Doctor of the Month – Dr. Aman Dhawan, MD

Aman Dhawan, MD is a board certified Orthopaedic Surgeon, subspecialty trained in Sports Medicine and Shoulder Surgery. He is a former associate team physician for the NBA’s Chicago Bulls, MLB’s Chicago White Sox, and the Big East’s DePaul University. Dr. Dhawan is a member of University Orthopaedic Associates, the official Orthopaedic providers for Rutgers University, Princeton University, Rider University, and US Rowing.

1) Can you discuss the current trends in youth and high school sports injuries?
It is estimated that over 30 million children in the United States participate in some form of youth sports. Youth sports are an exciting and engaging way for our kids to stay active and healthy, and there are numerous “life skills” that our children learn playing sports including team building, discipline, the value of practice, etc. However, we have in our country today an alarming rate of increase in youth sports injuries, an “epidemic” if you will, with injuries occurring to these athletes at a rate of 7-10 fold greater over the past decade compared to the one before.

Just to give you an idea of some actual statistics:

• High school athletes account for an estimated 2 million injuries and 500,000 doctor visits and 30,000 hospitalizations each year.
• More than 3.5 million kids under age 14 receive medical treatment for sports injuries each year.
• Children ages 5 to 14 account for nearly 40 percent of all sports-related injuries treated in hospitals. On average the rate and severity of injury increases with a child’s age.
• Overuse injuries are responsible for nearly half of all sports injuries to middle and high school students
• Although 62 percent of organized sports-related injuries occur during practice, one-third of parents do not have their children take the same safety precautions at practice that they would during a game.
• Twenty percent of children ages 8 to 12 and 45 percent of those ages 13 to 14 will have arm pain during a single youth baseball season.
• Injuries associated with participation in sports and recreational activities account for 21 percent of all traumatic brain injuries among children in the United States.
• According to the CDC, more than half of all sports injuries in children are preventable

Concern over this increase in injuries has led various organizations to come together, including the American Orthopaedic Society for Sports Medicine, The American Academy of Orthopaedic Surgeons, the American Academy of Pediatrics, the National Athletic Trainers Association, in addition to others, and develop programs, including the STOP (Sports Trauma and Overuse Prevention) campaign (www.stopsportsinjuries.org) , to help increase awareness and educate athletes, parents, coaches and medical providers on how these injuries can be prevented. The initiative not only provides education on injury reduction, but also highlights how playing safe and smart can enhance and extend a child’s athletic career, improve teamwork, reduce obesity rates and create a lifelong love of exercise and healthy activity.

2) What and when do you see in terms of patients with injuries related to resuming school sports and what is the most important aspect of preparation for returning to traditional fall sports (i.e. football, soccer, etc.)?
Two major areas I think all athletes, parents and coaches need to be aware of and educated as to prevention and treatment, are heat illness and overuse injuries.

A)Heat Illness/Injury:
Heat-related illness is occurring with increased frequency in youth sports. Heat stroke, a severe form of heat-related illness, is one of the three leading causes of death in athletes and likely the leading cause among athletes in July and August. Heat illness and injury is largely preventable. When an athlete exercises, the body’s temperature is elevated and the body sweats to cool itself down. During this process, body fluid as well as critical electrolytes are lost. If the body isn’t replenished with fluids and electrolytes, dehydration may occur and increase the risk of a heat illness such as heat stroke.

Some symptoms of heat illness/injury include:

• Chills
• Dark colored urine
• Dizziness
• Dry mouth
• Headaches
• Thirst
• Weakness

If heat illness progresses, more serious symptoms such as difficulty breathing, body temperature increasing to dangerous levels, muscle cramps, nausea, and tingling of the limbs—and even death—may occur.

The most effective treatment for heat-related illnesses is prevention. Strategies for prevention include:

• Proper training for the heat
• Fluid replacement before, during and after exertion
• Appropriate clothing—light colored, loose fitting and limited to one layer
• Early recognition via direct monitoring of athletes by other players, coaches and medical staff
• Monitoring the intensity of physical activity appropriate for fitness and the athlete’s acclimatization status
• If possible, having an athletic trainer on site during events and practices to properly prevent and treat heat illnesses

At the beginning of a strenuous exercise program or after traveling to a warmer climate, an athlete should initially limit the intensity and duration of exercise and then gradually increase it during a period of 7-14 days to allow time for the body to adjust to the new climate and environmental conditions. Athletes with respiratory, gastrointestinal or other illness should be evaluated before exercise, as these conditions increase the risk of heat illness.

Hydration should begin before the exercise period. Drinking 16 ounces of water or a sports drink is recommended one hour before exertion. Hydration should continue with 4-8 ounces of fluid every 15-20 minutes as long as exertion continues.

The type of fluid replacement depends on the duration of the event. Plain water is adequate for events lasting less than one hour. However, for events that last more than one hour or multiple bouts of exercise in the same day, the replacement fluid should contain carbohydrates, sodium and potassium, which are standard components of commercial sports drinks.

Weighing oneself before and after activity is a simple and easy strategy to measuring the level of hydration. If the athlete is lighter after an activity, then it is likely a fluid deficit has occurred and it’s necessary to replace the weight loss by drinking more during the next practice to approximate sweat losses. An athlete who loses more than two percent to three percent of body weight during exercise may be at a point of compromising performance and physiological function. If the athlete gains weight after an activity, then the quantity of rehydration fluid during activity should be reduced.

When you see any signs of heat illness or heat stroke, you may be dealing with a serious and even life-threatening emergency. Have someone call for immediate medical assistance while you begin cooling the individual at risk.

Treatment tips for an athlete with suspected heat injury include:

• Getting the athlete to a shaded area
• If it is heat stroke, cool the athlete rapidly using cold water immersion. If immersion is not available you may use spray from a hose, cold water sponging or placing cold towels over the entire body
• Monitoring body temperature
• Providing cool beverages if possible (i.e., if the athlete does not have altered consciousness)
• Getting medical assistance as soon as possible

(B) Overuse Injuries:
Overuse injuries are far more common in youth sports than acute injuries. They are often subtle and usually occur over time, making them challenging to diagnose and treat. They are the result of repetitive micro-trauma to the tendons, bones, and joints. Common examples include tennis elbow, swimmer’s shoulder, youth pitching elbow, runner’s knee, jumper’s knee, Achilles tendinitis, and shin splints.

These injuries occur because of repeated physical stress to a specific body part. We tend to think of “stress” in the context of its negative effect on our emotional wellbeing, but physical stress, which is simply exercise and activity, can be beneficial for our bones, muscles, tendons, and ligaments, making them stronger and more functional. This happens because of an internal process called remodeling. The remodeling process involves both the breakdown and buildup of tissue. There is a fine balance between the two, and if breakdown occurs more rapidly than buildup, an overuse injury occurs.

Training errors are the most common cause of overuse injuries. These errors involve rapid acceleration of the intensity, duration, or frequency of activity. Overuse injuries also happen in people who return to a sport or activity after injury and try to make up for lost time by pushing themselves to achieve the level of participation they were at before injury. Proper technique is critical in avoiding overuse injuries, as slight changes in form may be the culprit. For this reason, coaches, athletic trainers, and teachers can play a role in preventing recurrent overuse injuries.

Some people are more prone than others to overuse injuries. Imbalances between strength and flexibility around certain joints predispose individuals to injury. Body alignment, such as knock-knees, bow legs, unequal leg lengths, and flat or high arched feet, also impact overuse injuries. Many people also have weak links due to old injuries, incompletely rehabilitated injuries, or other anatomic factors.

Other factors include equipment, such as the type of running shoe or ballet shoe, and terrain — hard versus soft surface in athletic endeavors such as aerobic dance or running.

The diagnosis of overuse type injuries can usually be made after a thorough history and physical examination. This is best done by a sports medicine specialist with specific interest and knowledge of the sport or activity. In some cases, X-rays are needed and occasionally additional tests like a bone scan or MRI are required as well.

Some tips for treating an overuse injury include:

• Cutting back the intensity, duration, and frequency of an activity
• Adopting a hard/easy workout schedule and crosstraining with other activities to maintain fitness levels
• Learning about proper training and technique from a coach or athletic trainer
• Performing proper warm-up activities before and after
• Using ice after an activity for minor aches and pain
• Using anti-inflammatory medications as necessary

If symptoms persist, a sports medicine specialist will be able to create a more detailed treatment plan for an athlete’s specific condition. This may include a thorough review of your training program and an evaluation for any predisposing factors. Physical therapy and athletic training services may also be helpful

Most overuse injuries can be prevented with proper training and common sense. Learn to listen to your body. Remember that “no pain, no gain” does not apply here. The 10 percent rule is very helpful in determining how to take things to the “next level.” In general, athletes should not increase their training program or activity more than 10 percent per week. This allows the body adequate time for recovery and response. This rule also applies to increasing pace or mileage for walkers and runners, as well as to the amount of weight added in strength training programs.

Always remember to warm up and cool down properly before and after activity. Incorporating strength training, increasing flexibility, and improving core stability will also help minimize overuse injuries.

Seek the advice of a sports medicine specialist or athletic trainer when beginning an exercise program or sport to prevent chronic or recurrent problems. An athlete’s program can also be modified to maintain overall fitness levels in a safe manner while they recover from injury. Return to play should occur only when clearance is granted by a health care professional.

3) What is the most current understanding of concussions and how can parents ensure proper diagnosis and care of youth concussion?
A concussion is a traumatic injury to the brain that alters mental status or causes other symptoms. Many people assume they do not have a concussion if they have not lost consciousness. However, significant injury can occur without losing consciousness at all. Football players often say “I just got my bell rung” when a blow to the head causes ringing in the ears, but those symptoms are often consistent with concussion.

When concussion is suspected, a trained coach, certified athletic trainer, or the team physician should immediately perform an initial “sideline” evaluation. If left undiagnosed, a concussion may place an athlete at risk of developing second impact syndrome-a potentially fatal injury that occurs when an athlete sustains a second head injury before a previous head injury has completely healed.

Common signs and symptoms of a concussion include:

• Balance problems
• Difficulty communicating, concentrating
• Dizziness
• Drowsiness
• Fatigue
• Feeling emotional
• Feeling mentally foggy
• Headache
• Irritability
• Memory difficulties
• Nausea
• Nervousness
• Numbness or tingling
• Sadness
• Sensitivity to light or noise
• Difficulty falling asleep
• Visual problems – blurry or double vision
• Vomiting

Often athletes, parents and coaches ask “When is it safe to return to play”? All athletes who sustain a concussion, no matter how minor, should undergo an evaluation by a qualified healthcare provider before returning to play. Athletes can return to play after they are completely free of all symptoms of a concussion and remain symptom free during and after physical testing.

Unfortunately, it is difficult to determine if the brain has healed from a concussion; even after all symptoms have resolved, healing may not be complete. Neurocognitive testing can be a very helpful tool in determining brain function. With a comparison to a baseline test, this evaluation can be used in conjunction with a physician’s examination to reduce future risks.

Baseline testing collects data on an athlete’s cognitive and physical abilities prior to suffering the concussion. Baseline testing can include a neurocognitive evaluation (usually by computer) that tests multiple areas of brain function, including memory, problem solving, reaction times, and brain processing speeds. Symptom checklists, sideline assessment tools such as the Sideline Concussion Assessment Tool, and balance testing are other examples of baseline evaluations that may be helpful.