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Objecves

• Review the importance of injury prevenon from several perspecves Injury Prevenon Programs • Describe specific injury prevenon programs and their evidence of effecveness ACSM Team Physician Course Feb 2013 • Provide resources concerning athlete safety and injury prevenon – Clinicians, Athletes, Coaches, Parents Heather Gillespie, MD, MPH Assistant Professor, UCLA Team Physician, UCLA Athlecs

The “Cost” of Injury Injury Prevenon

• Financial • Environment/Facility Design – School/Team Health Care Budget – Athlete's Insurance • Equipment – Pro-Athlete Salary/Career • Rules/Regulaons • Time loss from sport – Team win-loss record • Screening • Athlete’s self-worth • Condioning Programs – Mood disturbances • Increased risk of recurrence • Proper Treatment of Injuries Before Returning • Long term to Sport – Premature OA – Decreased QOL • Athlete and Coach Educaon

Environment Equipment • Field and court maintenance • Helmets • Faceshields • Facility Design/Regulaons • Mouthguards – American Society for Tesng and • Shin guards • Eye protecon Materials Public Playground Safety • Padded goal posts Commiee. • Break away bases – ADA standards • Taping/bracing previous ankle injuries • Having emergency equipment available – Government zoning and building codes – Medical bag – AED – Specific sports organizaons – Ambulance – Splints, airways, etc – Marathon - electrolyte measurements

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Oversight Heat Illness • Rules/Regulaons • Injury Prevenon Intervenons: – Pitch Counts – Acclimazaon (5 to 10 days based on age, acvity, – Rules of parcipaon environment and equipment). • Restricted holds in wrestling, weight loss guidelines – Hydraon strategies • Restricted tackles in football (“Heads Up”) – Recovery (fluid status, core temperature and strength) • Restricted aggression in hockey – Implement sport/acvity condioning program with • Requiring specific equipment periodizaon • Sideline coverage – Medicaon/supplement management • Mass Event coverage – Clothing (loose-fing, light colors, breathable fabrics for exercise in the heat) and equipment (minimizing equipment on – Heat Illness days with excessive heat) – Hyponatremia – Modify and/or cancel sport-specific acvies based on • Emergency Acon Plans environmental condions

Pitch Counts Pitch Counts

• No Breaking pitches unl bones have matured (puberty) Minimum number of pitches thrown and recommended • Emphasize proper mechanics and year-round physical rest between oungs (mean ± standard deviaon). condioning programs. • If removed as pitcher: should not be allowed to return to Age, yrs 1 Day 2 Days 3 Days 4 Days the mound in same game 8-10 21 ± 18 34 ± 16 43 ± 16 51 ± 19 • Showcases are discouraged 11-12 27 ± 20 35 ± 20 55 ± 23 58 ± 18 • Discourage mulple overlapping leagues 13-14 30 ± 22 36 ± 21 56 ± 20 70 ± 20 • No more than 9 months pitching in any given year 15-16 25 ± 20 38 ± 23 62 ± 23 77 ± 20 • Encourage at least 3 months of arm rest 17-18 27 ± 22 45 ± 25 62 ± 21 89 ± 22 – including drills or any other stressful overhead acvies (quarterbacking, compeve swimming, playing soball, etc) • Specific rest periods recommended

Sports Health. 2009 November; 1(6): 514–517.

Screening Condioning/Training Programs

• PPE • Pre-season programs – Idenfy “at risk” athletes • Acclimazaon (heat, altude) • Injury Hx • Specific Training/Condioning Programs • Physical finding (PE) – ACL Prevenon Programs • Family Hx – Hamstring Injury Prevenon – Ankle Sprain Prevenon • Posive ROS – Idenfy already injured athletes – Athlete educaon

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ACL Injury “Costs” ACL Injuries

• ~250,000 ACL reconstrucons per year in US • 70% non contact mechanism • $2 billion cost annually • Modifiable Risk factors? – Neuromuscular control • Time loss from sport • Mood disturbances • Inc risk of second ACL injury • Premature OA • Decreased QOL

Prevenng Injury and Enhance ACL Prevenon Programs Performance (PEP) • Various programs • Warm-up, stretching, strengthening, plyometrics, and – Length of me (10-90 min); Avg 20 min sport specific agilies – 6 weeks  complete season – Various Intervenons • “address potenal deficits in the strength and coordinaon of the stabilizing muscles around the knee • Superior results with combining : joint” – Neuromuscular training/control • Emphasize: – Strength – Proper technique – Plyometrics – Posture – Jumping/landing techniques – Straight jumps up-and-down without excessive side-to-side movement • Examples: – – PEP, Sportsmetrics, 11, 11+, DNA So landings • 15-20 min

hp://smsmf.org/pep-program

PEP

• Warm-up • Agilies – Jog line to line – Forward run with 3 step – Shule Run deceleraon – Backward Run – Lateral Diagonal runs • Strengthening – Bounding run – Walking lunges • Stretching – Russian Hamstring – Calf – Single Toe Raises – Quad • Plyometrics – Figure Four Hamstring – Lateral Hops over Cone – Inner Thigh – – Forward/Backward Hops over Hip Flexor cone – Single leg hops over cone – Vercal jumps – Scissor Jumps

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11+ ACL Prevenon

• Review of 12 large scaled NMT studies aimed at lowering ACL injuries in • “Complete warm-up {program} to reduce female athletes: – RRR: 73.4% non-contact, 43.8% overall ACL injuries among male and female football – NNT: • 120 in overall ACL injuries players aged 14 years and older.” • 108 for one non-contact injury • Limitaons: • “Teams that performed 11+ at least twice a – High NNT – Compliance? Generalizability? week had 30 – 50% less injured players” • Addional benefits: – Reducon in other knee and ankle injuries • Standard warm-up, at least 2x/wk – Performance enhancement? • Future: • 20 min – Screen for high risk athletes? • “correct performance is of great importance” – Limited results and generalizability

Sugimoto, et al. BJSM 2012

ACL Prevenon Programs Ankle Sprain Prevenon

• Summary • ACSM Recommendaons: – Primary ACL injury prevenon programs work – Educaon and sport/acvity condioning program • Expensive with periodizaon including: • High NNT • Local muscle strengthening • + No injuries noted from programs – Eccentric emphasis – What happens when you stop program? • Improve dorsiflexion – Screen for high risk athletes? • Motor control • Research needed – Balance and core – Athletes with prior ACL injury (much higher risk ~10x) • Taping or bracing w/ Hx of previous ankle injury • Prevenon programs worth trying!!

Ankle Braces? Ankle Sprain Prevenon

• High school basketball players assigned to • Taping, bracing and neuromuscular training (NMT) are all wear lace-up ankle braces effecve for the prevenon of ankle-sprain recurrences • RRs of prophylacc measures (0.2 - 0.5) compared to controls • Acute ankle injuries reduced by 68% • Most literature on NMT • Braces did not affect the severity of the injury • Effect on first-me ankle sprains non-existent or very low or the rates of knee or other lower extremity injuries • Summary: combo of external measure (tape or brace) with NMT = best prevenve outcome and minimal burden

Babins EM. Lace-up ankle braces reduced acute ankle injuries in high Verhagen EA, Bay K. Opmising ankle sprain prevenon: a crical review and praccal school basketball players. Clin J Sport Med. 2012 Jul;22(4):379-80. appraisal of the literature. Br J Sports Med. 2010 Dec;44(15):1082-8. Epub 2010 Nov 3.

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Hamstring Injury Prevenon Hamstring Injury Prevenon

• Nordic Hamstring Exercise Program • Eccentric exercises

Hamstring Injury Prevenon Stretching??

• Randomized controlled trial of the efficacy of the Nordic hamstring exercise program • Tradional stretching rounes pre-exercise: • 942 soccer players – Inc flexibility for short period of me ~90 min • Progressive 10-week program – • Acute hamstring injuries No evidence to prevent injury • NNT • Stretching on regular basis away from roune – new or recurrent injury: 13 (95% CI, 9-23) – new injury: 25 (95% CI, 15-72) – Unknown injury risk reducon – recurrent injury: 3 (95% CI, 2-6) • Injury rate reducon • Risk of injury decreased in those that were more – new injuries and re-injuries: reduced by 70% aerobically fit – new injuries: 60% – recurrent injuries: 85%. • Tradional warm-up without stretching may • No injuries occurred during conducon of the Nordic hamstring exercise reduce injury risk • Compliance important!

Pope et al. 2000 Petersen J, et al. Am J Sports Med 2011

STOP Injury Prevenon (Sports Trauma and Overuse Prevenon) • Guidelines from professional organizaons • Developed by AOSSM in early 2007 – ACSM • Addresses overuse injuries in young athletes – AMSSM • Organizaonal partners – AOSSM – – NATA AAOS – AAFP – AAP – AAOS – NATA – AOASM – AMSSM – AAP – SAFE Kids USA

hp://www.stopsportsinjuries.org/

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STOP Youth Sports Safety Alliance

• hp://www.stopsportsinjuries.org/ • Baseball Injury Prevenon • Basketball Injury Prevenon • Spearheaded by NATA in 2010 • Cheerleading Injury Prevenon • Cycling Injury Prevenon • Sports Specific Resources • Dance Injury Prevenon • Mission: • Field Hockey Injury Prevenon • Figure Skang Injury Prevenon – Raise awareness, advance legislaon and improve • Athletes' Resources • Football Injury Prevenon • Golf Injury Prevenon medical care for young athletes across the • Coaches' Resources • Gymnascs Injury Prevenon • Healthcare Providers' Resources • Hockey Injury Prevenon country. • Inline Skang Injury Prevenon • Parents' Resources • Maral Arts Injury Prevenon – High school athletes suffer 2 million injuries, • Lacrosse Injury Prevenon • Rowing Injury Prevenon 200,000 doctor visits and 30,000 hospitalizaons • Issue Specific Resources • Rugby Injury Prevenon • Running Injury Prevenon every year • Concussion • Snow Sports Injury Prevenon • Condioning Tips • Soccer Injury Prevenon • Soball Injury Prevenon – Commied to reducing injury numbers and • Female Athlete Triad • Swimming Injury Prevenon • Tennis Injury Prevenon improving the health and safety of young athletes • Heat Illness • Volleyball Injury Prevenon • Overuse Injury • Water Polo • Wrestling Injury Prevenon hp://www.youthsportssafetyalliance.org/index.htm • Sports Nutrion

Youth Sports Safety Alliance Summary

Online Resources for: Asthma • Injury Prevenon comes in various forms Commoo Cordis Communicable and Infecous Diseases • Team Physician can influence all of these factors Concussion/Brain Injury Diabetes • Condioning Programs/Training Techniques Emergency Planning Environmental Cold Injuries – Only one factor Fluid Replacement and Hydraon Head-Down Contact in Tackle Football – Few specific injury prevenon programs, efficacy? Heat Illnesses Lightning Safety • Nutrion and Safe Weight Management Be Proacve Pre-parcipaon Physical Evaluaon Sickle Cell Trait – Look at injury rates for your program Steroids and Performance-Enhancing Substances – Spine Injuries Use literature and consensus statements/ Online resources Sudden Cardiac Arrest – Develop programs to address problems idenfied hp://www.youthsportssafetyalliance.org/index.htm

References References

• ACSM Team Physician Consensus Conference Statements • Ray TR. Youth baseball injuries: recognion, treatment, and prevenon. Curr Sports Med Rep. 2010 Sep-Oct; 9(5):294-8. hp://www.acsm.org/access-public-informaon/team-physician-consensus-conference- • Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers Am J Sports Med. 2002 Jul-Aug;30(4):463-8. statements • Babins EM. Lace-up ankle braces reduced acute ankle injuries in high school basketball players. Clin J Sport Med. 2012 Jul;22 • American Academy of Family Physicians (AAFP) hp://www.aafp.org. (4):379-80. • Noyes FR, Barber Wesn SD. Anterior cruciate ligament injury prevenon training in female athletes: a systemac review of • American Academy of Orthopaedic Surgeons (AAOS) hp://www.aaos.org injury reducon and results of athlec performance tests. Sports Health. 2012 Jan;4(1):36-46. • American College of Sports Medicine (ACSM) hp://www.acsm.org • Verhagen EA, Bay K. Opmising ankle sprain prevenon: a crical review and praccal appraisal of the literature Br J Sports • American Medical Society for Sports Medicine (AMSSM) hp://www.amssm.org Med. 2010 Dec;44(15):1082-8. • Kelly, Amanda Kay Weiss. Anterior Cruciate Ligament Injury Prevenon. Current Sports Medicine Reports. 7(5):255-262, • American Orthopaedic Society for Sports Medicine (AOSSM) hp://www.sportsmed.org September/October 2008. • American Osteopathic Academy of Sports Medicine (AOASM) hp://www.aoasm.org • Herman K, Barton C, Malliaras P, Morrissey D. The effecveness of neuromuscular warm-up strategies, that require no addional equipment, for prevenng lower limb injuries during sports parcipaon: a systemac review. BMC Med. 2012 Jul • Heads Up: Concussion in Youth Sports hp://www.cdc.gov/concussion/HeadsUp/youth.html 19;10:75. • American Academy of Pediatrics (AAP) h • Sugimoto, et al. Evaluaon of the effecveness of neuromuscular training to reduce ACL injury in female athletes: a crical review of relave risk reducon and NNT analyses. BJSM 2012; 46:979-988. p://www2.aap.org/secons/sportsmedicine/RelatedLinks.cfm • Fields, KB et al. Should Athletes Stretch Before Exercise? hp://www.gssiweb.com/Arcle_Detail.aspx?arcleID=736 • Youth Sports Safety Alliance • Malliaropoulos N, et al. Hamstring exercises for track and field athletes: injury and exercise biomechanics, and possible hp://www.youthsportssafetyalliance.org/Resources_Preparcipaon_Physical.htm implicaons for exercise selecon and primary prevenon. Br J Sports Med. 2012 Sep;46(12):846-51 • Petersen J, Thorborg K, Nielsen MB, et al. Prevenve effect of eccentric training on acute hamstring injuries in men's soccer: a • AOSSM STOP Sports Injury Program: Stop Sports Injuries hp://www.stopsportsinjuries.org/ cluster-randomized controlled trial. Am J Sports Med 2011;39:2296–303. • Naonal Athlec Trainers Associaon: hp://www.nata.org/posion-statements • Santa Monica Sports Medicine Foundaon: PEP program, hp://smsmf.org/pep-program • FIFA 11+ “a complete warm-up programme”: hp://f-marc.com/11plus/home/

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