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.

Preventing ACL Injuries

Dr. Adam Yanke, MOR sports medicine physician, recently sat down to discuss a study that showed athletes with fatigue are at higher risk for anterior cruciate ligament (ACL) injuries. One of the ACL injury prevention programs that Yanke recommends for young athletes is Knees For Life (Kneesforlife.org), which offers a downloadable brochure and an opportunity to obtain complimentary gym bag tags featuring warm up exercises and other prevention strategies.

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Why is Cheerleading A High-Risk Sport?

In spite of being a highly skilled sport, cheerleading may be dismissed by some as a trivial activity. This misconception is simply dispelled by statistics that cheerleading accounts for 66% of all catastrophic injuries in female US athletes.

Requiring an array of dynamic skills and discipline, cheerleading is not only a highly demanding endeavor but also markedly high-risk, illustrated by research reports that cheerleading is the most statistically dangerous sport for US women.

First and foremost cheerleading is a highly-skilled sport, requiring highly dynamic movement, gymnastic demands and dance elements, and like any athletic endeavour carries a high risk of injury – particularly at the professional end of the spectrum where stunts and performance carry a higher risk of fall and overuse injuries.

In fact, a study by the University of North Carolina (UNC) National Catastrophic Sports Injury Research found cheerleading to be the cause of more injuries to US females than any other sport. The author of the report Frederick Mueller, Ph.D. commented that “A major factor in this increase has been the change in cheerleading activity, which now involves gymnastic-type stunts.” Indeed gymnastics was found to be the second most prolific injury-causing sport in women.

A cheerleader requires the following prerequisite skills and strengths: agility, flexibility, coordination, balance, strength and precision of movement. Timing is also an essential facet in avoiding injury, particularly in terms of regarding the safety of your team mates. Dropping a team mate during a flip or pyramid can have serious repercussions, so a constant mental engagement and awareness is crucial at all times. The requirements for the above mentioned skills obviously intensifies with the proficiency of the team, particularly for cheerleaders performing at a professional or national level.

When considering the specific logistics of certain signature cheerleader stunts – such as ‘basket toss’ stunts, in which cheerleaders are thrown up to 20 feet into the air – the causation of extremely high injury risk statistics are clear.

A notable cheerleading injury incident that made transatlantic headlines was the case of Orlando Magic stunt team cheerleader Jamie Woode. Watched by thousands during the televised event, a treacherous mis-step caused Woode a devastating fall during a the first half of the NBA event between Orlando Magic and the New York Knicks. Landing on her head, the incident resulted in concussion, three broken vertebrae and a broken rib.

While cheerleading is an established sport in American culture, it is also gaining keen momentum in the UK. Recent figures show that 37% of British schools now offer cheerleading as part of the physical education curriculum, and 68 UK universities were represented at the UK University Cheerleading Nationals in 2015. Particularly with an increase in popularity, ensuring the safety of cheerleading participants with informed advice and regulation is crucial.

The importance of a good coach

As with any sport, a good cheerleading coach is fundamental to the pursuit of progressive quality training, the safety of the athlete and the avoidance of injury risk. Dr. Mueller states, “If cheerleading activities are not taught by a competent coach and keep increasing in difficulty, catastrophic injuries will continue to be a part of cheerleading.”

Improved regulation of coaching credentials and cheerleader safety training in the UK and USA have contributed greatly to a recent reduction in reported cheerleader injuries. Bodies such as cheersafe.org also provide cheerleading facilitators, parents and participants with comprehensive cheerleading safety information and checklists for extra-curricular cheerleaders, and those competing within teams in the educational system.

Main causes of injury in cheerleading

The injuries most prevalent in cheerleading are as follows:

  • Falling injuries – A high-risk product of stunt work, falling injuries can cause anything from surface abrasions and brushing, to severe fractures and concussion.
  • ACL injuries – Mis-stepped landings, a sudden change in direction or pivoting of the knee during full extension of the leg, are all contributing factors to the high risk of ACL injuries in cheerleading.
  • Overuse injuries – Common in many sports with intensive training, cheerleaders may be at risk or overuse injuries.

How can injuries be avoided?

A fully accredited and experienced coach providing full supervision and expert guidance is at the heart of safe cheerleading practice. Similarly it is the responsibility of the participating cheerleader to be responsible and fully aware of their own safety, as well as that of their team mates. The individual should ensure they are comfortable with any stunts undertaken, and that they have the sufficient training and ability to perform any given stunt.

Cheerleading regulatory bodies have placed restrictions and regulations on certain stunts, in order to minimize injury risk. A fully accredited coach will always train a squad according to these safety regulations.

As with any athletic endeavor, supporting training exercises are recommended to ensure sufficient levels of fitness and conditioning to help optimise performance, and negate the risk of injury. The recommended training and considerations are as follows:

  • Resistance exercises – This is important to gain and/or maintain sufficient strength in the lower back, shoulders and stomach. Pilates exercises and resistance weight training are excellent exercises for cheerleaders.
  • Stretching exercises – Flexibility is a vital performance requirement for cheerleaders. Dynamic stretching or yoga are excellent options for cheerleaders to improve performance and negate the risk of injury.

Correct injury rehabilitation – As a cheerleader’s performance effects not only their safety but also that of their team mates, it is crucial that cheerleaders do not return to squad training until fully cleared by a sports professional. If injured, seeking the correct treatment and rehabilitation program is essential.

Despite it’s perhaps frivolous depiction in popular culture, cheerleading is a serious sport carrying very severe risks of serious injury. Nonetheless, the correct adherence to regulation, undertaking proper comprehensive training with an experienced and fully-qualified coach and performing supporting exercises all significantly reduce the risk of cheerleading injury.

By SportsInjuryClinic

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.