Online Health Chat with Richard Figler, MD and Paul Saluan, MD
September 11, 2013
Sports provide children and adolescents with exercise to support overall health as well as provide fun and socialization. However, every time an athlete—child or adult—steps onto the playing field, mat or court, he or she runs the risk of suffering an injury or concussion.
Injuries occur in all sports—from ankle sprains and ACL (anterior cruciate ligament) tears to overuse injuries and concussions. Nearly every part can be affected by sports injury, including the head, neck, spine, arms, hands and fingers, legs and toes, and even internal organs. Injuries are a particular concern in children due to the potential for long-lasting consequences, including stunted growth due to a fracture at the growth plate or potential brain damage due to multiple concussions. Injuries can be caused by several forces, including twisting motion, external contact, repeat impact and high impact activity. The most important component to preventing these types of injuries is education. It is crucial to know the signs and symptoms of a sports injury or concussion, but equally important, is to know what to do after your athlete has suffered an injury.
Prompt and proper treatment can decrease time missed from the sport. It is important to help everyone from the athlete to the coach become more aware of sports injury by making injury prevention and concussion awareness part of your pre-game checklist.
About the Speaker
Richard Figler, MD, is a staff physician in the Center for Sports Health within the Orthopaedic and Rheumatologic Institute and the Concussion Center at Cleveland Clinic. He specializes in sports medicine, sports concussions, acute and chronic sports related injuries, pediatric and adolescent sports-related injuries, medical problems in athletes. He is also Team Physician for Solon High School and John Carroll University. Dr. Figler is board-certified in family medicine with a certificate of added qualification in sports medicine. His specialty interests include sports medicine, acute and chronic sports-related injuries, pediatric and adolescent sports-related injuries and medical problems in athletes.
Dr. Figler completed a fellowship in sports medicine at Brody School of Medicine at East Carolina University, in Greenville, NC after completing his residency and internship in family medicine at Pitt County Memorial Hospital, in Greenville, NC. He graduated from medical school from Case Western Reserve University School of Medicine, in Cleveland.
Paul M. Saluan, MD, holds joint appointments in the Center for Sports Health and the Center for Pediatric Orthopaedic Surgery within the Orthopaedic and Rheumatologic Institute at Cleveland Clinic. He is the Director for Pediatric and Adolescent Sports Medicine and the Director of Sports Health Community Affairs. He specializes in pediatric and adolescent sports medicine, arthroscopic surgery and pediatric orthopaedic surgery. He is certified in orthopaedic surgery by the American Board of Orthopaedic Surgery. In addition, Dr. Saluan is the developer and director of the orthopaedic arthroscopy skills lab curriculum. He also acts as a contributor to a pediatric outcomes instrument being developed to assist in pediatric injury/disease-specific outcomes research.
Dr. Saluan completed his fellowship in pediatric orthopaedics at University of Colorado Denver, The Children’s Hospital, in Denver after his residency in orthopaedic surgery and internship in surgery at Cleveland Clinic. He graduated from medical school at Case Western Reserve University School of Medicine, in Cleveland.
Let’s Chat About Pediatric Sports Injuries and Concussion
Moderator: Let's begin with your questions. We will try to get to as many as possible during the chat.
Signs and Symptoms and Causes of Concussion
Mollie: What are the warning signs and symptoms of a concussion?
Richard_Figler,_MD: A concussion typically occurs after a blow or jolt to the head followed by several symptoms that may be variable in intensity. The most common symptom is headache, followed by feeling ‘out of it’, confused, a ‘glazed look’, irritated, dizzy, nauseated, tired, off balance, or just ‘not right’. After the injury the symptoms may come on several minutes to hours later—so after the injury it is important to watch for signs and symptoms of concussion. It is important that after a hit to the head the athlete, as well as those around the athlete, are aware of the symptoms in order to recognize a concussion.
doggiekisses: Is it possible to get a concussion from repetitive shaking motion, such as handsprings or tumbling for long periods of time in gymnastics, without an impact?
Richard_Figler,_MD: It is less likely to get a head injury or concussion from this shaking motion. It is more likely to cause a neck injury which may present with dizziness or headaches in the back of the neck. It is just a less-than-likely mechanism.
Post-Concussive Syndrome and Medical Risks after Head Injury
KarensMom: What is post-concussive syndrome?
Richard_Figler,_MD: Post-concussive syndrome is defined as symptoms that last longer than what would be normally expected for concussion recovery. Most concussions improve in seven to 10 days, but some may last a lot longer. After a concussion student athletes may have difficulty with their ability to concentrate in school or find that their symptoms worsen with simple tasks such as studying or reading. When the symptoms after the injury last more than three months, the diagnosis of post-concussive syndrome is likely (although the exact time prior to this diagnosis is still being debated). Anyone that sustains a concussion and still has symptoms, such as difficulty focusing, changes in sleep patterns, or changes in behavior patterns, several weeks after their concussion should be further evaluated by a physician trained in concussion evaluation and management.
TippyRosewood: Are there increased medical risks to athletes who have suffered from multiple concussions?
Richard_Figler,_MD: The bottom line is—we are not sure. As with any other injury, the best way to approach it is to allow it to heal prior to returning to activity. Returning too soon may increase the risk of prolonged recovery and possibly longer term issues. We think that athletes who sustain numerous concussions or head injuries prior to a complete recovery between each of the injuries are at higher risk to have a more prolonged recovery and possibly issues affecting them well after their playing career. There has been talk about chronic traumatic encephalopathy in boxers and football players that more than likely had numerous concussions and continued to play despite having symptoms. Remember, this is a brain injury and the brain is a very complicated organ. We are continuing to find out more with research that is going on about concussions around the world. Let the brain rest and recover prior to returning to sport or activity to give it the best chance to heal completely. You would not run on a broken leg prior to it completely healing, would you? It is the brain—protect it!
Baseline Tests for Concussion
GritGirl: Our high school does a baseline test. Can a baseline test be done if the child participates in a sport such as a club team?
Richard_Figler,_MD: Baseline tests are a great tool to manage concussion. Knowing what one's baseline function is and then getting them back to their baseline after injury is our goal. Return the athlete to ‘normalcy’. Student athletes can take the baseline impact test by going to our website at cleveland clinic.org/concussion and navigating to impact. We are still validating an ‘app’ for the iPad that should make this easier, and more comprehensive than impact in the future, but we want to make sure it is a great tool prior to full release.
Paul_Saluan,_MD: If participating on a club team, the same rules do not apply for high school sanctioned teams. There's much variability amongst club teams at all levels. In short, this test can be done, but it is going to be highly variable in how this is administered.
Concussion Testing and Treatment
emilyrobertsfolkema1: If I suspect my child has suffered a concussion, should I take him to the hospital emergency room or can we start with our pediatrician?
Richard_Figler,_MD: Of course each head injury and concussion is individualized as far as treatment is concerned, but there are warning signs that would suggest that you should take your child to the emergency room (ER). If the headache is getting progressively worse or if they are not arousable, as well as any weakness, numbness or tingling in their extremities, means they should go to the ER. If they start acting irrationally or their behavior is significantly altered, they should go to the hospital emergency department. If they start to shake uncontrollably (seizure-like activity) or if they continue to get worse over a short period of time, your child should go to the ER. Of course, any other concerning signs or symptoms may warrant a trip to the ER. Most pediatricians are well trained in evaluating injuries, including concussions, and if needed, your doctor can send your child to a physician with more experience in managing concussions.
kd2frei: Is anything being done to better educate emergency room (ER) doctors, pediatricians and coaches about concussions? My daughter and other friends who have suffered concussions who went to the ER after their hits were not diagnosed. The possibility of a concussion wasn't even mentioned to us or the other parents. I am so thankful we sought treatment at Cleveland Clinic.
Richard_Figler,_MD: There is an effort nationwide (and locally) to educate physicians and health care providers about concussion evaluation and management. We are developing a care path that should assist with this task. Protect your child—should you ever be concerned that your child is not back to their ‘normal’, they should be held out until they are back to where you think they should be. Err on the side of caution. When in doubt, sit them out.
Mollie: What types of tests are there to diagnose a concussion?
Richard_Figler,_MD: The first step in diagnosing concussion is being educated about the signs and symptoms of concussion. If you are unaware of the signs and symptoms, you may miss the diagnosis. In essence, anyone that sustains a head injury and then has symptoms such as headaches, dizziness, being off balance, confused, trouble focusing, or nauseated, etc., has a concussion until proven otherwise. It is a ‘functional’ as opposed to a ‘structural’ injury. Therefore, one does not need to undergo MRIs or CAT scans to diagnose a concussion. Typically, standardized symptom check lists are used with questions that evaluate memory, and a neurological examination is conducted, including balance, coordination and reaction time, are all used to help diagnose a concussion. We have other tests utilizing computers and iPad-like devices that can help monitor the neuropsychological recovery of the athlete (includes visual and verbal memory). These tests are more useful if there is a baseline test done prior to the injury to assure that the athlete has returned back to ‘normal’.
Vestibular Therapy for Head Injuries
Nursegoodbody: My 14-year-old son sustained a head injury during soccer practice one month ago. He has seen our general practitioner and a CT scan that was negative. He had an impact test done twice, which showed significant changes from his baseline done one year ago. Vestibular therapy was recommended, and he had his first evaluation last Friday. He continues to have headache and dizziness at times, is very sensitive to light, and has not been able to tolerate a full day at school yet. We have limited his activities, television, computer screen, phone and bright lights, and of course sports, but his recovery isn't progressing like I'd hoped. How successful is vestibular therapy for treating head injuries? How long does the treatment need to last? Are there any other options?
Richard_Figler,_MD: Vestibular therapists are a vital part of our multidisciplinary team. They are great at treating dizziness, neck pain and balance issues that can be very prevalent in concussions. It does sound like your son is still suffering symptoms that may need further evaluation to point out some other management options for him to improve his day-to-day function. I would recommend that he sees a physician who specializes in concussion management. We tend to apply an ‘identify-and-avoid-triggers’ technique to limit the stimuli that would cause worsening symptoms. Sleep is typically an issue as well, and would more than likely need to be addressed. (The brain recovers with sleep). Although the vestibular therapist is a great start, he may need to see someone else in the ‘concussion team’.
Improved Helmet Design for Head Injury Prevention
kd2frei: What are your thoughts on the helmet caps that I have seen in the media this week? Do they work with the same technology as the mouth guard? Do they help in reducing the impact of collisions in football? They state that they may reduce impact by 33 percent. Should they be adopted by school districts or sports leagues?
Richard_Figler,_MD: It seems like a good idea that putting more cushion on a helmet will decrease the force transmitted to the brain to decrease a head injury or concussion. But, unfortunately, there is little evidence that has shown that they decrease the incidence of concussion. Hopefully, further research will show it decreases the incidence of concussions to protect our athletes. Proper-fitting equipment, abiding by the rules, knowing rules changes, proper tackling technique, and ‘seeing what you hit’ (or not leading with your head in football) are probably better ways to decrease concussions. We all hope that helmets will be better designed to decrease the risk of concussions, but it is elusive due to the nature of this collision sport.
Impact Severity Testing with Mouth Guard and Mouthpieces
TisTheSeason: I believe my school district is using a type of mouth guard to detect concussions. How does it work and should it be used for sports other that football such as ice hockey?
Richard_Figler,_MD: No mouthpiece or mouth guard can prevent concussion—they are used to prevent dental and oral trauma. The mouthpieces you ask about are ones that have imbedded accelerometers and impact sensing devices that can tell how ‘hard’ the hit was or how much ‘rotation’ occurred. Unfortunately, they cannot diagnose concussions, but they can make one aware of a hard hit that may induce a concussion. We don't know the exact amount of force that would cause a concussion—there are just too many other variables that go in to the injury. It is a good tool that should help us with research in the future to help develop better equipment that may decrease the severity of concussions, but they are still in the research phase.
Sports after Torticollis and Fracture
CheerMom: My 9-year-old daughter is an 'all-star' cheerleader, meaning she participates in highly athletic and gymnastic tumbling moves. Although she still has to master complex tumbling, she has already sustained torticollis to her neck last year for which she received physical therapy. Is she more prone to re-injure her neck because of this? Also, as a toddler she fractured (clean break) of her right forearm. Does this mean she would be more susceptible to breaking it there again?
Paul_Saluan,_MD: The torticollis is an interesting problem to develop while tumbling. This could be something that is recurrent if she does not keep on top of her physical therapy. I would consider doing the exercises that she received from them on a regular basis so as to avoid this problem from occurring again. In regard to the form fracture, once it goes beyond several years then enough remodeling occurs to the point where it is not susceptible to break again there. I would say that it should be just fine and not of a concern right now.
TippyRosewood: What does it mean if an athlete has ‘GIRD’ in their shoulder and what can they do about it?
Richard_Figler,_MD: GIRD stands for glenohumeral internal rotation deficit and is typically caused by overuse. It is best treated by a physical therapist with good knowledge of the shoulder and the biomechanics of throwing.
TippyRosewood: Why do scaphoid injuries take so long to heal?
Richard_Figler,_MD: Due to a poor route of blood supply to the bone. When the bone is trying to heal, it may not get the amount of blood supply it needs to heal it completely.
Identifying Sports Injuries
Lacrosse: Is there at trick to telling the difference between growing pains and a possible injury?
Paul_Saluan,_MD: Sometimes it is difficult to tell between the two. A trained healthcare provider would be able to tell the difference based on an examination and sometimes even using x-rays. The common thread is that if there is recurrent injury or recurrent pain that does not go away, then medical attention should be sought.
Dynamic vs. Static Stretching for Sports
CheerMom: What type of injuries might you expect in 'all-star' cheerleading tumbling moves if there has been a previous diagnosis of shortened heel cords in both feet (leading to outward toe-ing)? I used to do exercises to stretch the heel cord when she was younger, but feel most of the time I don't see the problem as much anymore—except if she is tired. I give her a verbal reminder to straighten her feet when walking, and it goes away. Should I go back to stretching them again? Her doctor said I could bring her in if there was a problem—but I just want to know whether the stretching exercises would be good for her now that she has less problems, or if I might make things worse if I start doing them again.
Paul_Saluan,_MD: If any part of an athlete’s body is overly tight, other parts of the body have increased motion to compensate. It would make sense to pursue a flexibility program in order to remain supple so that you can decrease her risk of injury. I would consider dynamic stretching as part of her routine, in order to decrease injuries to other parts of her body. Overall flexibility is a key to injury avoidance.
Lacrosse: I coach a lacrosse team of 30 middle school girls that are going through so much physically with hormones and growth spurts. Can you tell me or do you have a good resource for the best stretches both before and after practice to prevent injury? I have heard that stretching before can actually contribute to injury, that you should be warming up in the motions you will be using and then stretch after. What are your thoughts?
Paul_Saluan,_MD: Yes, actually the stretching program you want to be involved and is termed ‘dynamic’ stretching. This involves warming up the muscles and actually taking joints through a gentle range of motion while currently stretching the muscles through this arc of motion. This takes the place of what we used to do in the past, which was termed ‘static’ stretching. Performing dynamic stretching before and after events will lead to much better performance and hopefully to injury risk reduction.
Strength and Conditioning Exercise for Tumbling
CheerMom: What exercises do you recommend for overall fitness and strength to hopefully prevent injury in 'all-star' cheerleading?
Paul_Saluan,_MD: A good strength and conditioning program year-round is very helpful to maintain top athletic form. I would consider ‘periodizing’ her activities. This means that she incorporates different activities to improve her overall strength and conditioning throughout the year. A good exercise physiologist would probably be the best bet to get advice from. Also, try to decrease the overall impact that her body sustains in the off-season so she doesn't run into breakdown problems.
Moderator: The hour has gone fast. I'm sorry to say that our time is now over. Thank you Dr. Figler and Dr. Saluan for taking the time to discuss sports injuries, prevention and concussion awareness. Your answers were very detailed.
Richard_Figler,_MD: Thanks for your patience. I hope this was helpful. These were great questions. Remember, when it comes to concussions, ‘when in doubt. sit them out.’
Paul_Saluan,_MD: These were great questions. Thank you.
To make an appointment with Dr. Figler or Dr. Saluan or any of the other specialists in our Center for Sports Health at Cleveland Clinic, please call 877.440.TEAM (8326). You can also visit us online at clevelandclinic.org/sportshealth.
To make an appointment with Dr. Figler or any of our other specialists in our Concussion Center at Cleveland Clinic, please call 877.440.TEAM(8326). You can also visit us online at clevelandclinic.org/concussion.
For More Information
On Concussions and Sports Injuries
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Cleveland Clinic’s Sports Health Program, which is part of the Orthopaedic& Rheumatologic Institute and associated with Cleveland Clinic Children’s, enables pediatric specialists to provide consultation, diagnosis and management for children and adolescents with problems or injuries related to athletics.
Cleveland Clinic Sports health brings together top orthopaedic surgeons, primary care sports medicine physicians, physician assistants, nurses, physical therapists, athletic trainers and exercise physiologists all under the same roof through our multidisciplinary approach.
Cleveland Clinic Sports Health Team focuses on several areas from developing performance improvement, injury prevention and proper nutrition to rehabilitation and surgical correction.
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