When you played, did you have experiences of teams who were not cohesive on or off the field?
JD: In college (Simon Fraser University) the players would hang out together outside of games and practices. On the field we were a much better team. If a player from our team was cleaned out by an opponent we would take a note of it and be on their side for later in the game. You stand up for your players and it gave us a great amount of cohesion on the field. There was no animosity carried off the field when you are all friends both on and off the field.
How social were the teams?
JD: At college very much so. At club (Whatcom FC Rangers) the team was made from five different high schools so everyone had their own group of friends and it didn’t have the same feel to the team as at college. Partly this was because we didn’t train as much as we did at the higher levels, but partly it was because we came from all different areas and went away after practices. We didn’t do a ton of teambuilding, which probably affected our ability to play as a unit on the field.
It is hard to tell whether it was the group of players or the cohesion. We had a lot of players who were more selfish with the ball. They would try to take it beyond that third or fourth defender when they didn’t need to. Whether that was the group cohesion or just the type of players they were is hard to say.
Did the coach every try to do anything about it?
JD: No, the coach was good technically and tactically, but as far as interpersonal skills and the ability to bring people together he was not so good.
What activities did you do to work on it?
JD: We would play in tournaments in North West Washington, which is an area with a lot of lakes. The games would be Friday-Saturday, then after the games we would go out to the lake and go tubing and boating as a team. We would do that once or twice each summer and it probably helped us, but there was no continual cohesion plan throughout the year. For immediate results I think that was a nice way to do it though.
What are the most common soccer injuries you treat?
JD: Mostly ankle sprains, quad, hamstring and hip flexor issues. Mostly soft-tissue injuries.
Does it vary by gender? Age?
JD: As far as most common injuries, those are seen all over the board, not just in certain ages or genders. For the more serious injuries that take more time, the most common are broken legs and knee injuries. For knee injuries, females are two to ten times more likely to suffer a non-contact injury than males. Males tend to be more ankle injuries, bumps and bruises and quad injuries.
The ACL tear is a hot topic in youth soccer. Are there other injuries that you think are as important?
JD: I think the whole lower extremity is important for soccer: all the non-contact injuries as a whole. The exercises we do for ACL prevention transfer directly over to ankle and other injuries too. Hip balance work can reduce the incidences of quadriceps strains, hamstring strains and hip flexor overuse. Building athletic development helps reduce the incidence of non-contact injuries, whether it is knee, ankle, or hip. A lot of the injuries in kids now are overuse injuries. In the population as a whole now we see kids who play video games or sit around doing homework on their laptop, which leaves only a small amount of time that they are actually training. If you look at their general inactivity they train very hard in that brief amount of time, which works the muscles very intensely but doesn’t give them the consistent buildup from other aspects of life.
So you think lack of activity outside of practice is causing an increase in chronic injuries?
JD: Yes, they play soccer but they are not playing in the park, climbing fences and doing the activities we did as kids. Partly this is the sensitivity parents have, but also it is caused by all the technological distractions we now have, which goes all the way up to the adult level. People who work at an office for eight hours each day then try to play sport for four hours in the evening tend to develop injuries because their bodies are not used to it.
So more daily activity might actually help prevent chronic injuries?
JD: It is possible. A few years back kids would play all year around, but you would play five or more sports throughout the year. Now kids play one or two sports all year. Each one has a pre-season, a ramping up time and a tapering off time at the end. If you have two sports where the phases are not at the same time you could be ramping up and tapering off at the same time. That’s why I think having primary sport and active play is good. Too many structured sports on top of homework, lack of sleep, poor nutrition etc. can lead to chronic injuries.
Can you give us an idea of how much time/money it takes to rehab from common conditions?
JD: Starting with ankle sprains, it can be anywhere from a day or two with no cost up to four-six months and tens of thousands of dollars. Even with an ankle sprain you can rupture ligaments and require surgery. It isn’t as common with those but it can happen and there is a lot of rehab whether you have surgery or not. People say it is better break your ankle than get a really bad sprain because bone often heals faster than ligaments will.
For ACL your return to play for top professionals where they can dedicate every day to rehabilitation is going to be five to six months. For most people it will be seven to eight months before they are returning to sport and up to twelve months before they feel “normal” again when they are playing
Are players with previous injuries more likely to do the same thing again?
JD: There are a number of things that go to a re-rupture of your ACL. There are three types of graft that can be used for surgery: the first is a cadaver graft where they take tissue from a cadaver and put it in. Current literature is going away from this approach, especially in young athletes because you are not sure where the graft is from. It could be from a fifty year old individual that you are putting into a twenty year old who has very different demands from it. The second approach is the patella tendon graft, which is very strong but can have issues with knee pain down the road as they can get tendonitis and other issues. The third way is the hamstring graft, which is common but has the possibility to lead to weaker hamstrings after the surgery. Hamstrings are important because they are considered a secondary stabilizer for the ACL. The type of graft utilized is often based on surgeon preference, but it is important for the athlete and their parents to have a discussion with their surgeon regarding the different grafts and what would be best
With our rehab model right now it is very insurance-based. The insurance companies will cover your rehabilitation to the point at which you can walk up stairs; you can do your daily activities like going to school or work, so you don’t need to keep going to rehab. But there is a big jump from everyday activities to returning to sport safely. So a lot of players come back and they are not trained to be back in sports, making the ACL susceptible to rupturing again in the first month or two when they put high demands back on their body.
Another reason is that some players who have the surgery have never corrected the mechanics that caused it to happen in the first place, so they still have the exact same issues, which means they are still high risk to do the same thing again.
How do you deal with the psychological aspects of treatment at your clinic?
JD: If we see an athlete immediately after they have torn their ACL, before surgery, they usually have to wait a few weeks for the swelling goes down, which gives us time to get into the psychological aspects of it. You have to let them know that this is the most traumatic thing they have probably ever been through. We reassure them that it will get better, but that we understand how important it is to them. We justify their concerns but also lay them to rest. We need to take the time to heal both the psychological as well as the physical aspects of sport. Building self confidence is essential to a successful return to sport.
There is the whole psychology of sport that they are continually second-guessing themselves on whether it will happen again. A lot of the physical rehab includes mechanics drills but parts of it are also there to help build their confidence. We start with something very simple and safe and progress from there.
Do you recommend that players have counseling too, to help with their confidence?
JD: You certainly can. One of the best ways would be for whoever is rehabbing the individual to get in touch with the coach so they can pass on their concerns and suggestions for the course you should be working on together. You can suggest activities they can work on during practice time to get the confidence back in tackles in a very controlled environment. Gradually you add some speed and intensity to it, building the confidence slowly.
How should a coach know whether an injury is serious enough to need more than R.I.C.E.-type treatment at home?
JD: That’s a good question. If you have an athlete who is unable to take steps on a leg for more than 24 hours it is probably something that needs further workup. If there is gross deformity then it needs further workup. For overuse injuries, if they have had the same ailment for two to three weeks and their performance is being affected then it is probably worth having them checked out too.
Colorado recently passed a law requiring coaches to have concussion training. Are there other conditions you think they should also be trained on?
JD: I think immediate first aid is important. CPR and sports first aid courses and a basic taping, wrapping, splinting course would be very useful. I think a lot of athletes come in and buy ankle braces that are unnecessary. If they had a little training they could go through a quick tape job on the ankle, which would give more support to the specific location that is needed.
Is taping done by players purely psychological or does it have some benefit?
JD: There are two different fields of thought on that. A lot is psychological: an athlete gets comfortable with it as part of their routine. If I have an athlete who has been taped for the first half of the season I’ll keep doing it unless they want to stop, because it works for them. You don’t get a lot of support from the tape during the game as it will get loose, but it does provide a lot of biofeedback, and so as it goes it helps fire the muscle. So with tape you can actually have better ankle stability from your own muscle control than from an untapped ankle, especially someone who is post-injury.
Some of the bigger clubs pay for an athletic trainer to be at their fields. Do you think that is realistic for youth soccer? Should it be a higher priority for the smaller clubs?
JD: I think that they should have access to medical staff, whether it’s a phone call away or on site. Having a medical team who knows the athletes and the sport on hand is very important. If the club can afford to cover having an athletic trainer at the fields I think that is great, but if not I think just having someone who they know is available on call to ask immediate questions is ideal. This will also help with your previous question regarding triage of patient and when they need further work-up beyond the R.I.C.E-type treatment. Having medical staff on call can help answer if the athlete needs to be sent on for further evaluation.
I think in leagues you don’t get as much benefit from them being there, but during tournaments they can have better success, when players have another game later that day, with the between-game management. The more serious injuries will be called out to emergency services regardless of whether you have a trainer there, so they are not going to help as much with those situations. The trainer or medical staff can help with the rehabilitation process though, as a bridge between physical therapy and returning to the sport. If they know the sport and the coaches they can help players pass from rehab to playing.
What is your view of stretching before or after games? How should or shouldn’t it be done?
JD: My opinion is that static stretching is not essential to be done before games. Afterwards I think it is useful as part of the cool down. If nothing else it gives the athletes time to wind down, talk about the game and reflect. It also gives the muscles an opportunity to keep moving after the game instead of immediately going to the car. The goal right after the game is not to increase flexibility, which takes longer stretches than I would recommend for the cool down. For before the game I think as long as they are getting a dynamic warm up routine that puts them into all the various positions they are going to need during the game they will be good.
