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Youth S ports T rauma and O veruse P revention Dr. Christopher Piller , MD NAON Feb 23, 2013 . Background. Chair, Department of Orthopaedics and Sports Medicine, The Harbin Clinic, Rome, GA. Chief of Surgery, Redmond Regional Hospital Trained at ASMI with Dr. James Andrews 2004

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  • Chair, Department of Orthopaedics and Sports Medicine, The Harbin Clinic, Rome, GA.
  • Chief of Surgery, Redmond Regional Hospital
  • Trained at ASMI with Dr. James Andrews 2004
  • Team Physician:
    • Rome Braves, Berry College, Rome HS, GNTC
    • Formerly Auburn University
  • Board of Directors:
    • American Sports Medicine Fellowship Society
    • Harbin Sports Health Foundation
  • Product Development Consultant and Instructor: Arthrex Corporation, Naples, FL
the problem
The Problem
  • 30 million children participate in organized sports (Source: Safe Kids USA)
  • Participation in high school athletics is increasing, with more than 7.3 million high school students participating annually

(Source: National Federation of State High School Associations)

the problem1
The Problem
  • Forty years ago approximately 4 million boys and girls participated in high school athletics nationwide, 7.4% of which were girls.
  • Today this figure has nearly doubled to 7.6 million participants with 41% being girls.
the problem2
The Problem
  • For both genders the rate of participation continues to rise at an average rate of 45,000 athletes a year.
  • The importance and benefits of participation in youth sports are well documented.
  • With childhood obesity rates triple what they were a generation ago, sports participation should be actively encouraged. However, being active comes with the risk of injury.

Football — It carries the highest overall risk of injury of any high school sport at 3.5 injuries for every 1,000 times the athlete participates in a practice or game.1,3

  • The top three locations of injury were: head/face (24%), knee (17%), and hand/wrist (11%).3

Soccer — For female athletes the top three locations of injury were: ankle (29%), head/face (22%), and knee (15%).3

  • In contrast, 26% of male soccer injuries occurred at the head/face, 18% at the ankle, and 17% at the knee.3

Basketball — Basketball had the highest risk of ankle injuries for male athletes out of all sports surveyed (31%).1

  • Head/face injuries (24%) were the second most common with the knee a distant third, comprising 10% of injuries.3
  • Female athletes followed the same trend: ankle (25%), head/face (24%), and knee (20%).3

Baseball and Softball — Although both genders had the lowest rates of injuries out of all sports, the injury patterns between the two are strikingly different.3

  • Male athletes demonstrated a far greater chance for hip/thigh/upper leg (13%) and shoulder injuries (18%), compared to females’ injuries at 3% and 4%, respectively.

Baseball and Softball (cont.) - Females injured their wrist (24%) and ankle (19%) more, with males sustaining only 9% and 8% of injuries.


Volleyball — It has the third lowest rate of injury behind softball/baseball.1

  • However, these athletes are still prone to injury, with by far the majority of injuries occurring at the ankle (39%),knee (17%) and head/face (13%).3

Wrestling — It has the second highest rate of injury out of the sports discussed here (2.01 injuries for every 1,000 activities).1,3

  • Wrestling athletes most commonly sustain injuries to the head/face (23%), shoulder (16%), and knee (13%).3


1. National Federation of High School Associations.

2010-11 High School Athletics Participation Survey. 2011.

2. National Health and Nutrition Examination Survey, Obesity

rates among all children in the United States. Centers for

Disease Control and Prevention. Last Updated April 2012.

3. Comstock D, Collins CL, McIlvain NM. Data from the High

School Sports-Related Injury Surveillance Study, US, 2010-11.

Unpublished Raw Data, 2011.


the problem3
The Problem
  • More than five million kids (1 in 6) under the age of 18 suffer a sports-related injury each year with approximately half of these due to overuse.
  • High school athletics account for more than 2 million injuries annually (1 in 4), including
    • 500,000 doctor visits
    • 30,000 hospitalizations

(Source: Centers for Disease Control)


The Problem

  • Young athletes are specializing in sports (and positions) at an earlier age, with more than 3.5 million children under the age of 14 treated annually for sports injuries.(Source: Safe Kids USA)
  • Overuse injuries account for half of all sports injuries in middle school and high school.

(Source: Safe Kids USA)

the problem4
The Problem
  • Most high school athletes do not have access to trained sports medicine professionals (ATCs) on site (58%)
  • Most high school coaches are not well trained in the recognition and provision of emergency treatment for catastrophic injuries and/or illness
  • Deaths and/or lifelong disabilities have increased in recent years.

Dr. James Andrews:

  • “The escalation of injuries in kids, especially as they relate to overuse is alarming.”
  • “Sports participation teaches kids priceless lessons about life, health and sportsmanship, but they need to be playing various sports, switching up their routines and armed with the correct information and tools to stay on the field and out of my operating room.”

The Lasting Problem

A child’s history of injury is…..

  • A risk factor for future injury during both their youth and adulthood.
  • A contributor to long term degenerative diseases, such as osteoarthritis.

The Lasting Problem – Part 2

70% of kids participating in sports drop out by the age of 13 because of:

  • Adults:Coaches and Parents
  • “Burnout”
  • Injuries

These children lose the benefits of exercise, teamwork and healthy competition!


April is Youth Sports Safety Month and the American Orthopaedic Society for Sports Medicine (AOSSM), the American Academy of Orthopaedic Surgeons (AAOS), and the STOP Sports Injuries campaign are teamed up with the release of a new radio and print public service announcement (PSA) on overuse sports injury prevention in kids.


Founding Collaborators of the STOP Sports Injuries Campaign

  • American Orthopaedic Society for Sports Medicine
  • American Academy of Orthopaedic Surgeons
  • American Academy of Pediatrics
  • American Medical Society for Sports Medicine
  • National Athletic Trainers’ Association
  • National Strength and Conditioning Association
  • Pediatric Orthopaedic Society of North America
  • SAFE Kids USA
  • Sports Physical Therapy Section

More than 400 other organizations, institutions, sporting leagues and teams have joined the campaign since it launched in April 2010.


STOP Sports Injuries: Council of Champions

Sam Bradford

NFL quarterback and

Heisman Trophy Winner

Dale Brown

Former Louisiana State University Basketball Coach

Reverend Dr. Richard P. Camp, Jr.

Former Nationally Ranked Track & Field Athlete

Tom Condon

NFL Football Agent, Creative Artists Agency

Delos (Toby) Cosgrove, MD

President and CEO, Cleveland Clinic

James R. Andrews, MD


Neal S. ElAttrache, MD


Hank Aaron

Major League Baseball Hall of Famer

Marjorie J. AlbohmPresident, NATA

Bonnie Blair

Olympic Speed Skater

Nicholas Bollettieri

Professional Tennis Coach


STOP Sports Injuries: Council of Champions (continued)

Bo Jackson

Former NFL and MLB Player

James C. Justice, II

Chairman and Owner, The Greenbrier Resort

Stephen D. Keener

President & CEO, Little League Baseball, Inc.

Ian Lawson

Worldwide President, DePuy Mitek, Inc.

Dennis Lewin

Board of Directors Chairman, Little League Baseball International

Howie Long

NFL Hall of Famer, Broadcaster

Lars Engebretsen, MD, PhDProfessor and Director, Orthopaedic Center, University of Oslo

Joe Gibbs

CEO, Gibbs Investments, LLC

Jerry Goodman

President, Health Care Systems (HCS)

Smith & Nephew

Eric Heiden, MD

Former Olympic Speed Skater,

Orthopaedic Surgeon

Jay R. Hoffman, PhD, CSCS, *D, FNSCA, FASCM

President, NSCA


STOP Sports Injuries: Council of Champions (continued)

Christie Rampone

Olympic Soccer Player

Reinhold D. Schmieding

President and Founder, Arthrex

John Smoltz

Major League Baseball Pitcher

Bart Starr

Former Green Bay Packer

John R. Tongue, MD

President, AAOS

Kevin Wilk,

Director of Rehabilitative Research, ASMI

Jim Wilson, III

Chairman and CEO, Jim Wilson & Associates, LLC

Robert L. Masson, MD

President, Neurospine Institute and Chairman, NSI Foundation

Teri McCambridge, MD

Chairperson, Council on Sports Medicine and Fitness

Renaldo NehemiahHurdle World Record holder and former San Francisco 49er

Jack Nicklaus

PGA Golfer

Jerry Pate

PGA Golfer

Rick Peterson

Former MLB Pitcher and Coach

corporate sponsors
Corporate Sponsors
  • Arthrex – Champion Level Supporter
  • DePuy Mitek Inc. – Champion Level Supporter
  • Smith & Nephew – Champion Level Supporter

Campaign focuses on 25 Sports






Field Hockey

Figure Skating





Inline Skating


  • Martial Arts
  • Rowing
  • Rugby
  • Running
  • Skiing and Snowboarding
  • Soccer
  • Softball
  • Swimming
  • Tennis
  • Volleyball
  • Water Polo
  • Wrestling

Educational Content

  • Sports tips
    • Sport specific information
  • Specific educational tip sheets focused on various audiences
    • Parents
    • Athletes
    • Coaches
    • Healthcare providers
  • Video podcasts

Website and Technology

Comprehensive Website Features:

Educational resources

Media center

Downloadable applications

Online survey


Public Service Announcements

Social media interaction through Facebook and Twitter


AOSSM, AAOS and the STOP Sports Injuries campaign have several tips to share with all parents, coaches and young athletes to help prevent injuries

basic recommendations
Basic Recommendations
  • Schedule an appointment for your child to receive a pre-participation physical to determine any pre-existing conditions or injuries.
  • Encourage your child to properly warm up and cool down before and after an activity.
  • Obtain instruction on proper training and technique.
basic recommendations1
Basic Recommendations

4. Develop skills that are age appropriate, and increase training gradually. Recent research has shown that specializing in one sport at an early age can actually be detrimental to skill development.

5. Encourage your child or player to rest and take a break, and to speak up if they are in pain or think they are hurt.


Why are Injuries on the Rise?

  • Immature bones
  • Insufficient rest after an injury
  • Poor training or conditioning
  • Specialization in just one sport
  • Year-round participation

What Can We Do to Prevent Overuse and Trauma Injuries?

Promote injury prevention on multiple levels, including:

  • Learning about the STOP Sports Injuries campaign and visiting www.STOPSportsInjuries.orgfor resources
  • Take the Pledge on the website to prevent injuries
  • Holding ongoing discussions about the importance of rest with athletes
  • Mandating pre-season physicals
  • Enforcing warm-up and cool down routines
  • Encouraging proper strength training routines

What Can We Do to Prevent Overuse and Trauma Injuries?

Additional tips:

  • Drink enough water based on activity and temperature levels
  • Educate athletes on proper nutrition for performance
  • Supervise equipment maintenance
  • Encourage kids to speak with an athletic trainer, coach or physician if they are having any pain.

Additional Prevention Strategies

Work with local athletic governing bodies to mandate pitch counts and limit number of matches or tournaments played.


Additional Prevention Strategies

  • Encourage participation for fun and limit emphasis on winning
  • Discourage early specialization
  • Treat symptoms of problems/injuries EARLY
youth baseball
Youth Baseball
  • In the USA, it is estimated that sixteen million boys play some form of organized baseball.
  • Five million of them play in an organized youth baseball league outside of school.
  • Many of these have no mandated rules and regulations for preventing injuries.
  • In 2010, Little League Baseball implemented maximum pitch counts and mandatory rest days after starting as pitcher
youth baseball1
Youth Baseball
  • Of the sixteen million youth baseball participants, it is estimated that 7 to 20 percent between the ages of nine and thirteen will suffer an injury requiring medical attention, with the total estimated medical costs for these injuries at close to $1.8 billion.
  • The overwhelming number of injuries stems from the fact that many baseball players play their one sport year-round on multiple teams.
youth baseball2
Youth Baseball
  • Children are at risk for sports-related overuse injuries as a result of improper technique, poorly fitting protective equipment, training errors, muscle weakness, and imbalance.
  • James Andrews, MD, “Any Given Monday”, 2013

What is Overuse?

Overuse is considered excessive and repeated use that results in injury to the bones, muscles or tendons involved in the action.

  • Factors Contributing to Overuse Injuries:

1. Immature bones

2. Insufficient rest after injury

3. Poor training and conditioning


Proper Technique is Key

  • Provide proper instruction on throwing mechanics
    • Discourage the teaching of curve balls until high school (puberty)
    • Ban the radar gun in youth sports
    • Mandate a 3 month “rest-period” each year for throwing athletes
youth baseball awareness
Youth Baseball Awareness
  • Be aware of common overuse injuries associated with baseball pitchers.
  • Educate parents that pain plus tenderness, especially in a joint, are often signs of overuse and should not be ignored.
  • Educate parents about Little League baseball’s new pitching rules and regulations.
  • Encourage parents to monitor pitch counts and required rest periods based on their child’s age.
youth baseball awareness1
Youth Baseball Awareness
  • Watch for and respond to signs of fatigue.
  • If a youth pitcher complains of fatigue or looks fatigued, let him or her rest from pitching and other throwing.
  • Youth pitchers should learn good throwing mechanics as soon as possible. The first steps should be to learn, in order: (1) basic throwing, (2) fastball pitching, and (3) changeup pitching.
youth baseball awareness2
Youth Baseball Awareness
  • Preseason physicals are important for detecting preexisting health risks.
  • Adequate hydration is essential.
  • Prevention is the key!
youth baseball rules and regulations
Youth Baseball Rules and Regulations
  • Follow limits for pitch counts and days of rest. (Pitch counts should be monitored and regulated.)
  • Avoid using radar guns.
  • Youth sports leagues should provide and require first aid training for coaches. (This training should include recognition and immediate response to head, neck, and spine injuries, as well as heat-related illnesses.)
youth baseball rules and regulations1
Youth Baseball Rules and Regulations
  • Youth sports leagues should have clear, enforceable return-to-play guidelines for concussions, neck and back injuries, fractures, and dislocations.
  • Proper equipment (including face guards on batting helmets) and field surface conditions should be required.
youth baseball rules and regulations2
Youth Baseball Rules and Regulations
  • Pitchers should not throw breaking pitches (curveballs, sliders)in competition until their bones have matured (around thirteen)
  • Pitchers should be discouraged from participating in tryout showcases.
  • Medical coverage should be present at all sporting events.
  • Proper officiating can keep all players using safe-play techniques.
youth baseball tips
Youth Baseball Tips
  • Warming up
  • Check out the coach
  • Cross-training
  • Take breaks from participation
  • Don’t ignore shoulder, arm or elbow pain
  • James Andrews, MD, “Any Given Monday”, 2013
  • Football is one of the most popular sports played by young athletes, and it leads all other sports in the number of yearly injuries.
  • In 2007, more than 920,000 athletes under the age of eighteen were treated in emergency rooms, doctors’ offices, and clinics for football-related injuries.
  • US Consumer Product Safety Commission
  • Both overuse and traumatic injuries can occur during football due to the combination of factors:
      • intense practice sessions
      • seasonal weather
      • high speeds
      • full contact.
  • Players must be taught not to tackle leading with the head, as head-to-head contact can lead to traumatic and catastrophic injuries, including concussions, cervical spine injuries, and even death.
  • “Heads Up” Campaign by CDC
  • “See what you hit, and hit what you see”
  • There is no foolproof way to prevent concussions, although well-maintained and properly fitting helmets, face masks and mouth guards are keys to minimizing the risk of injury.
  • Another threat to a player’s long-term prospects is his leg or knee injuries.
  • The traumatic injuries in football include those to the anterior or perhaps even the posterior cruciate ligament (ACL and PCL), collateral ligaments (MCL and LCL) and to the menisci or other cartilage of the knee.
  • Proper stretching is recommended
  • Weight and flexibility training to strengthen the muscles around each joint.
  • Conditioning is also important, as fatigue can contribute to a player’s vulnerability to injury.
  • Bracing is not been shown to decrease risk of ACL injuries, but might slightly decrease risk of MCL injuries
  • Coaches must emphasize the importance of not locking the knee when blocking. A joint that is bent slightly and relaxed (the so-called athletic position) is at less risk to injury.
  • Balance exercises, as well as learning to jump and land in a flexed position, are also important preventative measures.
  • “ACL Injury Prevention Programs”
  • James Andrews, MD, “Any Given Monday”, 2013
heat illnesses
Heat Illnesses
  • Heat related illness occurs when the body is unable to adequately preserve a constant internal temperature due to both intrinsic and environmental stressors.
  • It encompasses a wide range of issues from simple heat edema and heat rash to the life threatening condition of heat stroke.
heat illnesses1
Heat Illnesses
  • It is estimated that up to 400 deaths a year occur due to heat related illnesses.
  • Felt to be the 3rd most common cause of death in athletes behind cardiac and head/neck injuries.
  • The majority of heat related problems present as cramps and or edema.
  • Cases of heat exhaustion and heat stroke are more rare, but also much more serious.
heat illnesses2
Heat Illnesses
  • Certain variables that may be of concern include environmental stresses, the individual’s level of acclimatization to the environment, as well as medications, patient age, and any co-morbid conditions the patient may have (hypertension, obesity, etc)
  • Heat edema, heat rash, and cramping are common and not very dangerous
heat illnesses3
Heat Illnesses
  • Heat Exhaustion presents with symptoms of fatigue, dizziness, nausea, fainting, committing, headache, and weakness.
  • Heavy sweating and cold, clammy skin are often seen.
  • Core body temperatures are in the range of 98.6-104 degrees Fahrenheit.
heat illnesses4
Heat Illnesses
  • In Heat Exhaustion the neurologic status is stable and patients have normal mental status, an important distinguishing factor.
  • Symptoms usually resolve rapidly with proper treatment. Rest, hydration and reducing core temperature quickly.
  • Left untreated, heat exhaustion can progress to heatstroke and therefore must be recognized and treated early.
heat illnesses5
Heat Illnesses
  • Heat Stroke is the most serious of the constellation of heat related illnesses.
  • It is life-threatening if left untreated.
  • The classic triad of symptoms includes core temperatures in excess of 104 degrees Fahrenheit, profuse sweating, and neurological disturbances such as difficulty walking, confusion, irritability and coma.
heat illnesses6
Heat Illnesses
  • Heat Stroke has many risk factors including environmental as well as individual factors.
  • Use of certain medications or supplements, alcohol use, obesity, improper clothing or equipment, and deconditioning may all predispose an individual.
heat illness prevention
Heat Illness Prevention
  • Appropriate hydration and acclimatization to the environment is very important.
  • Proper clothing and equipment.
  • Education of parents, coaches, and trainers of the warning signs to look for can also make a big difference in recognition of problems early.
  • The use of more gradual training programs by athletic teams, especially at the beginning of the season, has also been promoted recently.
  • Heat Related Illnesses, Matthew Pollack, MD, Sports MD Website, Sep 01, 2011
  • L. Armstrong et al. Exertional Heat Illness during Training and Competition. ACSM position statement 2007.
  • Casa, D.J., et al. Curr Sport Med Rep 2005, 4: 115-127.
  • Bergeron, M.F, McKeag, D. et al. Youth Football: Heat Stress and Injury Risk. Med Sci Sports Exerc 2005 Aug 37 (8): 1421-1430.
  • Eichner, E.R. Heat Illness in Football. Presented at AMSSM Annual Meeting, 2005 April, Austin, TX.
  • Wexler, R. Evaluation and Treatment of Heat-Related Illness American Family Physician. June 1, 2002.
  • Pratt, A. Putting the Chill on Heat-Related Illness. Contemporary Pediatrics. June 2005, vol 22, no. 6.
  • Coris EE et al. Heat Illness Symptom Index (HISI): a novel instrument for the assessment of heat illness in athletes. South Med J. 2006 Apr; 99(4): 340-5.
importance of pre participation physical examination
Importance of Pre-Participation Physical Examination

• To identify athletes at risk of sudden death • To identify medical conditions that may require further evaluation and treatment before participation• To identify orthopedic conditions that may require further evaluation and treatment, including physical therapy, before participation• To identify at-risk adolescents and young adults who are at risk for substance abuse, violence, depression, and so on• To satisfy legal requirements of athletic governing boards

importance of pre participation physical examination1
Importance of Pre-Participation Physical Examination
  • The PPPE is also an opportunity to identify athletes who have a history of concussion and who may still be experiencing post-concussion symptoms.
  • Identifying these athletes and referring them for further medical treatment is one way to reduce the incidence of second impact syndrome, another cause of sudden death in young athletes.
  • Importance of Pre-Participation Physical Exam (PPPE) Terry Zeigler, SportsMD website, Feb 17, 2011
how common are concussions
How common are concussions?
  • Approx 1.6 million sports-related concussions per year
  • For athletes in contact sports risk can be as high as 6 in 10 per season
  • 4/5 concussed athletes do not recognize they have had a concussion
  • Contact/Collision sports are the highest risk sports
    • Football, soccer, wrestling, lacrosse, cheerleading, basketball, equestrian
what is a concussion
What is a concussion?
  • “…a pathophysiological process involving the brain, induced by traumatic biomechanical forces.
  • Concussion results in a graded set of clinical syndromes that may or may not involve loss of consciousness or memory dysfunction.
  • Concussion typically results in a functional disturbance with the rapid onset of short-lived impairment of neurological function that resolves spontaneously…”

Summary and Agreement Statement of the 1st International Symposium on Concussion in Sport.

Clin J Sports Med 12(1): 6-11 , 2002

what is a concussion1
What is a concussion?
  • A brain injury that disrupts the normal function of the brain
    • Shaking a snow globe
  • Caused by a blow, bump, or jolt to the head or body
  • Often referred to as a “getting dinged,” “your bell rung,” or “stunned.”
  • Signs and symptoms can occur immediately after or days to weeks after the injury
  • A variety of signs and symptoms
  • Often does not involve a loss of consciousness
what does a concussion look like
What does a concussion look like?
  • Symptoms described by athlete
    • Nausea
    • Headache
    • Balance problems or dizziness
    • Double or fuzzy vision
    • Sensitivity to light and/or noise
    • Feeling foggy or groggy
    • Concentration or memory problems
    • Confusion
what does a concussion look like1
What does a concussion look like?
  • Signs observed by another
    • Appears dazed or stunned
    • Is confused about assignment
    • Forgets plays
    • Unsure of game, score, or opponent
    • Unsteadiness, clumsy
    • Can’t recall events around hit
    • Answers questions slowly
    • Loses consciousness
    • Overly angry or sad
    • Behavior or personality changes
what does a concussion look like2
What does a concussion look like?
  • Delayed Signs and Symptoms
    • Can appear days to weeks later
    • Sleep irregularities
    • Fatigue
    • Foggy
    • Forgetfulness
    • Personality changes
    • Depression
    • Lethargy
    • Inability to perform usual daily activities
single classification
Single Classification
  • No longer use grading scale
  • Brief loss of conscious does not correlate with severity
    • <10% have LOC
  • Amnesia is also a poor predictor of severity
  • Athlete-centered decision-making
  • One classification:


concussion management
Concussion Management
    • Every concussion should be assessed and treated by a medical doctor experienced in current concussion management
    • Harbin Clinic has Dr. David Hale, Dr. Chad Wagner, Dr. Brad Bushnell along with Robert Baudier, ATC
  • Issues
    • Onsite / Acute vs Follow-Up Management strategies
    • Assessment of ongoing symptoms at rest and post exercise challenge
if you suspect concussion
If you suspect concussion
  • Remove from play during a game
  • “When in doubt, sit them out”
  • Evaluation
    • Symptoms, Memory, Balance by athletic trainer
    • SCAT1 or SCAT2 with balance testing
  • Serial Examination
    • Regular monitoring for deterioration by trainer
    • Ongoing adult supervision
    • Do not leave them alone
  • No same day return to play for athlete
  • Avoid Aleve, Advil, Aspirin
  • Do not let them drive themselves home
warning signs
Warning Signs
  • Ongoing adult supervision
  • Symptoms become worse
    • Headache
    • Nausea/Vomiting
    • Balance
    • Vision
  • Athlete becomes lethargic or difficult to keep awake
    • Do not wake up if time to sleep
  • Inability to move an arm or leg
  • Convulsions
  • Urgent MD evaluation and possible head scan
    • Emergency Department
    • Urgent care center
    • Doctor’s office
mri or ct scanning
MRI or CT Scanning
  • A concussion will not show up on a CT Scan or MRI
    • Other bad things will
  • When consider head scan:
    • Symptoms get progressively worse
    • Convulsions
    • Persistent symptoms
    • Unresponsive
    • Suspected facial or skull fracture
    • Signs of stroke
second impact syndrome
Second Impact Syndrome
  • Second concussion occurs before first concussion resolved
  • Massive brain swelling
  • Brain may swell after single head injury
  • More common in children
  • 50% mortality rate
  • >75% have permanent neurological impairment

Jaquan Waller, 16

JH Rose High School

Greenville, NC

Died September 20,2008

second impact syndrome1
Second Impact Syndrome
  • Because the brain is more vulnerable and susceptible to injury after an initial brain injury, it only takes a minimal force to cause irreversible damage.
  • The brain’s ability to self-regulate the amount of blood volume to the brain is damaged resulting in increased cerebral blood volume which can result in brainstem herniation and death.
second impact syndrome2
Second Impact Syndrome
  • The pressure to the brain increases rapidly causing brain death in as little as three to five minutes. Because brain death is so rapid, second impact syndrome has a high fatality rate in young athletes.
  • The actually incidence of SIS is not well documented in the literature (Bey, T. & Ostick, B., 2009).
second impact syndrome3
Second Impact Syndrome
  • Because this is a life-threatening emergency, life-saving measures must be taken within minutes for there to be any hope for the athlete.
  • Treatment should be undertaken to maintain an airway, and to provide rescue breathing and CPR if necessary.
sis prevention
SIS Prevention
  • Any athlete may be at risk for SIS if he/she returns to sports competition while still experiencing the symptoms from an initial injury.
  • The key to preventing SIS is to ensure that athletes do not return to sport with any post-concussion symptoms.
sis prevention1
SIS Prevention
  • Legislation is being discussed (at both the national and state levels) to mandate that athletes do not return to sport on the same day that they are concussed and that they do not return to sport unless they have been cleared by a sports medicine professional.
  • Education regarding the proper diagnosis and management of a concussion needs to occur throughout sports communities at all levels of involvement including the athletes, parents, coaches, athletic administrators, physicians, and sports medicine personnel.
  • Arnheim, D. & Prentice, W. (2000). Principles of Athletic Training. (10th Ed.). McGraw Hill: Boston, MA.
  • Bahr, R. & Maehlum S. (2004). Clinical Guide to Sports Injuries. Human Kinetics: Champaign, IL.
  • Bey, T. & Ostick, B. (February, 2009). Second Impact Syndrome. Western Journal of Emergency Medicine: 10(1): 6-10.
  • “How Often do Concussions Occur? Sport concussion Epidemiology. Accessed May 20, 2010.
  • “The High Price Athletes Pay to Compete in High Risk Sports”. Accessed May 20, 2010.
  • Sullivan, J.A. & Anderson, S.J. (2000). Care of the Young Athlete. Published by the American Academy of Pediatrics and American Academy of Orthopedic Surgeons.
concussion follow up management
Concussion Follow-up Management
  • Rest
  • Rest
  • Rest
    • Physical and mental
  • Evaluation by a medical doctor
    • Concussion history and symptoms
    • ImPACT Computerized Testing
    • Neurological exam
    • Memory and concentration testing
    • Balance testing
rest absolute rest
Rest? = Absolute Rest!
  • Physical Rest
    • No training, playing, exercise, weights
    • Beware of exertion with daily activities
  • Cognitive rest
    • Mental tasks can worsen symptoms and delay resolution
    • No television, reading, video games, internet, texting.
    • Keep out of school until symptoms lessen
    • Limit or eliminate tests, homework, essays, reading
    • Caution against daytime sleep
    • Gradually add in schoolwork as symptoms resolve
are all concussions the same
Are all concussions the same?
  • No, every concussion is different
    • Every athlete is different
  • Most Concussions
    • Progressively resolves without complication within 2-3 weeks
      • <25 % within 7 days; 20 % take longer than 3 weeks
      • Most high school concussion resolve between 10-18 days
    • Rest at home for a few days until can function at school
    • Repeat ImPACT testing when asymptomatic
    • Rest until all symptoms resolve and ImPACT at baseline then graded exercise program for return to play
are all concussions the same1
Are all concussions the same?
  • Predictors of prolonged recovery >3 weeks
    • “Fogginess”, balance issues, difficulty focusing/concentrating
    • Migraine history
    • Prolonged loss of consciousness (>1 minute)
    • History multiple concussions?
    • Younger athlete
  • Impacts their whole life
    • No sports  Depression?
    • No school  effect grades; limited social life
  • Rest vs. “withdrawal”
  • 2% may not recover after 6 months
neuropsychological testing
Neuropsychological Testing
  • Integral part of the diagnosis & management of sport concussion
  • Athletes minimize symptoms
  • Helpful for diagnosis, prognosis, and return to play
  • ImPACT
    • Memory, concentration, reaction time, decision making tested
    • Baseline test is important
    • Normative data for no baseline
    • Post-injury tests
graded exertion program
Graded Exertion Program


  • No activity – complete rest
  • Light aerobic exercise
  • Sport-specific training
  • Non-contact training drills (may start resistance training)
  • Full contact practice after medical clearance
  • Return to play


  • Recovery
  • Increase HR
  • Add movement
  • Exercise + coordination + thinking
  • Restore confidence and assess function skills by coaches
  • 24 hours per step
  • 3-4 days total
  • If there is recurrence of symptoms at any stage, return to previous step after 24 hours rest
potential long term impact
Potential long term impact
  • Potentially more serious consequences in children
    • Poor school performance, lower test scores, depression
    • Prolonged cognitive symptoms
  • Multiple concussions may lead to:
    • Depression
    • Early-onset dementia
    • Chronic memory difficulties
    • Chronic headaches
    • Suicidality
    • Chronic Traumatic Encephalopathy
  • Autopsy studies in deceased NFL players and professional wrestlers and boxers
concussion prevention
Concussion Prevention
  • Decrease helmet to helmet hits
    • Proper Tackling Technique
    • Penalties
    • “See what you hit”
  • No helmet has been shown to decrease the rate or severity of concussions
    • Trying to decrease force transmitted to brain
  • Mouth guards do not prevent concussions
  • Secondary prevention with proper return to play guidelines
final points
Final Points
  • “When in doubt, sit them out”
  • All concussions should be evaluated by a physician experienced with current concussion management
  • 80% don’t know when they have had a concussion
    • ImPACT useful
  • Be aware of the signs and symptoms of a concussion
    • Headache, dizziness, memory loss, confusion, etc.
  • Return to play is based on lack of symptoms, ImPACT testing and completion of a graded exercise protocol
  • No athlete should return to play the same day after suffering the signs of a concussion
  • Centers for Disease Control and Prevention
    • “Heads Up”: Concussion in Youth Sports
  • American Medical Society for Sports Medicine Position Statement: Concussion in Sports
  • Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague, 2004
  • Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport, Zurich, 2008
  • NCAA Sports Medicine Handbook 2010



What Does the Future Hold?

  • Better prevention of injury
  • New surgical techniques are being evaluated to treat injuries – less invasive
  • Ongoing research to understand the injury risk and how to prevent
  • Continued rise in injury rates unless education is increased

Let’s Work Together to STOP Sports Injuries

And Keep Kids in the Game for Life!