture very well. If I’m suspicious for a snowboarder’s fracture and the x-rays look normal, I’ll often order a CAT scan as this can be a much more accurate way to diagnose this fracture.

Treatment of the snowboarder’s fracture depends on how big and how displaced the broken fragment is. For a small fracture that is in normal alignment, we can treat these without surgery. This typically means about 4 to 6 weeks of having the foot and ankle in a cast and no weight bearing on the leg. Large and displaced fractures are typically treated with surgery—the fragment is moved back into its normal position and screws are inserted to hold it in place. Recovery after surgery also includes a period of non-weight-bearing, followed by gradual restoration of motion, strength, and function of the ankle joint.

ssd.bannerOutcomes of snowboarder’s fractures are typically good if the injury is diagnosed early and appropriately treated.

Most athletes are able to get back to normal physical activity within 4 to 6 months. However, significant problems can result if this fracture is missed and appropriate treatment is delayed. These include non-healed bony fragments causing pain and poor function, as well as early arthritis of the joint, which can significantly limit movement of the foot. When a snowboarder presents with acute pain on the outer side of the foot or ankle after an injury on the slopes, it’s very important to see a skilled physician for a proper exam and appropriate diagnostic imaging to avoid missing this injury.

Safe Sledding

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Sledding is a fun winter activity that can be enjoyed even by the youngest kids
  • Sledding is generally very safe but a surprising number of serious injuries do occur each year, mostly from the sledder hitting immovable objects such as trees
  • The single most important safety point is to sled in an area with no risk of running into trees, posts, or rocks

It’s actually somewhat cold here in the San Francisco Bay Area, it was about 32 degrees calvin_and_hobbes sleddingthis morning when I took our dogs out for a walk and it got me thinking about the snow. So today I’m going to go over some tips for those of you whose kids are involved in the sport of competitive sledding. Ha! True, bobsled and luge are competitive sports practiced by many young athletes but today we’re just going to go over some recreational sledding safety points. Recreational sledding is one of those rare few remaining activities available to children that’s generally about fun and isn’t bogged down by super-competitiveness.

It’s easy to think of sledding as a low-key benign activity (which it usually is…) yet there are risks associated with sliding sports that must be minimized in order to prevent injury. Each year, there are between 20,000 and 90,000 sledding injuries in the United States requiring emergency department care. Some of these injuries are fatal or result in life-long disability. More than 60 sledding related deaths have been reported since 1990. One of my best friends from high school- an expert competitive skier- was paralyzed from the waist down when doing some simple sledding with his daughter.

The main risks in sledding occur when the sled or sledder hits an immovable object such as a tree or rock or a collision occurs between a sled and a person. Injuries include sprains, strains, cuts, and fractures. Sleds can reach speeds of up to 25 miles per hour. The most dangerous injuries are to the head and spine. Collisions with motor vehicles are particularly dangerous.

Injury Prevention Tips

  • Most important: use a safe sledding area! No obstruction such as trees, rocks, and posts. The potential path of the sled should not cross streets, water, or any drop-offs. Ideally, the area chosen will be specifically designated for sledding.
  • No tow-sledding, such as with a snowmobile.
  • Helmets should be worn by all children, especially those younger than 12.
  • All children should have adult supervision.
  • Make sure that children or adults supervising children control sledding “traffic” to make sure that active sledders don’t run into sledders who are finished or who are walking back up the hill.
  • Sit on a sled facing forward. Headfirst sledding is more dangerous.
  • Have enough light to see where you’re going. Sledding near trees in darkness is a dangerous combination.
  • Physical and mental fatigue may be factors that contribute to injury risk.
  • Sleds with steering mechanisms are safer than unsteerable products such as toboggans
    or discs.
  • Plastic sheets or other
    objects that can be penetrated by rocks or vegetation should not be used.

Sledding is a really fun winter activity and generally very safe, but the injuries that dossd.banner
occur can be devastating. Follow the safety guidelines and you’ll likely have a great time in the snow and keep yourself out of trouble.

IS SUGAR KILLING OUR KIDS?

By Dev K. Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Processed sugar and high fructose corn syrup are likely responsible for a number of negative health issues, such as obesity and metabolic syndrome
  • Create a lifetime healthy habit by eliminating processed sugars from a kid’s diet, whether athlete or not

This week I’d like to highlight a brief and excellent article by Gary Taubes that appeared sugarrecently in the Wall Street Journal, titled “Is Sugar Killing Us?” This article is a summary of some of Taubes’ key findings to be expanded upon in his coming book about the dangers of processed sugar. His premise in a nutshell: processed sugar (such as granular white sugar and high fructose corn syrup) is responsible for a myriad number of ills in the human body, most significantly obesity and diabetes.

I first came across Taubes’ work back in 2002 when he published an article on the cover of the New York Times magazine that featured a photo of a big juicy steak covered in butter and the title was “Fat Doesn’t Make Us Fat”. I remember reading the article and thinking he was nuts. Everybody knows that fat is the evil, avoid it and you won’t get clogged arteries and you won’t get fat. Right? Furthermore, I grew up believing the body treated all calories equally. Which was why as a college student I ate at least two bowls of Cap’n Crunch every morning for four years…

Fast forward 14 years and Taubes’ opinions look to be far closer to the truth. Processed sugar is the likely key factor in increased fat accumulation in the body, a principal trigger to the development of metabolic syndrome in adults, and many other life affecting health issues. It’s pretty clear that there are substantially more bad things that can happen to you from consuming processed sugar and high fructose corn syrup than good.

To be clear, I’d like to separate naturally occurring carbohydrates such as those found in ssd.bannerfruits and vegetables from processed sugar. There are many anti-carb zealots that eliminate most fruits from their diets because of the insulin response the carbs in the fruit creates, but for young athletes and kids who are not athletes I’d strongly recommend including multiple fruits and vegetables in a normal diet. There is no responsible child nutritionist who would eliminate fruits and vegetables from a child’s diet. So when Taubes refers to “sugars” he’s mainly referring to white granular processed sugar, and high fructose corn syrup.

This post was a significant diversion from my usual posts about youth sports health, but this topic is huge for all of us. Sugar will kill us. I’m a believer.