Hit Your New Year’s Goals

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

Key Points:

  • New Year’s goals can be achieved with the right set of guidelines to help you
  • Pick a relatively small goal and go bigger when you succeed with the smaller one
  • Use a visual key like a big red X on a calendar for each day you succeed
  • Reward yourself for successful days and weeks
  • Go easy on yourself if you miss a few days and then get back on track

This is the time of year when patients will come in to the office for a “tuneup” prior to starting an exercise regimen. This commonly happens for my 40-60 year old patients but it’s an occasional teenager who has the same objective. They’ve made getting fit and losing weight a New Year’s resolution. Unfortunately, the majority of those folks will fail, and will fall off their new program within a matter of a few weeks.

One of the keys to sticking with any new exercise or lifestyle change is to turn it into a habit.

Creating a new habit and then making that habit permanent can be tough but with some key steps it can be achieved by anyone. If you’re interested in making a major habit change I’d strongly encourage you to read Charles Duhigg’s book: The Power of Habit. In the introductory video you’ll see him describe the three parts of any habit, whether a good habit or a bad habit. There’s a cue (the stimulus), an action (that’s the habit), and a reward (the thing you get from the habit).

It’s interesting to think that a bad habit is associated with a “reward” but Duhigg provides compelling evidence. And so it is with diet and exercise. If you resolve to cut out processed sugar you need to make this a habit. Ditto if you have a resolution involving fitness.

Of the three parts of a habit, I find that the “reward” part is really underappreciated. Too often there’s a feeling that there has to be substantial pain involved in making a new habit but that’s not the case at all. On a daily basis you could give yourself a tiny reward for accomplishing a goal, and perhaps a bigger reward for a larger accomplishment. Just don’t make the reward something that undoes your hard work! For example, if your goal is to eliminate processed sugar during the day don’t reward yourself with a nighttime candy bar!

There are a lot of great people writing about the best ways to pick goals and change habits. Besides Charles Duhigg, I also really like Tony Robbins. There’s also a very nice set of guidelines by Jen Miller in the New York Times.

Here are my overall keys to success for any goal:

  • Pick the right goal. The acronym associated with good goal setting is “SMART”, which means pick a Specific goal and not something vague, make it Measurable, be sure it’s Achievable, choose something Relevant to your life, and put a Timeline on it.
  • Start small. This is related to picking the right goal. You’ll feel empowered to continue if you succeed in very small goals initially, then build with new goals. Many folks pick huge audacious fitness goals but this can be a setup for problems, especially if it’s something totally new for you. I find this is particularly true surrounding exercise. If you’re coming from a place of minimal activity, start with a 20 minute walk rather than a half hour fast run.
  • Use an actual calendar to mark off your progress. Believe it or not, paper actually works best. Keep a calendar where you see it every day. For every day you achieve your daily goal put a big red X on the day. Keep making X’s.
  • Reward yourself on a daily, weekly, and monthly basis for keeping your new good habit going.
  • Go easy on yourself if you have a setback. Things happen that are out of your control and even with the best of intentions you might miss a day or a few days with your new habit. This is not a failure, just a speedbump.

Here’s to your success- Happy New Year!

SideLineSportsDoc

Coming Back From: Knee Meniscus Surgery

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

Key Points:

  • Recovery is highly variable, but generally speaking most young athletes can return to sprinting, cutting, and jumping sports at about 6 weeks after partial meniscus removal surgery
  • Generally speaking, most young athletes will return to sprinting, cutting, and jumping sports at about 4 months after meniscus repair with stitches
  • Beware about claims to return fully to sports at 2 weeks after surgery (or less…) – this is very rare
  • Success rates are very high with properly followed rehab

College football fans recently witnessed the strange sideline incident where Ohio State quarterback JT Barrett reportedly injured a knee when colliding pregame with a photographer. But from my standpoint as an orthopedic surgeon the most incredible part was that Barrett had knee surgery on the Sunday after that game and then played in the Big 10 championship game against Wisconsin only 6 days after surgery. I have no details about exactly what was done in Barrett’s knee, but media reports indicate it was surgery to trim a torn meniscus. Furthermore, the stats from the Wisconsin game show that not only was he effective as a passer but he also rushed for 60 yards! This is uncharted territory.

Most orthopedic surgeons would honestly tell you it would be incredibly unusual for a player that relies on speed, quickness, and the ability to turn on a dime to be fully ready that quickly.

So how long should it realistically take?

The meniscus is a shock absorber in the knee, a horseshoe shaped structure situated between the two major knee joint bones. There are two menisci in each knee, and either meniscus can be torn in patterns generally like the ones shown in the photo (from OrthoInfo, the American Academy of Orthopaedic Surgeons).

If surgery is done for a torn meniscus it will most often be a partial removal, which is somewhat like trimming a hangnail from your toe. It’s a relatively quick procedure (usually about 15-20 minutes) and weightbearing is allowed immediately after surgery. The second possible procedure is called a meniscus “repair” where stitches are placed in the meniscus to sew it back together. After a meniscus repair there is usually a period of partial weightbearing on crutches that lasts several weeks.

The type of surgery performed has a major influence on the speed of the rehabilitation. With the commonly performed partial meniscus removal there is an early emphasis on minimizing swelling and regaining motion. Comfortable walking generally takes about a week or two. The highly variable part is return of power, speed, and the ability to cut hard or pivot. This is the part that takes the longest time and will usually take 2-4 weeks. So if we add the weeks up it will be a minimum of 3 weeks and perhaps up to 6 weeks for full return to sprinting, cutting, and jumping.

With meniscus repair with stitches there could be 4-6 weeks on crutches, followed by regaining full walking ability, and finally getting the knee sport-ready with strength, power, and speed. There is some overlap in the phases but when all the time is added up you’re looking at 3 to 4 months until the player is ready for unrestricted sprinting, cutting, and jumping.

In the discussion above I’ve focused on return to sprinting, cutting, and jumping. So the timeline for return to sports will depend on whether you need to do those things in your sport. If you are a cyclist or swimmer you should expect a faster return to your sport. Distance runners will generally return to full training faster than sprinters but likely longer than cyclists.

Young athletes should expect a high chance of successful return with proper rehab and time after surgery. But it’s only a very rare few who can come back as fast as JT Barrett.

Logo

Coming Back From Shoulder Separation

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

Key Points:

  • A “shoulder separation” is a different injury than a shoulder dislocation
  • The shoulder separation involves a sprain to the ligaments of a joint at the point of the shoulder near the end of the collarbone
  • We will often see these injuries when a player is tackled or falls to the ground on the point of the shoulder, with the arm at the player’s side
  • Most shoulder separations from sports injuries can successfully be treated without surgery

I’ve written recently about shoulder dislocation, a serious condition in which the ball portion of the shoulder (humerus) becomes completely dislodged from the socket. This week we’ll discuss a shoulder separation, another common shoulder injury. But first let’s clear up some terminology to avoid confusion.

A separated shoulder refers to an injury to the ligaments of the acromioclavicular joint (commonly known as the AC joint), which is the joint between the end of your collarbone and the upper part of your shoulder blade. It’s located near the point of the shoulder.

Most shoulder separations occur during some type of hard fall or contact, such as a quarterback being tackled on to his shoulder, or a cyclist falling and landing on his shoulder. When I see a hard fall to the ground I’ll be suspicious for either a shoulder separation or a broken collarbone if the athlete fell with the arm tucked in to the side, and I’m suspicious for a shoulder dislocation if the athlete fell on to the outstretched hand.

There are six types of shoulder separations. Types 1 and 2 are the most common ones we see in sports injuries and are treated without surgery. Type 3 injuries are also reasonably common, and most of these are treated without surgery (although there is some debate about early repair for the throwing shoulder of an elite athlete…). Types 4-6 are not seen very often in sports injuries and these will require surgery. I refer to these as “types” although some surgeons will call these “grades”.

  • Type 1 – The ligaments have a mild sprain without a tear.
  • Type 2 – The AC ligament tears, leading to a partial separation.
  • Type 3 – The AC ligament and other associated ligaments tear, leading to a complete separation.
  • Types 4-6 – These are complete separations, serious injuries often requiring urgent surgery. I have seen one type 4 separation in a D1 quarterback during my 23-year career.

Here are typical return to play times for the common types:

  • Type 1: You can usually return to play 2-3 weeks after the injury, depending on your sport and position. You should be comfortable, with full motion, normal strength, and ability to do sport specific motions. Treatment includes rest and anti-inflammatory medication.
  • Types 2 and 3: A Type 2 injury takes about 3-4 weeks to fully heal, and a type 3 injury takes about six to eight weeks to heal. We’ll almost always treat these without surgery, and we’ll use the same return to play criteria as indicated above for the Type 1 injury. If you’re in a collision sport (such as football) I’ll usually recommend you return to play with an AC joint pad to minimize the chance of another injury.

SideLineSportsDoc

PITCH SMART RECOMMENDATIONS FOR YOUTH BASEBALL

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

Key Points:

  • Young pitchers are at risk for arm injuries due to a number of factors, and pitching while fatigued is perhaps the biggest risk for injury
  • MLB’s Pitch Smart guidelines are designed to reduce injury risk while still allowing for the competitive development of the young player.
  • Parents, coaches, and league administrators would be wise to implement the Pitch Smart recommendations for their pitchers

As spring and summer baseball is ramping up, I’d like to remind our readers of a terrific Grant Lewisresource for the young pitcher- MLB’s Pitch Smart guidelines. I’ve written about pitch counts, the “100 inning rule”, and pitching injuries in several other blog posts but it is worth pointing out some of the reasons why we should revisit this topic. Pitch Smart is an effort by Major League Baseball to critically evaluate factors responsible for injury risk to young pitchers and then create guidelines to minimize that risk. Pitch Smart is partnered with many of the brightest minds in sports health for throwers and has produced a set of recommendations based on evidence and experience.

The result of their effort is a set of age appropriate recommendations designed to keep young pitchers as healthy as possible.

We’ve definitely made progress in recognizing and putting in place recommendations to reduce injury risk, but as the website points out we still have some work to do. For example, a survey of youth pitchers published in 2014 showed that of the pitchers responding to the survey many were engaging in behaviors that risk the health of their arms:

  • 45% pitched in a league without pitch counts or limits
  • 5% pitched on consecutive days
  • 4% pitched on multiple teams with overlapping seasons
  • 2% pitched competitive baseball for more than 8 months per year

Those published statistics are a few years old and hopefully we’ve made some progress in this area thanks to the efforts of Pitch Smart and others.

Take a look at the age-specific guidelines. They are divided into 5 age groups. For example, in the 15-18 year group which would cover most of our high school aged athletes some of the key recommendations are:

Screen Shot 2017-03-10 at 9.56.33 AM

Players can begin using breaking pitches after developing consistent fastball and changeup

  • Do not exceed 100 combined innings pitched in any 12 month period
  • Take at least 4 months off from competitive pitching every year, including at least 2-3 continuous months off from all overhead throwing
  • Make sure to properly warm up before pitching
  • Set and follow pitch-count limits and required rest periods
  • Avoid playing for multiple teams at the same time
  • Avoid playing catcher while not pitching
  • Players should not pitch in multiple games on the same day
  • Make sure to follow guidelines across leagues, tournaments and showcases
  • Monitor for other signs of fatigue
  • A pitcher remaining in the game, but moving to a different position, can return as a pitcher anytime in the remainder of the game, but only once per game
  • No pitcher should appear in a game as a pitcher for three consecutive days, regardless of pitch counts

In my opinion, Pitch Smart’s recommendations are another example of much neededSideLineSportsDoc changes designed to keep young players playing longer and healthier. These are recommendations rather than rules, but if you are a league administrator I’d urge your league to have a close look at these recommendations and adopt them for your players.