High School Athletes The new injury prevention plan

By Dr. Tim Maggs

32 years ago, when just starting in practice, I contacted our local high school football coach and offered my services to his team. A couple times a week I would work on any players who asked for help. As great as the job seemed, it was short lived. As soon as the school physician got wind of my involvement, I was introduced to the politics of sports. The athletic director informed me I was not to come onto the campus again.

So, my simple goal was to get back onto campus, and through the front door this time, not some side door where no one knew I was there. Along the way, I’ve learned a lot. We live with a broken sporstmedicine system, and this age group is all but ignored.

Here’s the deal;

• Just about all healthcare decisions are based upon health insurance guidelines. Most high school athlete’s care will depend upon what their insurance covers. So, they have to be injured before they can do anything. Anyone in the healthcare delivery industry knows that health insurance coerage is shrinking at a severe rate (increased co-pays and deductibles with decreased coverage), and unfortunately, the care of high school athletes is jammed underneath this broken healthcare system umbrella. Athletes, especially middle and high school athletes, have needs that are much different and far greater than the needs of the general population. These needs are ignored. 
• All middle and high school athletes receive a physical prior to the season beginning, but the majority of this examination is a medical exam, i.e. eyes, ears, nose and throat. Yes, these tests are needed, but the biomechanical exam, which checks the muscular, neurological and skeletal systems, is absent. The examiner will perform a scoliosis screening. (This is like saying the absence of terminal cancer means you’re healthy). As in, there’s a lot more to biomechanics than a scoliosis screening. 
• We live in a reactive healthcare system dictated by economics. These kids are never looked at until they’re hurt. Secondly, our front line docs (primaries) are not trained in biomechanics, therefore, are not qualified to accurately diagnose or treat these injuries. The “System” then kicks into a costly referral system, going from the primary to the orthopedist to the physical therapist or chiropractor, and the treatment goal is to get rid of the pain/injury. No biomechanics involved. 
• The New York Giants and Chicago Bulls used a conditioning pyramid, with the base of that pyramid containing 6 categories; aerobic capacity, body composition, joint mobility, strength endurance, core strength and anaerobic capacity. These professional athletes needed to pass tests in all 6 categories before they could enter the weight room. In almost every high school in this country, kids begin aggressively working out with weights with questionable supervision and absolutely no biomechanical evaluations. This egregious omission WILL produce devastating long term detrimental effects. 
• When an athlete becomes injured, the goal is to reduce the symptoms, but never correct the underlying problem. Fig. 1 shows an example of the biomechanical imbalances that exist in all of us, and it is these imbalances that lead to the majority of injuries in athletes. These imbalances originate in the feet (our foundation), and if this imbalance is not addressed, we have a limited potential in balancing the rest of the structure. 
• We’re sitting on a ticking time bomb. Many of these kids suffer with low level injuries that don’t meet the criteria for taking action. But, all of these kids have mild to extreme biomechanical faults, and our current sportsmedicine system prefers to perform joint replacements and prescribe a lifetime of pharmaceuticals later rather than address the issues now.

Possible solutions;

Chiropractors and Physical Therapists—you’re the biomechanical providers out there, so you need to step up. The first step is to get to the schools and educate the families and coaches. Then offer your services for a complete biomechanical exam for all athletes, not just those injured. This should take place before the season begins. A biomechanical exam can be found at www.StructuralManagement.com. Prescribe flexible custom orthotics as a first step in balancing their biomechanics.

Family Drs.—admit this isn’t your specialty, and work with the families to find a chiropractor or physical therapist who will help with the biomechanical needs of the athlete.

Athletic Directors—realize you are the lynchpin to all parents and athletes in your school district. Your role is critical. Work with those who are capable of providing more biomechanical information to this group. Don’t settle for that age old response, “We’ve done fine without this so why do we need it now”.

Coaches—you’re the ones who have the most contact with these athletes. Teach them about prevention and the importance of being disciplined in taking care of themselves. Help to build the bridge between families and biomechanical providers in your communities. Small injuries are warning signals. Please don’t promote the “No Pain, No Gain” mantra. Realize that pain is a warning signal for underlying biomechanical imbalances.

Parents—don’t stop until you find someone who will perform a biomechanical exam on your child. It will help detect the predictable sights of injuries, and will uncover the reasons why chronic injuries persist. And, encourage corrective recommendations.

Other than that, have a great month.

Building the High School Athlete Practice

Click here to read this article published in the American Chiropractor January 2010.  

High School Athletes and Structural Management®: The Future of Chiropractic Sportsmedicine

Click here to read this article that was published in The American Chiropractor August 2007.

What About the Kids?

by Timothy J. Maggs, DCIssue:September 2005
Chiropractic Products

Structural exams must be performed on child athletes

In the mid-1990s, I spent 4 years working in the New York Giants’ strength department with Al Miller, their head strength coach at the time. During those years, I also spent some time working with Coach Al Vermeil in the Chicago Bulls’ strength department. Coach Miller has gone to the Super Bowl five times, and Coach Vermeil won six championships with the Bulls, so we can assume that these two coaches know something about conditioning.

Together, the two of them developed a conditioning program (Figure 1). This conditioning pyramid has at its base six categories: aerobic conditioning, anaerobic capacity, core strength, joint mobility, strength endurance, and body composition. These six categories represent the very foundation of conditioning, and it is mandatory for all players to begin their conditioning at this level.

Figure 1: The conditioning pyramid that coaches Al Vermeil and Al Miller created represent the very foundation of conditioning.

When a player joins either of these teams, either through the draft, free agency, or a trade, he is required to prove himself in these six categories before he can enter the weight room. Every athlete on these teams must be able to pass certain tests in these categories before they can introduce weight to their structure. Miller and Vermeil both proclaim that this is the beginning of injury prevention.

Middle School/High School Standards

In most states, all student athletes are required by law to complete testing before they can participate in sports for the year. Although this sounds very protective and appropriate, it in fact is thoroughly inadequate. The standard exam (Figure 2, page 32) required by each state is a medical exam—starting with the eyes, ears, nose, and throat—and ends with a paltry structural exam, the performance of the Adam’s Test for scoliosis. The corresponding line for scoliosis says, “Scoliosis: positive_________ negative_________,” as though scoliosis is the only condition worthy of notice in the spine.

Figure 2: The standard student-athlete school exam required by each state is a medical exam—starting with the eyes, ears, nose, and throat—and ends with a paltry structural exam.

The child who passes this test is then put through demanding conditioning, training, and participating in his or her respective sport. Children as young as middle-school age are entering the weight room these days to begin their long journey of conditioning. Added to the fact that no one performs any type of thorough structural exam on these children is the issue of proper guidance in the weight room.

While with the Giants, I witnessed Coach Miller individually bark out individual commands to each and every player, based on the accumulation of knowledge the team had gained during the prep phase with each athlete. At our local middle and high schools, either the coach, a gym teacher, a parent—or no one—watches our kids. With the competitive nature of youth and their desire to show how strong they are, it doesn’t seem illogical that improper weight work will occur.

The startling truth is that coaches, gym teachers, and parents are putting our children through a demanding amount of physical stress with no prior knowledge of their structural conditions. In many cases, these workouts are inappropriately supervised. The immediate fear is that children might get injured while participating in these activities. This matter is complicated by one of the two following protocols that will take place if an injury does occur:

1. The trainer will evaluate the child and make recommendations, and, if the condition is severe enough, refer the child to the local orthopedist or to the child’s primary health care provider. At this point, the child is caught in the loop of seeing doctors and therapists who have no idea of biomechanics, the cause of the injury, the degree of the injury, or the course of action that should take place.
2. The trainer, who is overwhelmed with too many responsibilities, will make a simple recommendation, ignoring the need for further, appropriate follow-up.

The long-term concern is that degeneration of the human frame is caused by imbalances in the structure, which, over time, become fixated joints. Eventually, this young person becomes an adult with an accelerated degenerative process that is taking place in his or her body. Of course, our health care industry has made it almost commonplace for aging athletes to require some level of care for their aching, worn-out joints. These treatments range from medications (such as anti-inflammatories, corticosteroids, and hyaluronic injections) to surgeries (such as arthroscopic, bone fusion, and joint replacement). Not only do they provide answers once the joints have worn beyond a certain point, but this has become a tremendously profitable industry.

And this is OK with everyone? Personally, I am outraged at the collective negligence that is allowed in the supposed protection of our pediatric population today. It is ignorance (lack of appropriate examination), followed by more ignorance (not recognizing the importance of strategic and safe conditioning), followed by ultimate ignorance (waiting for a person to rot out and then provide radically expensive crisis care).

The National Federation of High School Sports

Approximately 1 year ago, I contacted Jerry Diehl, president of the National Federation of High School Sports, and told him about the critical void that existed in our middle and high school conditioning programs. After a brief pause, he stated that the federation is aware of the void, but is unaware of how to address it.

I have continued my dialogue with Mr Diehl in an effort to solve this crisis. Structural exams must be performed on all children wishing to participate in sports today, prior to the beginning of the season. Structural exams can be performed without x-rays, until the child turns 12 years old, when appropriate standing x-rays need to be taken.

The Structural Fingerprint®™ Exam

This exam detects structural imbalances, weaknesses, and distortion patterns. It is ideally performed on nonsymptomatic patients; however, it can also be performed on the injured. As many of our young athletes are under the age of 12, structural x-rays should only be considered if they are clinically warranted. Once a child reaches age 12, standing structural x-rays need to be taken to determine the starting point for that child.

The x-rays provide 75% of the information needed. They allow the examiner to determine biomechanical distortions and imbalances, as well as many other possible findings. Assuming that the examiner knows how to biomechanically interpret the information on the x-rays, this information contributes greatly to the conditioning recommendations for this child. In addition to the exam and x-rays, examination of the feet and knees is crucial.

Foot and Knee Exam

Most children will pronate (have flat feet) prior to age 7 or 8. Once a child is past age 8, the medial arch he or she presents with is considered to be the arch he or she will live with. Since the majority of the population pronates, the odds are high that there will be some possible pronation involvement. Prior to age 12, custom-made orthotics should be considered, as body balance and efficient joint mobility is the prevailing goal. Once a child reaches age 12, a complete examination should take place, including x-rays, and the child should use adult orthotics for the shoes.

Figure 3: With regard to the knee, an evaluation of the Q angle will inform the examiner about the balance of this hinge joint.

With regard to the knee, an evaluation of the Q angle (Figure 3, page 34) will inform the examiner about the balance of this hinge joint. This angle represents the angle formed by the quadriceps tendon as it travels over the patella and then attaches to the tibial tubercle. In the textbook case, pronation of the corresponding foot will often produce an increase of this angle. Unfortunately, an increased Q angle can also not be textbook, showing positive when least expected and negative when expected. Therefore, it must be examined—both knees on all patients—to know the status of this test.

Research has shown an associated increase of many knee injuries when an increased Q angle is present, and the addition of custom-made orthotics to the equation will reduce the stress in the knee caused by the imbalance. If all active children could receive this evaluation and the supportive care needed, the number of injuries in youth sports would be drastically reduced. The amount of future joint degeneration would also be reduced, altering the course of many people’s lives. This approach might also put a dent in the profitability of modern medicine.

It is incumbent on all of us to demand a change in the way kids enter the sports arena. Structural exams should become mandatory, and the standards used by coaches Miller and Vermeil should also be used for the thousands of young athletes today. Until we raise the bar and demand such a change, it is unlikely anyone will see to it that this happens.

Timothy J. Maggs, DC, specializes in sports and industrial injury management and is a graduate of the National College of Chiropractic. He writes and speaks at numerous engagements.