New, Tougher Concussion Guidelines for Athletes The Centers for Disease Control estimates that 1 to 3 million

sports-related concussions occur each year in the United States.

As if that weren’t bad enough news, growing evidence shows that

many athletes, coaches, parents – and even healthcare providers –

have been slow to recognize how serious these injuries actually

are, leading to inadequate evaluation and management.

What are concussions?

Concussions are brain injuries following a traumatic event. Symp-

toms can vary over time and activity level making them difficult to

recognize. Headache is the most common symptom, but dizziness,

fogginess, nausea, vomiting, balance disturbance, light and sound

sensitivity, double or blurry vision also may occur.

While athletes from any sport may suffer a concussion, those

involved in contact and collision sports are at the highest risk.

Additional risk factors can add to the frequency or severity of

concussions, such as:

• poor fitting or improper equipment

• technique

• neglect of sports rules

• genetic factors

• a history of previous concussion or recent concussion

• younger age

• a history of previous cognitive impairment (Athletes who suffer

a concussion are three to five times more likely to suffer a

second concussion that same season.)

What new rules may help?

To decrease the risk of injury and re-injury, many sports governing bodies

have developed new recommendations for concussions. Recently, the

National Football League recommended athletes with loss of conscious-

ness, nausea, vomiting, photosensitivity, memory or cognitive function,

balance problems, or persistent headache be removed from practices

or games. Athletes must undergo an independent medical evaluation once

their symptoms have resolved (both at rest and with exertion) prior to

returning to competition.

In 2010, the NCAA mandated that all institutions submit a concussion

management policy. Also this year, the National Federation of State High

School Sports recommended all high school athletes suspected of suffer-

ing a concussion be removed from competition and evaluated by a medical

professional prior to returning to play. Washington State has even taken

this one step further, making it a legal requirement to seek medical

clearance prior to returning to sport.

While many athletes experience only temporarily symptoms lasting one

to two weeks, some athletes have effects lasting weeks to months. That

is why it is important for athletes to undergo a thorough evaluation by

a physician before returning to activity. Effective management strategies

can allow athletes to return to competition more safely.

We hope these new recommendations will lead to a better understanding

of the nature of these injuries, and prevent athletes from returning too

soon back to play.

Paul Gubanich, MD, MPH, is a primary care sports medicine physician

with an interest in sports concussions and the primary care sports

medicine physician for the Cleveland Browns.

If you have any questions about sports concussions or require

treatment, please contact Dr. Paul Gubanich at the Sports Health

Center at 216.518.3468.

Sports Health

A newsletter for athletes, coaches, parents and

active individuals | Fall 2010

Competitive

EdgeINSIDE: DENTAL INJURIES | COLD WEATHER EXERCISE | VOLLEYBALL JUMP

TRAINING | SPIN THE RIGHT WAY | UNDERSTANDING PLANTAR FASCIITIS

HOME GYM HANGUPS: LATERAL HIP & RESISTANCE BANDS

Jump into Fall with VolleyballVolleyball is a relatively safe

and injury-free sport. For instance,

consider that 68 percent of all

injuries occur during volleyball

practice – not during the game.

Knee and ankle injuries account

for 36 percent of all injuries in

volleyball players. To help avoid

such injuries, three things are key:

leg strength, balance and agility.

Research shows that athletes who participate in a formal jump program

experience four times fewer serious knee injuries. Cleveland Clinic’s

JUMP RIGHT program utilizes strengthening, agility and balance to help

train individual athletes to improve their jumping technique – and as

a result decrease injuries.

The program consists of:

• a pre-test

• three phases of exercise/activity progression

• a post test

During the pre and post-test, the athlete’s jumping abilities are

video-taped and measured. The first phase educates the athlete on

proper jumping technique with double-leg activities and addresses

their strength deficits. The second phase incorporates more single-leg

techniques since research has found that – due to blocking and

spiking requiring landing with bilateral feet – players need more work

with single-leg techniques. The final phase involves more balance and

agility activities, including grapevine, running and change in direction.

As a whole, JUMP RIGHT addresses an athlete’s core and entire

lower body.

So when should players begin the program? Ideally, they should start

JUMP RIGHT during the transition from middle school to high school,

but jumping athletes at any stage may benefit. An athlete who is well

developed and demonstrates a more “knock knee” posture may benefit

from beginning sooner. Increasing buttock and hip strength, balance

and agility will improve his or her jumping technique and prevent injury.

Amanda Gordon, MPT, works with a range of young competitive ath-

letes, as well as “weekend warriors.” She played four years of volley-

ball at Baldwin-Wallace as a setter and currently coaches JV volleyball

at Brecksville/Broadview Heights High School.

Compeitive Edge | Fall 2010

Knee pain: Did you know?

• The most common type of knee pain that results in missed

practice and/or games is patellar tendonitis, or pain just below

the knee cap.

• Knee pain can be caused by repetitive loading of the tendons

in the knee during the “slowing down” or eccentric phase of

jumping. Therefore, players have difficulty absorbing the

energy produced while landing a spike or block in volleyball.

• Research has found that knee pain also can be caused by

having a “valgus” knee position, or an unaligned “knock-kneed

position.” This posturing can be caused by hip weakness as

well as possible hip, knee and foot alignment issues.

Dressing for Cold Weather Exercise

Follow These 5 Tips to Keep Your Routine on TrackThe mercury may be falling, but that doesn’t mean you don’t have to

sideline your running shoes for the winter. Instead, a little preparation

can go a long way toward full enjoyment and high performance levels

during colder weather.

Your choice of clothing, for instance, can be the difference between

a great outing and a disaster. That’s because a decrease in core body

temperature drives the body’s responses to cold exposure, which can

cause early fatigue and decreased performance.

Proper attire can help you maintain your core body temperature and

reduce cold weather-related risks. Keep these five tips in mind to make

sure Jack Frost doesn’t sideline your sport this season:

1 Layers, layers, layers! – Layering is your best winter sports

strategy. The layer closest to your skin should be a moisture-

wicking material, like lightweight polyester or polypropylene, to take

moisture away from your skin to the outer layers to evaporate. The

second layer is the insulating layer, which should be wool or polyester

fleece. The third, outer layer ought to be wind and rain repellent.

When exercising in the cold, this third layer should be removed unless

it is raining, snowing or very windy. If worn during exercise, this layer

can trap sweat and not allow for proper evaporation. You can always

put the top layer back on during any outdoor rest times.

2 Cover your head – Be sure to cover your head with a hat or

helmet to decrease heat loss.

3 Mittens or gloves? – If finger dexterity is not important for your

cold weather activity of choice, wear mittens instead of gloves.

If gloves are necessary, consider wearing a thin liner under the gloves

for better insulation.

4 Protect your feet – Dry, warm feet are essential for decreasing

the risk of a cold-weather injury and preventing blisters. Socks

should wick moisture away from your feet to your boot. Avoid cotton

socks. Cotton keeps moisture next to the skin. More appropriate fabrics

include wool or synthetic fibers with a moisture-wicking capability.

5 Don’t forget about fit – If you layer socks, be sure the boot is

large enough to ensure proper circulation.

Besides your choice in clothing, other factors to consider in preparing

for cold weather exercise are age and fitness level.

People over 60 years of age as well as children are at an increased

risk of hypothermia. These populations should use extra caution when

exercising outside in the cold. Parents should remind their children to

keep their hats and gloves on and to avoid getting wet.

While a higher physical fitness level does not directly improve the

body’s ability to regulate temperature in the cold, it can allow people to

exercise for longer periods of time at a higher intensity, which can help

maintain core body temperature.

Did you know? Understanding Core Temperature

A drop in your body’s core temperature causes:

• a decrease in blood flow to the skin

• an increase in heat production through shivering

• lowered dexterity that can inhibit performance in activities that

require catching, throwing or marksmanship

• an increased amount of energy needed by the body at a given

exercise intensity

Elizabeth Sprogis, MA, is an exercise physiologist with Cleveland

Clinic Sports Health. She specializes in helping individuals of any age

group meet their wellness needs, improve their sports performance,

and set appropriate goals.

So your heel hurts when you first get out of bed

in the morning – and every time you sit down for

a while, and then start walking? Chances are you

have plantar fasciitis.

The problem typically isn’t in the diagnosis, but

rather how to get rid of that pestering pain.

What is it?

Plantar fasciitis is a localized degeneration and irritation of the thick

fibrous tissue that connects your heel to the base of your toes and

makes up the majority of your arch in your foot. You are not alone if

you have it; Nearly 15 percent of people will be affected by it during

their lifetime. That’s about 2 million sufferers per year.

What causes it?

The trauma that causes the pain is usually linked to increased,

repetitive stress to the plantar fascia. This causes microtears to occur

at the area under increased load, right at the inside aspect of the

bottom of the heel. It can be due to an increase or change in exercise

volume or intensity, walking or working out in different/new shoes

or a new surface, or a combination. People with tight calves and

hamstrings, and those that are overweight, seem to be more prone

to plantar fasciitis.

How is it diagnosed?

A good, thorough history and physical exam should solidify the

diagnosis. A set of X-rays may show a bone or heel spur right where

the plantar fascia attaches to the heel. This is an area of increased

stress, typically due to the tightness of the plantar fascia.

What helps?

The approach to treating plantar fasciitis is multifaceted and individu-

alized and can be guided by your physician and physical therapist

team. Recovery is dependent on how long you have suffered – the

longer you have had it, typically the longer it will take to get better.

Supportive shoes can make a big difference. Flat shoes, such as

flip flops, have been implicated in the onset of plantar fasciitis. Make

sure you have the right type of shoes for your feet. If you are unsure,

a good running shoe store or your therapist may offer guidance.

Heel cups can lessen the pain with each step, and over-the-counter

arch supports can help support the arch and relieve some of the

pressure on the plantar fascia attachment. Some people need custom

orthotics, but technology has made some of the over-the-counter

brands nearly as effective and comfortable, and they are a more

inexpensive option.

Many people benefit from multiple stretches to loosen up the fascia,

Achilles tendon, calf (especially the soleus muscle) and hamstring.

Localized icing and over-the-counter pain medications, including

anti-inflammatories, can provide some pain relief. If the pain is sig-

nificantly worse with those first few steps out of bed in the morning,

a night splint that keeps the plantar fascia from tightening overnight

can be very helpful. If that doesn’t work, other options include

taping, bracing, injections or shock wave treatments – and for the

severely recalcitrant cases, potential surgery.

Plantar fasciitis treatment requires patience. Unfortunately, there are

no quick fixes, but with dedication, you should be back up on your

pain-free feet soon.

Richard Figler, MD, is a primary care sports medicine physician.

He is board-certified in family medicine with a Certificate of Added

Qualification in Sports Medicine. He is the primary care sports medi-

cine physician for John Carroll University and Solon High School.

Oh my aching feet!

Understanding Plantar Fasciitis

Spin the Right Way

Tips for stationary cycling

The season for increased indoor activity is rapidly approaching,

and many active adults will begin returning to their local gym

for group exercise classes. One very popular group class is indoor

“stationary cycling,” often referred to as “spinning” class. This

exciting workout can be very demanding for the avid cyclist be-

cause effort is limited only by your personal perception of intensity

and you may have an instructor who is encouraging everyone

to go harder.

But remember, this isn’t a private class and, typically, half of

the group wants and needs motivation to do little more than move.

Here are three basic guidelines to help you get the most from

your workouts:

1 Most of the stationary bikes are made of steel – and you are

not! So if something doesn’t fit right, something will break.

You can bet it will be you. To avoid injury, follow the general guidelines

for bike fit in the diagram below. Note the positioning of:

• the degree of leg extension (red leg position) and the position of

the knee relative to the pedal (blue leg position), upper body

position and reach angle

• the foot and pedal spindle and the vertical tracking line of the knee.

• the pitch of the seat, and the neutral to negative pitch of the seat.

• If you intend to become a more-than-occasional cyclist, you should

seek out more specific bike fit guidelines that match your particular

body – and increase your power and comfort.

2 Now that you’re set up and ready to start pedaling, the following

tips will you reduce unnecessary discomfort from poor form:

• If you have not yet learned to pedal at a high cadence without

bouncing all over the seat, it means you need to slow it down.

It takes time for your body to acquire this skill of high cadence.

• Avoiding any inclination to apply excessive resistance during your

first few classes. Keep it easy and pain free! It’s best to allow

your body a few cycling sessions to become accustomed to the

kinetics of cycling.

3 Since stationary cycling is exciting and challenging, becoming

overly enthusiastic is easy. Working beyond your desirable level

of effort is quite common in a group cycling class – and almost a

guaranteed outcome, unless you incorporate some method to monitor

yourself. The most common “technology-based” method of monitoring

is with a heart rate monitor worn on the wrist. The less “technical”

method is by using the “talk test.” (If you have a tough time talking,

you’re working out too hard. This is one of those occasions when if a

little is good, more is not always better!)

There is a common observation among cycling coaches that

people don’t go easy enough when you say, “Go easy.” And

they don’t go hard enough when you tell them, “Go hard.”

To gain the most benefit from your efforts, consult a well-creden-

tialed trainer who can balance your frequency, intensity and

duration of exercise to match your goals.

Frank J. Iannotti, ACSM-HFS, is the Coordinator of Performance

Training Services at Cleveland Clinic Sports Health where he

provides bike fit and cadence analysis for professional and ama-

teur cyclists, along with performance training for cyclists and

other multisport endurance athletes.

Compeitive Edge | Fall 2010

Compeitive Edge | Fall 2010

?What to Do When an Athlete Has a Dental InjuryAs fall sports are underway, parents everywhere are heading out

prepared to cheer on their child. But are you prepared to deal with the

variety of dental injuries that may come with that hit, foul or check?

Sports-related dental injuries can range from minor chips to the com-

plete loss of a tooth (also known as avulsion). If a tooth is chipped, the

broken pieces should be gathered and taken to the dentist for repair.

If the entire tooth has been knocked out, it is important to act swiftly

and carefully to increase the chances of saving the tooth. Here are

some tips to keep in mind:

• Confirm that it is an adult tooth. Baby teeth are not re-implanted.

• Never touch the tooth by the root, as there are important fibers

(called the periodontal ligament) present, which are necessary for

proper healing.

• If the tooth is visibly soiled, rinse briefly with tap water – but never

scrub the tooth. Immediately re-implant the tooth, if possible.

• If re-implantation is not possible, the tooth should be taken with your

child to the dentist or the nearest emergency room.

• Never allow the tooth to dry out. The best fluids to transport the

tooth are Hank’s Balanced Salt Solution (found at your local pharmacy)

or milk. Or, have the child keep the tooth in his or her cheek.

If the tooth is replaced into the socket within five minutes of being

knocked out, it is likely the tooth can survive. Between five and 60

minutes, there continues to be a good survival rate as long as the tooth

has been stored properly. If the tooth is out of the mouth for more than

60 minutes, the chance for survival decreases significantly. Consult

your dentist for additional replacement options. At the dentist or emer-

gency department, the tooth will likely be re-implanted and splinted to

the adjacent teeth for a period of two to eight weeks. During that time,

a root canal will be necessary for long-term survival of the tooth.

Despite the best methods for saving an avulsed tooth, it is clear that

prevention is the best strategy. According to the American Dental Asso-

ciation, an athlete is 60 times more likely to suffer dental injuries when

not wearing a mouthguard. A properly made mouthguard can protect

the teeth by cushioning the impact and dispersing the forces. Whatever

the type of mouthguard (ready-made, boil-and-bite or custom-formed

by a dentist), it can add a tremendous amount of protection and should

be used with all contact sports with the potential for mouth injury.

Enjoy the fall season and play safe!

Todd Coy, DMD, is a dentist in Cleveland Clinic’s Head and Neck

Institute and Director of the General Practice Residency program.

He is the team dentist for the Cleveland Cavaliers and a member

of the Academy of Sports Dentistry.

Competitive Edge Competitive Edge offers active individuals, athletes, coaches and athletes’ parents updates from Cleveland Clinic Sports Health professionals on nutrition, health and injury prevention.

Editorial Board: Alan Blauch, PT; Gary Calabrese, PT; Rick Figler, MD; Bob Gray, MS, ATC; Tricia Hamad, MEd, ATC; Susan Joy, MD; Heather Nettle, MA; Katherine Mone, MEd, RD, LD

Interim Director, Cleveland Clinic Sports Health: Richard Parker, MD

Managing Editor: Ann Milanowski

Designer: Irwin M. Krieger

We welcome your questions or comments.Contact Information:Cleveland Clinic Sports Health Center/SH02 5555 Transportation Blvd. Garfield Heights, Ohio 44125

Email: sports-health@ccf.org

The information contained in Competitive Edge is for educational purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician’s medical assessment and medical judgment.

For a tour of the Cleveland Clinic Sports Health Complex just off I-480 in Garfield Heights, please contact Beth Rimmel at rimmelb@ccf.org.

© 2010 The Cleveland Clinic Foundation

10-SHL-005

SIDE-LYING LEG RAISE:Begin by lying on your side on the ground, hips and legs stacked on top of each other and slightly bent. Lift the top leg and place the toe of that foot behind the heel of the lower leg. Lift and lower the top leg in a slow, controlled motion, making sure to keep your leg slightly behind you. Repeat on both legs two to three times on each side for 10-15 repetitions.

STANDING RESISTED HIP ABDUCTION:Start by standing, feet shoulder width apart with a resistance band tied around the ankles. Place all of your weight on one leg and move the other in a slow, controlled motion to the side and slightly behind you at about a 30° angle. Use a chair for balance, if needed. Repeat on both legs, two to three times on each side for 10-15 repetitions.

RESISTED LATERAL SQUAT:Start by standing, feet slightly wider than shoulder width apart with a resistance band taut around your ankles. Sit back into a half- squat position. Take 10 small steps, keeping a wide stance and staying in the squat position. Change direction to take 10 steps to the left. Repeat two or three times on each side.

Home Gym Hang-Up

ADVANCED 1

RESISTANCE BANDS are especially useful in strength training for beginners or to target specific

muscle groups. The shorter the band is the more resistance it will provide. This allows for variability

between exercises and can be modified by hand position or tautness around an object to achieve

the proper resistance for each movement.

BEGINNER 1 2 3

INTERMEDIATE 1 2 3

2 3

Katie Rothstein, MS, Exercise Physiologist

The muscles of the lateral hip are often overlooked, but are an important part of lower body stability and play a large role in injury preven-

tion of the knee, hip and lumbar spine. One of the exercises from the following hip abductor progression should be incorporated into any

strength routine two to three times per week in addition to basic lower body training exercises. These exercises will specifically target the

glutes, with the goal of providing stability to the hip and knee during normal walking, running or jumping.

Disclaimer: You should always check

with your doctor before starting a

new exercise routine or increasing

intensity. If you experience pain

while doing these or other exercises,

stop immediately and contact your

physician.

The Cleveland Clinic Foundation9500 Euclid Avenue / AC311Cleveland, OH 44195

Tune in!Cleveland Clinic experts will offer tips, tricks and advice to weekend warriors and student athletes on

“Sports Health with Cleveland Clinic,” a bi-weekly TV show which premiers on Sports Time Ohio (STO) at 7:30 p.m., Thursday, Oct. 14. Check your local listings for channel information.

Northeast Ohio TV personality Brian McIntyre will host the show, covering everything from nutrition to sports psychology to stretching and training.

Same-Day Appointments and Convenient Locations 877.440.TEAM (8326) | sports-health.org

Sports Health

Competitive

EdgeA newsletter for athletes, coaches, parents and

active individuals | Fall 2010

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