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.

OUR SPINE STRESS FRACTURE MINI-EPIDEMIC

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

Key Points:

  • Stress fractures in the low back (lumbar spine) are injuries that can result in months off from sport and in some instances can lead to withdrawal from the sport
  • Many types of low back pain can be managed early on, before anything serious happens
  • Seek qualified medical care for pain that doesn’t improve after a few days of rest and simple treatment, or for pain that is affecting performance

One of the high schools where I’m team physician appears to be having a mini- epidemic low backof low back (lumbar spine) stress fractures. We were going through our fall season injury stats with our athletic trainers this week, and I was surprised to see that low back pain was now the third most common main complaint of the athletes we saw in the training room, and an alarming number of those young athletes turned out to have stress fractures of the lumbar spine.

Stress fractures of the lumbar spine, and stress fractures anywhere in the body are reportedly uncommon. A study published in 2014 by Changstrom and colleagues found that in the high school athlete population, stress fractures accounted for only 0.8% of reported injuries across 8 seasons.

When I first started my orthopedic practice in the early 1990s I’d have to say I didn’t think too much about stress fractures. We simply weren’t trained to put it near the top of our thought processes when evaluating young athletes with pain. Then a series of studies principally focused on military recruits started to raise our suspicions. Furthermore, improved understanding of the role of low bone mineral density, low energy availability, the female athlete triad, and the prevalence of overuse injuries in young athletes has heightened the team physician’s awareness even further.

The result of all those years of improved knowledge means that as an orthopedic team physician I’m much more aware of the possibility of a stress fracture. In the low back I’ve become much more attuned to some signs that would indicate the need for proper imaging studies. A sudden start of pain, possibly associated with a “pop” is a red flag. Pain that doesn’t improve in spite of several days of rest is another red flag. Localized tenderness on one side of the spine can be a sign of an underlying stress fracture. And a young athlete who feels she/he simply can’t play is a big red flag.

ssd.bannerStill in spite of improved awareness I have the feeling we’re not doing enough in the earliest phases of the problem. A stress fracture is one of those classically preventable problems, where rest and treatment early on might result in a short time off from play, but playing through and then treating at the stress fracture phase can result in months off from play, and sometimes withdrawal from the sport. For me it means that our trainers, physicians, and strength coaches are going to have a very close look at all athletes with low back pain and be very cautious about return to play. We may end up sitting more kids out early but I’d rather do that than lose them for months.

If you’re a parent of a young athlete with low back pain I’d urge a cautious approach for you too. If you hear complaints of low back pain from your son or daughter, if it lasts more than a few days, or if it’s affecting their play I’d strongly recommend early evaluation from a qualified physician. Don’t let this injury become a game-ender.

BONE LOSS IN YOUNG FEMALES: ONCE IT’S LOST IT’S TOUGH TO GET IT BACK

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

Key Points:

  • A woman develops about half her bone mineral content during her adolescent years, and healthy bone mineral content and bone mass lower the risk for stress fractures
  • If a young woman has poor bone mass as an adolescent, one study has shown that there’s nearly a 90% chance that she’ll continue to have low bone mass 3 years later
  • That study along with many others clearly point out that it is very difficult to regain bone mass once it’s lost and a strategy to maintain healthy bone mass from the start is critically important

I think I jinxed myself last week when I wrote about stress fractures in the foot because ahs_White-TEAM-xc_4476this week I saw two more young female runners with stress fractures, this time in the hip. With so many young women playing sports (which is definitely a good thing!) I thought it was worth looking at the topic of bone loss in young female athletes a bit deeper. The specific question this week: if a young female has issues with low bone mass or bone density can she regain it later on?

It’s been shown that a woman develops about half of her bone mineral content during her adolescent years. In these formative years, factors such as decreased or absent menstrual cycles, lower body mass index, decreased calorie intake, and participation in endurance running sports can negatively affect bone content. An important question then becomes whether these young female athletes regain that lost bone later on in life.

One of the better studies I’ve seen on this subject was published in 2011 by Barrack and colleagues. Unfortunately the study results were not encouraging. The researchers analyzed 40 female runners with an average age about 16 years. They then administered a survey three years later to evaluate menstrual status and sports training and performed DEXA scans to assess bone mineral density.

Here’s the really unfortunate part: 87% of the female runners with low bone mineral density at the first test still met the criteria for low bone mass three years later. Compared to females with normal bone mass levels, those with decreased bone mass tended to run more total miles and more miles in the off season. Almost half had menstrual irregularity or took oral contraceptives for menstrual irregularity. What was harder for the authors to determine was whether the bone loss was irreversible or whether those females engaged in activities, such as increased running, or had factors, such as menstrual irregularities, that prevented them from regaining bone mass.

This study and others point out how important it is for a young female athlete to takessd.banner bone health seriously. If you’re a young woman runner with lingering bone pain please get it evaluated properly. If you’re not having regular menstrual cycles, you should discuss that issue with your OB-GYN or family doctor. If you’re having nutritional issues with calorie intake or food quality, please consult a nutritionist early on and take corrective steps.

The Barrack study shows that once bone loss occurs in adolescent runners, it is unlikely to significantly improve. Almost 9 out of 10 young female runners in this study continued to have low bone mass three years later. It’s far better to develop and keep healthy bone mass early on rather than to fight to make it up once it’s lost.