Philly.com
Sports Doc
Posted: Tuesday, September 15th, 2015

It’s that time of year. Fall sports are in full swing. Hopefully you had a productive pre-season that prepared you for the fall. Here are some tips to keep players safe and injury free this fall.

Fitness: If you weren’t in shape going into pre-season, hopefully you survived it without any injuries. If you did sustain an injury in pre-season, make sure you address it now as it will only linger and will likely get worse during the season. Next summer, make sure you get in shape prior to pre-season in order to avoid the same problems.

Overuse Injuries: Stress fractures, shin splints, tendonitis, etc These all occur because of ramping up intensity too quickly. Two and three a day practices on hard fields or indoor courts after a summer off is a recipe for disaster for overuse injuries. If you sustained an injury during pre-season, you need to be evaluated by your athletic trainer as playing through it never works and almost always makes the injury worse and prolongs recovery.

Heat Illness: This is hot topic. The myth of hydrating is finally being dispelled. You should drink when you are thirsty and not be forced to drink excessive fluids. But, you also need to be allowed to drink freely and coaches cannot restrict fluid intake either. And sports drinks, they’re not really needed. Water is the best along with meals that include some salty food to replace the electrolytes lost during training. For players with cramping, sweat testing can be done to assess the cause and how to replace fluids and electrolytes appropriately. The Heat Institute at West Chester University is a local facility that can perform sweat testing with the appropriate replenishment recommendations.

Concussions: I don’t think we need to talk too much about concussions as we all know the significance of these injuries. Any concussion should be taken seriously and needs to be evaluated by your team’s athletic trainer and a physician who specializes in concussion evaluation and management. The current medical guidelines from the most recent consensus statement say “no return to play on the day of concussive injury should occur.” And the “athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise.”  Please take concussions seriously as athletes can suffer lifelong post-concussive symptoms if not managed appropriately. 

Best of luck to all of the athletes and their teams this fall. Hopefully we only see you in the newspaper and not in the athletic training room or physician’s office.

Philly.com Sports Doc
Posted: Tuesday, July 15, 2014, 1:14 

PMRIO DE JANEIRO, BRAZIL - JULY 13: Christoph Kramer of Germany receives treatment as referee Nicola Rizzoli looks on during the 2014 FIFA World Cup Brazil Final match between Germany and Argentina at Maracana on July 13, 2014 in Rio de Janeiro, Brazil. (Photo by Robert Cianflone/Getty Images)

Concussions in soccer are becoming more evident, as seen in the World Cup final. Germany’s Christoph Kramer was injured in a shoulder-to-head collision during the first half. He appeared concussed to the average viewer. Kramer even told the German newspaper Die Walt, “I can’t really remember much of the game.” 

Germany’s medical staff evaluated Kramer on the sideline and returned him to the match. Approximately 15 minutes, later Kramer fell down on the field and was subsequently substituted.FIFA’s concussion management protocol is based on Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport, which is the gold standard for concussion management. The SCAT 3 and pocket SCAT 2 are the concussion tools used to evaluate athletes suspected of having a concussion. According to the consensus statement, if it is determined that the athlete has suffered a concussion, he is immediately removed from the game and may not play for a minimum of one week.

Did Kramer pass his sideline testing? Was the German staff not competent in assessing his concussion? Did they return him to play despite having a concussion?

From my observation, he had some obvious signs that would have raised serious concerns about a concussion. We will never know what truly occurred on the sideline, and these situations are becoming more common as seen in this World Cup like Gonzalo Higuaín in the final match, Javier Mascherano in the semi-finals and Álvaro Pereira in the group stages. 

In any American sport, Kramer would have been removed from the game and a thorough concussion assessment would have been performed. The NFL even has independent concussion evaluators on each sideline to limit any bias from the team physician.

International soccer is behind American sports in the assessment and management of concussion. One problem is that they don’t take them as seriously as we do here in the U.S.

Having to play down a man during the evaluation and the limited number of subs is another big problem for concussion assessment and management in international soccer. If the quick sideline test – as performed in the U.S. – shows signs of a possible concussion, a more formal evaluation can take upwards of 10-15 minutes to perform, which means the team will have to play down a man until it’s completed. 

Another issue is who is doing the assessment.  As we’ve seen, the team physicians have been very liberal about letting a player return. There is talk in soccer circles about having an independent physician on the sidelines that has the final say, much like the NFL. Another option may be to allow a temporary sub until the concussion evaluation is completed.

Besides a cultural change, there will need to be some significant rule changes to allow appropriate and unbiased sideline concussion evaluations in international soccer. I just hope that these changes occur before it ends up in the courts as it did here with the NFL.

Philly.com Sports Doc
Posted: Monday, April 28, 2014

Injury statistics

A 2007 study by Dick et al in the Journal of Athletic Training looked at injury rates for the women’s lacrosse using the NCAA injury surveillance system from 1988-2004.

The results show the game injury rate was twice the rate for practice (7.15 versus 3.30 injuries per 1000 athlete-exposures [A-Es]). Preseason practice injury rates were almost twice as high as regular-season practice rates. More than 60% of all game and practice injuries were to the lower extremity.

Approximately 22 percent of all game injuries and 12 percent of all practice injuries involved the head and neck. In games, ankle ligament sprains (22.6%), knee internal derangement (14.0%), concussions (9.8%), and upper leg muscle strains (7.2%) accounted for the majority of injuries.

In practices, ankle ligament sprains accounted for the largest proportion of all injuries (15.5%), followed by upper leg muscle strains (11.7%) and knee internal derangements (6.1%).

Participants had almost 5 times the risk of sustaining a concussion or a knee internal derangement during a game compared with practice and 3 times the risk of sustaining an ankle ligament sprain during a game. The greatest proportion of game injuries (44.3%) resulted from no direct contact. A total of 35.9 percent of game injuries were associated with other contact (primarily stick or ball) and 18.6 percent with player contact. The majority of practice injuries (62.0%) involved a non-contact mechanism. A total of 22 percent of game and 24 percent of practice injuries were severe enough to restrict participation for at least 10 days. In games, knee internal derangements accounted for almost half of all severe injuries, followed by ankle ligament sprains. Head injuries represented 7 percent of the severe game injuries. In practices, lower leg stress fractures, knee internal derangements, and ankle ligament sprains were the primary severe injuries.

Lower Extremity

Lower extremity injuries account for over 60 percent of all collegiate women’s lacrosse injuries. The majority of these injuries can be divided into the following diagnoses: ankle sprains, knee internal derangements, upper leg strains, and lower leg stress injuries.

Ankle sprains account for 22.6 percent of game and 15.5 percent of practice injuries. These are primarily lateral ankle sprains which are caused by the ankle rolling inward during cutting and pivoting. Most ankle sprains are minor and players can return quickly to practice and competition. These injuries should initially be evaluated by your team’s athletic trainer. Depending on the severity, players with minor injuries may return immediately with taping or bracing. More severe injuries may require time away from the sport and more substantial treatment including evaluation by a sports medicine physician and subsequent rehab. There may be a period of immobilization and limited weight bearing depending on the extent of the injury. Rehab involves regaining range of motion and flexibility, strength, and balance with a gradual progression to full sports activities.

Knee internal derangements account for 14 percent of game and 6.1 percent of practice injuries. The two most common diagnoses are ACL tears and meniscal tears. In women’s lacrosse, ACL injuries account for a great number of knee internal derangement due to the significantly higher rate of ACL injury in female athletes compared to males. Both meniscus tears and ACL tears are serious injuries and should be evaluated by a sports medicine physician. Although most of these injuries require surgery, there are some players who can finish the season. If an athlete is to finish the season with one of these injuries, she needs to undergo a structured rehabilitation program and meet specific objective goals before being cleared to return to sports.

Upper leg strains account for 7.2 percent of games; 11.7 percent of practice injuries. These injuries are primarily hamstring strains. Hamstring injuries can be difficult to treat and there is still debate on the best course of treatment. In my experience, the initial phase of treatment focuses on reducing pain and inflammation while regaining flexibility. The second phase involves regaining strength in the injured and initiating lower level sport specific activities. The final phase involves higher level sport specific activities and a structured return to sport progression.

6.5 percent of practice injuries involve lower extremity stress injuries. These can include stress reaction or exertional compartment syndrome, which combined are commonly called shin splints, as well as stress fractures. Lower extremity stress injuries are almost always due to repetitive overload stress. This can be caused by increased training loads in under conditioned athletes, overtraining, lower extremity biomechanical issues, or a combination of all three. The first treatment is to reduce the volume and/or intensity of training. At times, athletes need to be shut down depending on the severity of symptoms.

These injuries should be evaluated by both the athlete’s athletic trainer and a sports medicine physician to rule out more serious diagnoses such as a stress fracture. The athlete should also have a biomechanical analysis performed to help correct any underlying dysfunction that may be contributing to the problem such as over pronation or weak gluteus medius.

Concussions

Concussions are the 3rd most common game injury and 6th most common practice injury in collegiate women’s lacrosse. In this study, concussions resulted in 7 percent of all injuries requiring greater than 10 days of missed time. This correlates with concussion research showing that that most concussions resolve within that time frame. As we have learned from contact sports such as football and hockey, concussions are serious injuries and should be treated as such. An evaluation by a sports medicine clinician trained in concussion assessment should be performed in order to develop an appropriate treatment plan. This may include time away from the classroom as well as from the playing field.

Upper Extremity Injuries

Upper extremity injuries in women’s lacrosse account for less than 1 percent of all injuries and therefore were not tabulated in this study. This is likely due to the rules that prohibit checking in women’s lacrosse.

As you can see, ankle sprains and knee internal derangements (ACL tears and meniscus tears) are the two most common injuries followed by upper leg muscle-tendon strains (hamstrings) and concussions. Upper extremity injuries are uncommon in women’s lacrosse. Any injury should be evaluated by your athletic trainer to assess the severity of the injury and determine the appropriate plan of care.

Philly.com Sports Doc
Posted: Friday, April 4, 2014, 5:45 AM

Injury statistics

A 2007 study by Dick et al in the Journal of Athletic Training looked at injury rates for the men’s lacrosse using the NCAA injury surveillance system from 1988-2004. The results show a nearly 4 times higher rate of injury in games than in practice (12.58 versus 3.24 injuries per 1000 athlete-exposures [A-Es]).

Pre-season practice injury rates were more than twice that of in-season. In-season game injury rates were almost twice as high as those in the postseason (12.60 versus 7.54 injuries per 1000 A-Es).


A total of 48.1% of all game and 58.7% of all practice injuries were to the lower extremity. The upper extremity accounted for another 26.2% of game injuries and 16.9% of practice injuries, whereas 11.7% of game and 6.2% of practice injuries involved the head and neck.

• In games, ankle ligament sprains (11.3%), knee internal derangements (9.1%), concussions (8.6%), and upper leg contusions (8.0%) and muscle strains (7.5%) accounted for most of the injuries.
• In practices, ankle ligament sprains accounted for 16.4% of all reported injuries. Upper leg muscle/tendon strains (11.4%) and knee internal derangements (7.1%) were also common injury categories in practices. Concussions accounted for 3.6% of practice injuries.

Players were 9 times more likely to sustain a concussion in a game than in practice, 5 times more likely to sustain a knee internal derangement in a game than in a practice, and almost 3 times more likely to sustain an ankle ligament sprain in a game than in a practice.

Most game injuries (45.9%) resulted from player contact, whereas the rest were equally distributed between other contact (primarily contact with the stick) and no direct contact to the injured body part.

In games, knee internal derangements accounted for 27.3% of all severe injuries, followed by acromioclavicular joint injuries (7.3%), ankle ligament sprains (7.1%), and upper leg muscle strains (5.6%). Concussions accounted for 3% of severe game injuries.

 In practices, these same areas, except for acromioclavicular joint injuries, accounted for most of the severe injuries. 45.9% of game injuries were associated with player contact, and 12.9% were associated with stick contact.

Contact with the ball was associated with only 3% of all game injuries. Most concussions (78.5%) were associated with player contact, with stick contact accounting for another 10.4%.

The majority of practice injuries (50.0%) involved no direct contact. 21% of both game and practice injuries restricted participation for at least 10 days.

Lower Extremity

Lower extremity injuries account for roughly half of all collegiate lacrosse injuries. The majority of injuries can be divided into the following for diagnoses: ankle sprains, knee internal derangements, upper leg strains, and upper leg contusions.

Ankle sprains account for 11.3% of game and 16.4% of practice injuries. These are primarily lateral ankle sprains which are caused by the ankle rolling inward during cutting and pivoting. Most ankle sprains are minor injuries and players can return quickly to practice and competition. These injuries should initially be evaluated by your team’s athletic trainer. Depending on the severity, players with minor injuries may return immediately with taping or bracing. More severe injuries may require time away from the sport and more substantial treatment including evaluation by a sports medicine physician and subsequent rehab.

There may be a period of immobilization and limited weight bearing depending on the extent of the injury. Rehab involves regaining range of motion and flexibility, strength, and balance with a gradual progression to full sports activities.

Knee internal derangements account for 9.1% of game and 7.1% of practice injuries. The two most common diagnoses are meniscus tears and ACL tears. Both of these are serious injuries and should be evaluated by a sports medicine physician. Although most of these injuries require surgery, there are some players who can finish the season. If an athlete is to finish the season with one of these injuries, he needs to undergo a structured rehabilitation program and meet specific objective goals before being cleared to return to sports.

Upper leg strains account for 7.5% of game injuries; 11.4% of practice injuries. These injuries are primarily hamstring strains. Hamstring injuries can be difficult to treat as seen by looking at the length of time missed on an NFL injury report. There is still debate on the best course of treatment for hamstring injuries. In my experience, the initial phase of treatment focuses on reducing pain and inflammation while regaining flexibility. The second phase involves regaining strength in the injured and initiating lower level sport specific activities. The final phase involves higher level sport specific activities and a structured return to sport progression.

Lastly, upper leg contusions account for 8% of game and 3% of practice injuries. These contusions are usually the result of players being hit by balls, sticks, or other players. These injuries are usually minor and involve decreasing pain, regaining flexibility, and regaining strength. Return to sports is usually fairly quick for most of these injuries.

Concussions

Concussions are the 3rd most common game injury and 5th most common practice injury in collegiate lacrosse. The high rate of concussion is likely due to the contact form both stick and body checking. In this study, concussions resulted in only 3% of all injuries requiring greater than 10 days of missed time. This correlates with concussion research showing that that most concussions resolve within that time frame.

As we have learned from contact sports such as football and hockey, concussions are serious injuries and should be treated as such. An evaluation by a sports medicine clinician trained in concussion assessment should be performed in order to develop an appropriate treatment plan. This may include time away from the classroom as well as from the playing field.

Upper Extremity Injuries

AC joint injuries are the most common upper extremity injury in lacrosse accounting for 5.1% of game injuries and 1.9% of practice injuries. These injuries are usually self-resolving and improve with conservative care. AC joint injuries should be evaluated and treated by your athletic trainer. Treatment usually involves a period of rest and immobilization if needed. Initially, goals are to reduce pain and regain range of motion. Once symptoms resolve, a strength program should be initiated with a gradual progression back to sports.

Shoulder sprains/strains account for less than 3% of all injuries in men’s lacrosse. These are minor injuries that resolve with conservative care. As any injury, they should be evaluated by your athletic trainer who will develop a program to regain range of motion and strength with a supervised return to play, if any time away from the sport is needed.

Shoulder subluxations/dislocations account for less than 3% of all injuries. These are more serious and need immediate evaluation by your team’s athletic trainer with a referral to a sports medicine physician. These injuries require a longer time away from sports and a more prolonged rehabilitation program. Dislocations may require surgical stabilization which is why a physician consultation is needed.

Thumb fractures are another uncommon injury in lacrosse. They are almost always the result of being hit by a stick. These injuries are usually significant and require time away from sports and some type of physician treatment. This can be as minimal as splinting or as significant as surgery, depending on the severity of the fracture.

As you can see, ankle sprains and knee internal derangements (meniscus tears and ligament injuries) are the two most common injuries followed by concussions. Upper extremity injuries are much less common and usually less severe as well. Any injury should be evaluated by your athletic trainer to assess the severity of the injury and determine the appropriate plan of care.