PPE Coalition for Youth Sports and Safety
PPE Initiative Launch Event & Press Conference: May 13, 2010

Across the U.S. there is no formal standardization of the young athlete’s pre-participation medical evaluation (PPE or pre-participation evaluation). States have varying standards and requirements on what needs to be checked and who may perform the evaluation. These examinations are important since many disorders that can cause serious problems may be picked up during the evaluation.

The newly formed PPE Coalition for Youth Sports and Safety held a press conference at the National Press Club in Washington, DC this morning. This event launched an initiative to standardize and upgrade the pre-participation physical evaluation. This was done in conjunction with the publication of the fourth edition of the PPE Pre-participation Physical Evaluation, written with the collaboration of 6 medical societies, including the American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.

A standard and thorough pre-participation physical evaluation is vital for the health and safety of young athletes. The purpose of the Coalition is to encourage the use of a standard PPE. To provide a safer environment for the athletes, the coalition is pressing to create a specific standard.

A website has been established to promote the initiative. You may download the new standardized PPE H&P form

PPE 4th Edition

Information on the organization, the founding and participating organizations, and the newly published text is available at the new website: http://www.ppesportsevaluation.org/ .

The American Academy of Podiatric Sports Medicine is one of the founding members of the coalition and was recognized at the event along with the other founders. I attended this event as a representative of the AAPSM.

Among the speakers was Jim Ryun, was the first high school runner to run a mile in under 4 minutes. He set a high school record of  3:55.3 for the mile, which stood for 36 years.  Former Congressman Ryun also held the world record in the mile, 1500-meter, and 880 yard runs. He participated in three summer Olympic games in 1964, 1968, and 1972. He won the silver medal in the 1500 meter run in 1968. Recently ESPN declared him to be the best high school athlete ever, finishing ahead of Lew Alcindor (Kareem Abdul-Jabbar). Jim Ryun spoke of the importance of having physical education included within a revised “no child left behind” law. With the rise in childhood obesity there is no reason to have only one year of PE required in the 4 years of high school. To much amusement he told of not making the baseball or basketball team, but being able to join the cross country team. With a rapid increase from no running to up to 60 miles per week, he found that his first injury was an incredibly painful case of shin splints.

Also speaking was Congressman Mike McIntyre  of North Carolina. He is the founder of the Congressional Caucus on Youth Sports. As a member of the “Blue Dog Coalition” he attempts to forge a bipartisan agreement on health and fitness related issues. His feelings were strong on the importance of safely encouraging youth health and fitness. He spoke of how what we teach our children is our message to a far-off future that we will not be around to see.

Included in the initiative was recognition of the importance of serving children with special needs an including these special athletes in all of the initiatives that are now set in motion. The AAPSM has long supported initiatives along this line as evidenced by the Special Olympics “Fit Feet” project.

Many other initiatives were discussed including the fight against childhood obesity which has long been a goal of the American College of Sports Medicine, the American Academy of Podiatric Sports Medicine, the American Academy of Pediatrics and the President’s Council on Physical Fitness and Exercise along with all of the organizations which participate in the Joint Commission on Sports Medicine and Sports Science. The recently completed White House Task Force on Obesity and the newly created Let’s Move program were mentioned as hopeful programs to change the trend of increasing childhood obesity.

Encouraging healthy eating and regular exercise for everyone within the context of safe programs is all of our jobs.

PPE

This applies to young and old,  and for those who are slim and not so slim.  Everyone who can do so needs to move for optimal health and to keep both the mind and the body in good working order. The PPE initiative will help  young people as safe as possible and be an aid in detecting serious diseases which may put them at risk. For those who pass successfully through the PPE the greater risk will be in not participating.

Resources:

PPE H&P form (PDF)  http://www.ppesportsevaluation.org/evalform.pdf

Preparticipation Physical Evalution – 4th Edition and further information: http://www.ppesportsevaluation.org/body.html

You Got To Move!

A study published in the Journal of the American Medical Association, Jan. 13, 2010 gave disappointing results in using plasma rich protein to treat non-insertional Achilles tendinopathy. It showed no difference between using a sham injection of saline and combining it with a painful eccentric stretching protocol  in comparison with an injection of plasma rich protein injection along with the standard painful eccentric stretching protocol.

The authors note that previous studies did not have good control groups. In this small study, 27 patients were in the placebo group and 27 in the treatment group. The VISA-A score was used to assess improvement. Both groups improved somewhat without a significant difference between the two groups.

The study was called a “preliminary communication” which is often done with small studies. Other studies on similar topics with fewer than 30 individuals studies have also been billed as “preliminary studies”, but when they are talked up afterward, the “preliminary study” status is usually forgotten. As far as study design goes, the design, blinding, and performance of the study seems just right. I am not entirely convinced of the efficacy of the painful eccentric stretching protocol and would have not minded another study group omitting that treatment. Apparently it is not a panacea (or there would not be studies looking to add to the results), although the initial preliminary study made it sound as though it would be. Follow up journal articles by the primary author of the first study have been positive and are referenced below. Others have expressed reservations on the methodology. (see Woodley et. al. 2007 and Kingma et. al. 2006) Eccentric stretching and overload for tendinopathy has mixed results at best in other body areas.

Note: VISA-A is the Victorian Institute of Sports Assessment-Achilles

References:

Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial
Robert J. de Vos; Adam Weir; Hans T. M. van Schie; et al. JAMA. 2010;303(2):144-149 (doi:10.1001/jama.2009.1986)

Alfredson H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med. 2003;22(4):727-741.

Alfredson H and Cook J (2007), A treatment algorithm for managing Achilles tendinopathy, new treatment options, British Journal of Sports Medicine, 41, 4, 211.

J J Kingma, R de Knikker, H M Wittink, T Takken. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med 2007;41:e3 (http://www.bjsportmed.com/cgi/content/full/41/6/e3). doi: 10.1136/bjsm.2006.030916 (concludes: Studies on the effectiveness of eccentric overload training in patients with Achilles tendinopathy show many methodological shortcomings)

Woodley, B.L., R.J. Newsham- West, and D.B. Baxter, Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med, 2007. 41: p. 188-199.

Additional Information:

Pribut, S.M.,  Top 5 Running Injuries. Podiatry Management, 2008

Blog on: Heel Lifts and Achilles Tendinitis

Dr. Pribut on Achilles Tendinopathy

Dr. Pribut on The Science of Tendinopathy

Tendinitis is often used incorrectly as a generic term for overuse tendon injuries. The term that should be used is tendinopathy. Tendinitis and tendinosis both refer to microscopic changes that are seen on biopsy. Even spelled as “tendonitis”, it is still incorrect. The current view is that long term overuse tendon injuries display little to no inflammation. While the original meaning of the word inflamation refers to something feeling like it is “on fire”, the medical term refers to histopathology and microscopic examination. While it may still hurt and in a sense feel as bad as if it were on fire, we need to start calling the injury tendinopathy. Of course the biggest problem is that when a doctor tells you that your problem is “tendinopathy” it will take a 20 minutes of discussion to define what is meant by that.

The running injuries website has been updated to include an overview on the science of tendinopathy. We’ll update this page as new information and research appears.

After unusually persistent aches and pains during training or after your race, you may decide it’s time for a visit to your sports doc. Of course, we hope you’ve increased your training slowly, checked your shoes and done your best to  learn how to avoid the doctor’s office.

Now that you’ve decided it is time for a visit, how can you make that visit work in the best way possible for you?  What should you bring? Of course bringing yourself in is the most important thing.  The following items are helpful. And the running shoes are often contributors to the injury and it can be very helpful to examine them.

Try to bring in the following items:

Notes on your injury:

• When did it start?
• Where does it hurt?
• When does it hurt?
• What has changed in your training?
• What speedwork or harder than normal running have you been doing?
• What shoes did you wear before you were injured, when injured and what are you wearing now?
• What surfaces have you been running on?
• What have you tried to make things feel better?

Things to bring:

• Current running shoes ( the newest running shoes you have used)
• Previous running shoes (recent ones which may have contributed to your injury)
• Orthotics (if you use them)
• Running/Exercise Log (if you have one)

Now that you’ve trained properly after having a medical exam and clearance to run, you are nearly ready for the big day. Prudence should keep you upright for the next 26.2 miles. Some have said “Start slow, and finish slower”. But that may not be your plan. Make sure you run within your means. Be certain to taper for 3 weeks. And let’s make another list:

• 3 training runs of 18 – 20 miles should have you set for your marathon.
• Taper and run much less for 3 weeks.
• You may gently carbo load. Don’t “deplete”. Don’t gorge. And don’t eat new or spicy foods for the 4 – 5 days before the marathon.
• Sleep well the nights before the marathon.
• Don’t drink too much the night before. Don’t use drugs. (In Woodstock the word was to avoid the brown acid.)
• Don’t take herbal diet or stimulant mixes. They are not checked by the FDA and may have unhealthy contents.
• Hydrate wisely. You may hydrate before the race. Don’t drink till you slosh. Don’t overhydrate. For the slow marathoner, hyponatremia (low blood sodium) from taking in too many fluids is a bigger danger than dehydration. Some races have scales for you to weigh yourself on. If you weigh more as the race goes on, you are drinking too much.
• Wear a medical condition and allergy bracelet or have the information attached to your shoe.
• Eat your regular long run breakfast.
• Warm up gently.
• Don’t start out too quickly.
• Pay attention to your body. Dizziness, faintness, chest, shoulder, jaw pain or tightness should be checked with the medical team immediately.
• Drink and eat foods you’ve used before on your training runs.
• Don’t sit down abruptly at the end of the race. Walk around a bit as a gentle cool down. If you sit, your muscles will likely tighten up and you may not get back up again easily.

General Tips

• Wear shoes that you’ve had good success with and shoes that are broken in.
• Make sure the rest of your clothes are also comfortable and broken in also including your sports bra or other sports underwear, shorts, singlet, sweats and socks.
• Use broken in Coolmax socks or another “wicking” fiber for all of your runs and  on race day.
• Try to get adequate sleep over the last month so your body can be as well recovered as possible from all the training you’ve been doing.
• Eat healthy throughout your training. Don’t overeat  or drink much alcohol  on the night before  your  race. Do eat a carbohydrate rich meal for a few evenings before the marathon.
• Wear outer layer clothes you can throw away as the race goes on and you warm up. If you are going to be at the race line early, dress warm for the morning chill, and be prepared to ditch your outer layers as the race draws near or as you go along and warm up.
• Use the same fluid replacement and  gel that you’ve practiced with on your long runs. Beware of under hydration and over hydration. If you are running for longer than 4 hours, consider using weighing stations if your marathon has them available to attempt to avoid hypernatremia.
• Remember to go out slower than you think you should so you can have a negative split and  not burn out somewhere before mile 20.
• Figure out where some of those cameras will be taking your photo so you can  look  good for your marathon portrait.
• Don’t forget after the race that you should rest about one week before running again and then “reverse” taper.

Things To Bring:

1. Race number  and safety pins. Pin this to your clothes two nights before the race.
2. Running Shoes and all your racing clothes
3. Clothes to toss, if it is cold. Long sleeve teeshirts, sweat clothes.
4. Change  of clothes for after the race.
5. Money for emergencies.
6. Body glide, if you’ve used it for areas  that rub on previous long runs.
7. Your own food for after the race  in case the race runs  low.
8. Plastic  container of water  or sports drink to drink before the race
9. Toilet paper to carry in your carry-along, in case of emergency.
10. Very light  weight, miniature camera if you don’t expect to win.
11. Throw away reading material for the  long  wait before the race.

For post marathon recovery, I have some tips on recovering from the marathon and a reverse taper program.

I just came across the following “tips” video performed by Toby Tanser via Mark Remey at RW

Last Minute Marathon Tips: shot with Nikon D90 from Mike Kobal on Vimeo.

Army 10 Miler

I’ll be speaking this coming Saturday, October 3, 2009 at 9:45 am at the race expo in a clinic for the Army Ten Miler. The clinics are at the DC Armory and are free and open to all. There should be ample time for Q&A’s. I plan to touch on the following topics: “exercise good for what ails you”, evolution and running, avoiding injury, getting your shoes right, moving up to 26 safely, and adjusting for injury. If there is any topic you’d like covered in the lecture portion, let me know and I’ll try to work it in. Or feel free to ask during the Q&A.

This year is the 25th anniversary of the Army 10 Miler Race. 30,000 runners are registered for it. It is known to be the largest 10 mile race in the United States and there is no 10 mile race in the world that is known to be larger than this.

OCD is not always in your mind. It could be in your knee, elbow or ankle. And it can certainly be a pain to have. In many cases the injury is missed initially and under treated. What we are talking about is osteochondritis dissecans, also known as osteochondral fracture, defect, or  osteochondral injury. It is an injury to the cartilage and subchondral bone which happens most often in the knee, ankle or elbow. In the athlete, who has had an inversion injury, even a minor one, it happens most often on the lateral (outer) ankle. In some

cases the forces are not large. The injury is staged from a compression or contusion to a fully displaced fragment of varying size. With under treatment it can progress from an early stage to a much worse stage. For simple injuries, Stage 1 especially, the treatment is most often what we’ve mentioned for severe ankle sprains “put a cast (or pneumatic walker) on it”.

More detailed information and classification systems including the Berndt-Harty classification and modifications of that system are in a new article: Dr. Pribut on OCD of the Ankle (Osteochondritis Dissecans and Osteochondral Injuries)

Dancing to the tune of “Put A Ring On It” you get carried away and find that you’ve tripped over an object lying on the carpet. Or more likely, you’ve stepped in a hole, stepped wrong coming down stairs or twisted your ankle on an uneven trail while running. Of course basketball is especially known for a notoriously  high number of ankle spains.

Once it is determined that it ranks as “bad” what should you do? The Lancet compared a Bledsoe boot, Aircast Splint, Circular Wrap, and a plaster cast as treatment for “bad” ankle sprains and found the cast best, followed by the AirSplint. “Bad” sprains were Grade III which includes complete tear of a ligament. The assessment included an x-ray, since the patients included were unable to bear weight on the ankle. The Ottawa Criteria were used.

The conclusion was that in this group, the casting was superior to the other methods of treatment. The duration of cast use was 10 days. The investigators noted other studies have used time periods of up to 6 weeks, and the exact time needed to assist healing is not known. Noted also was the possibility of long term and even permanent injury resulting from an ankle sprain.

In my office, I have long used the AirSplint Pneumatic Walker for this condition with good results. The authors of the Lancet study noted that in some cases the ankle sprains resulted in long term, and occasional permanent injury. Rehabilitation methods were not compared and studied. A podcast interview with the lead author was interesting. Citations of animal studies indicating improved healing with motion were noted. But the author felt that they would all change their clinical practice based on their study. Happily I have treated humans, not rabits, and learned from it. I’ve been using similar therapy for a long time, and don’t need to make dramatic adjustments. The lesson here though, could be for emergency rooms around the globe to learn more about and improve their treatment of ankle sprains. Bad treatment has led to the saying “a sprain is worse than a break”. With appropriate treatment, rehabilitation, and follow up. It doesn’t have to be so.

For more general information on ankle sprains see: Dr. Pribut on Ankle Sprains

Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomised controlled trial S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke,
The Lancet, Volume 373, Issue 9663, Pages 575 – 581, 14 February 2009. Article Direct Link

All The Single Ladies – Dangerous Version

All The Single Ladies – Safe Version

Runners like to run where they can. But sometimes where they can run easily is not the best place for them. With a bit of effort you can often find a place that works well for you and your specific problem set.

The ideal surface is firm but not incredibly hard. Packed dirt is often called the perfect surface. In the opinion of most sports medicine doctors, you should avoid running on concrete at all costs. It is just too hard a surface with too much shock and force transmitted. Crowned surfaces may also cause problems because they may cause one leg to act longer than the other. Effectively, you’ve created an artificial leg length inequality, meaning you are running with one leg significantly longer than the other.

Other opinions on surfaces will vary depending on what your specific problems are. For those with Achilles Tendon problems such as Achilles Tendinopathy or tendonitis we’ve already recommended avoiding surfaces that are too soft. Your heels will squash down into the surface and over stretch the Achilles tendon. Individuals with plantar fasciitis or medial tibial stress syndrome may not fare well on overly soft surfaces either, since their feet may pronate excessively on an extremely soft surface.

Running downhill can be tough on your knees. Those with peripatellar pain syndrome should consider just walking down the hills, or skipping them altogether. Many coaches have their runners run the uphill, but wisely walk back on the downhill. On the other side of the leg, of course, those with a calf or Achilles injury should not be charging up the hills either.

And the worse surface, in evidence where I live, is ice. You should not consider running on ice at all. Snow, may be slippery, but you may find a good foot plant, but ice, is not nice. If you want to run on ice, get a pair of ice skates and glide across it instead.

Billy Joel – Running On Ice

Point / Counter Point: The Truth is Out There Somewhere (or maybe here)

Every now and then the “Fear Factor” comes to the Internet. And if you travel the running blogosphere, you’ll discover that sometimes it takes the form of a red alert for heel lifts for Achilles tendonitis. It seems that some would rather have you run in pain or give up because of the pain for fear that a 1/8″, 1/4″ or 3/8″ lift which alleviates the pain could cause a tendon to “pop”. There is evidence that the sound of a tendon popping may come after an indiscriminate intratendinous injection of steroid though. 

The truth is one should pay attention to what your body is telling you. Running in pain which causes an alteration in form is not good. It will most likely lead to both your original injury not improving, and a few additional injuries because of your altered gait.   

With the knowledge that medicine is an art and a science, it is probably best to avoid dogmatic opinions such as  ”no, no ,no” to a heel lift. While some will be helped with shoe and surface corrections, orthotics, stretching and strengthening alone, the addition of a 1/8 – 3/8″ heel lift can often make the difference in both comfort and eventual healing of this condition. The lift is used on both sides to avoid creating a longer leg and altering the gait in such a manner that could create low back pain, hip pain or other problems in the absence of the affected leg being a short limb. The lift is best made of a non-compressible material. It is extremely important to avoid compressible materials which will lead to continued slow stretch movement which could add to either activating the stretch reflex of the achilles tendon or allow for eccentric contraction of the muscle-tendinous complex. This may work to inhibit the healing of the tendon, and stop the individual from being able to run without pain. We certainly, and the ladies among us, especially, will vary our heels by much more than this over the course of a week. A slight change in the heel contact and foot angle should not put your Achilles tendon at greater risk of injury. 

While there are flaws in evidence based medicine and in the ability of us to accurately predict those most likely to become injured, there is  no evidence that 1/8 to 3/8 ” lifts cause ruptured Achilles tendons. Not even the slightest hint that muscles and tendons would be ruined by such a lift or adapted so much that you’ll never be the same. I do not know of any study that shows a 1/4″ lift used for a limited amount of time each day could shorten the muscle/tendon complex. There is adequate time spent in other shoes, barefoot, and even doing stretching exercises. 

Running in pain without a heel lift, or more dramatically running on a soft surfacer with a mushy, over cushioned shoe or a racing flat is far more likely to lead to chronic pain and disability. Proper orthotics are a must, along with avoiding over cushioned running shoes to prevent the tendon while functioning from being over stretched and causing eccentric working of the muscle-tendon complex . There seems to be no reason to avoid a heel lift, but it is not the be all and end all of a program to treat Achilles tendonitis. 

For more details:

Website article: Dr. Pribut on Achilles Tendon Injuries

 Previous Blog entry on Achilles Tendon and stretching

Quick Search of Textbook Comments On Heel Lifts:

I wasn’t sure what I’d find in the texts, but thought it would be interesting to see what other minds have come up with on this issue. I did not think that Noakes would agree with the heel lift, but he did. I do not know what is the scientific basis or aggregate clinical experience to imply that heel lifts are the worst possible therapy for this problem. 

Alfredson, H. and Cook, J. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 32 “Pain in the Achilles Region” p.  606 “A heel lift worn inside both shoes (0.5 – 1.0 cm, .25-0.5 “) is a good practical way of unloading the region. 

Alfredson is famous for his self termed “painful” eccentric stretching for non-insertional Achilles tendinopathy. He has published numerous articles on Achilles tendon problems and on the treatment of them. I am not convinced that eccentric stretching is appropriate in as many cases it is recommended. If you find something isn’t working, including the eccentric work is not helping, you need to change the approach. Measurements have shown that the calf is often weak in eccentric strength when one has Achilles tendonitis. One approach is to work on strengthening that (which can be painful). The other is to diminish the pain by lessening stresses which add to the eccentric contraction strength required. Both approaches and sometimes a combination may be appropriate for different patients and at different times for a specific patient.  I continue  to read Alfredson’s  articles with interest. 

Bradshaw, C. and Hislop, M. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 31 “Calf Pain” Since the calf includes the muscles which create the Achilles tendon, we’ll look at comments in this chapter also. “A heel raise should be used on the injured and uninjured side”. 

Title, C. and Schon, L. “Achilles tendon disorders including tendinosis and tears” in Baxter’s The Foot and Ankle In Sport, Second Edition. Mosby Elsevier. Eds. Porter, D. and Schon, L. 2008. “The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching and at times, shoe modifications and heel lifts. Initial treatment should include …At times, a heel lift (one fourth to three eights inch)….”

Noakes “The Lore of Running, Fourth Edition”  Human Kinetics Press. 2003. Noakes feels a shoe with a heel height of higher than 12 – 15 mm and says “most authorities agree that a 7 to 15 mm heel-raise should be added to the running shoes”.