Injury Prevention

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Why Do We Focus on Injury Prevention?

Why Do We Focus on Injury Prevention?

When I was an Orthopaedic Surgery resident doing a rotation in a major metropolitan (before I committed to Sports Medicine instead of surgery), I asked one of the surgeons “how about us doing an ACL prevention program?”  His answer surprised me. He replied: “Why would I do that? Repairing ACLs is how I make my living.” I didn’t think that was the right answer, and I still don’t.

As a sports medicine specialist, I have a real commitment to musculoskeletal health ever since entering the field in the 1990’s.  There are three specific ways that Integrative Sports Medicine takes injury prevention seriously for our community and patients.

Here are some of the ways we provde our commitment to injury prevention:

  1. We Partner with stopsportsinjuries.org This is big.  Stop Sports Injuries is an international program initiated by the American Orthopaedic Society for Sports Medicine, and they provide extensive, sport-specific educational materials meant for patients, parents and coaches.  They partner with one medical practice per geographical area, and Integrative Sports Medicine is their local partner. Why? They recognize through discussions with our team that we are committed to the musculoskeletal health of people, regardless of whether they are our patients.  Injury prevention injury information from Stop Sports Injuries is available on our website and can be found here.
  2. Providing the Sportsmetrics program –  Sportsmetrics is the only on-site program proven to reduce injury risk.  This injury prevention program is typically for student athletes age 14 and up and is done at ISM.  It is a physical program that identifies and corrects movement and balance imperfections that can lead to serious injuries such as ACL tear.  Our Athletic Trainer is going through certification in this program and it will be available in February 2019. 
  3. Being mindful of root causes of sports injuries – When you or your loved one is in for a visit, we pay attention to movement patterns that may have caused the pain and/or injury that we are treating at the time.  If we do identify an adverse movement pattern, we do not just let it go. We make sure it gets treated, usually by a Doctorate in Physical Therapy.

Integrative Sports Medicine out of the office and on the field!

Integrative Sports Medicine out of the office and on the field!

Dr. Brad just finished up the season with the Preston Pumas as their football team physician. He donated his time on Tuesday afternoons as well as his Certified Athletic Trainer staff time to be sure that a medical provider was present for the safety of the players. As team physician, Dr. Brad is able to immediately assess players for possible concussion, sprains, fractures, and other injuries. Care decisions are coordinated with the players family, coach, and other medical providers. Follow up injury care is available at Integrative Sports Medicine. By being immediately available, Dr. Brad is able to assist with return to play decisions and help relieve the coaches of that often pressured decision. Thanks Doc!

Youth Sports Injuries

Participation in youth sports is rapidly growing and with that comes a rise in overspecialization leading to an increased risk of injury. Overspecialization is typically seen as those playing a single sport more than eight months per year. According to the Centers for Disease Control and Prevention (CDC) more than 3.5 million kids under the age of 14 obtain medical care for sports injuries each year. Within this overuse injuries account for almost half of all middle school sports injuries. Furthermore, by age 13, 70% of kids quit playing sports due in part to the pressure from parents, coaches and adults.1

Overspecialization in youth sports is increasing as colleges are beginning to recruit athletes at a younger age, which parents often view as scholarship opportunities.2 However, the rise in single sport athletes prior to puberty is causing overuse injuries, emotional and social stress as well as burnout leading to drop out of sports at an early age. Placing additional stress on these young student athletes can lead to anxiety, withdrawing from friends and family, as well as a decrease in recreational play they previously enjoyed.6

Overuse injuries, such as tendonitis, are the number one injury in middle school sports due to the increase in intensity and the repetitive nature of single sport training.4 Stress fractures, lower extremity sprains and strains are also at the top for leading injuries in youth sports.3 More severely, concussions, anterior cruciate ligament (ACL) tears, labral trauma in the shoulder and ulnar collateral ligament (UCL) injuries in the elbow also commonly affect middle school athletes.5 The Nebraska School Activities Association sites that single sport athletes are 70% more likely to suffer an in-season injury over those who play multiple sports.7

With the increase in youth sports injuries comes the need for treatment, specifically by an athletic trainer or sports medicine doctor. How do you know when to seek services from these health care professionals? Medical intervention is recommended for acute injuries when pain is persistent, swelling or locking of the joint is present, there is a visible deformity or in the presence of radiating pain. In the case of an overuse injury, medical care should be sought when pain worsens with continued activity, conventional treatments such as rest, ice, and pain medications are no longer effective and when sleep is disturbed due to pain.8

Many youth sports injuries can be avoided by allowing and encouraging young athletes to play multiple sports, especially at a young age. By exposing youth athletes to a variety of sports it has been shown to increase strength, speed, agility and decrease the risk of injury by promoting neuromuscular balance.6 Rest is also an important factor in avoiding injury in youth and adults. The Sports Fitness Injury Law Group recommends three months of rest from training and competition for full recovery as well as 1-2 days off per week during the competitive season.6 All of these factors may lead to a more enjoyable and healthy experience for young athletes for the duration, and hopefully long lasting future as a student athlete.

  1. American Orthopaedic Society of Sports Medicine website. 2019
  2. National Center for Biotechnology Information, U.S. National Library Medicine
  3. Bechy G, Rauh M. Middle School Injuries: A 20-year (1988-2008) Multisport Evaluation. Journal of Athletic Training. 2014 Jul-Aug; 49(4): 493-506
  4. National Childrens Website. 2019
  5. John Hopkins Medicine Website. 2019
  6. Sports Fitness Injury Law Group. Overspecialization in Youth Sports: The Risk and Rights of Young Athletes (Part I). Feb 2017
  7. Nebraska School Activities Association. Young Athletes and Families Divided Over the Risks of Sports Overspecialization. May 2018
  8. Healthy Children Website. 2018

How to Prepare for a Marathon

Is running a marathon on your bucket list?

Once you’ve decided that you are ready to take on the challenge of 26.2 miles, you want to make sure you prepare and complete your marathon in a safe, injury-free manner.

How to Prepare & Avoid Injury

Plan to take anywhere from 12-20 weeks to train for any running event. Better yet, first train for the building blocks of a marathon. Start with a 5k, then 10k, work your way up to a half marathon and then finally a marathon. Although this will take you longer, it will ensure a safer training routine and help you avoid injury.

First and foremost, make sure you have good running shoes; you’ll be using these a lot. You want shoes that support your foot structure but still allow movement. Most running stores have associates trained in gait patterns and can help you choose a shoe that is right for you and your activity. Shoes have a maximum life span depending on the miles you put on them, so it’s possible that you will need more than one pair when completing your training goal.

It is important to keep in mind that you will not run every day, in fact, you only need to run 3-5 times per week, with your “long run” once every 7 or so days. This will allow you to gradually build your base mileage over the course of weeks. When going out for your run, pick a pace that you can sustain so that you do not slow down later in the run. Built in cross-training days are also important to help you improve your cardio without the stress/impact of running. Moreover, it is imperative to understand that rest and recovery periods are just as important as the runs themselves.

If you are unsure how to start training for an upcoming marathon, there are multiple training programs available online to help you schedule your runs. The program you choose should have you start by running every other day, gradually increasing your mileage, and then increasing to consecutive running days. Keep in mind that if you start to feel pain during or after a run, you should stop and consult a sports medicine physician to see that it is safe for you to continue your training. It is easy to develop overuse injuries if you are not carefully following a gradual training program.

Good luck in your training!

What We Know: ACL Injury Prevention Programs

Over 200,000 injuries to the ACL (anterior cruciate ligament) occur in the U.S. each year. A tear to the ACL puts most people out of commission for quite some time. In fact, recovery from an ACL injury often requires surgical intervention and approximately one year of rehabilitation.

Can You Prevent an ACL Injury?

We cannot control our anatomy, but we can control our movements. ACL prevention programs work to improve how we move in order to help prevent injury. ACL programs typically focus in three area: plyometrics, neuromuscular training and strength training. Many ACL injuries happen when someone jumps and lands. As the person lands, one knee caves in towards the other knee ( an increased valgus knee position)

Prevention programs focus on plyometric training to teach you how to avoid this positioning. A good program helps you understand how you land from a jump by using feedback. You may watch your body positioning in a mirror or you may have a trained person verbally tell you. With practice, proper landing movement can be achieved.

Neuromuscular and Strength Training

Plyometric training teaches you to avoid vulnerable positioning. Neuromuscular and strength training must be included in order to ensure proper movement. When you move, your nerves communicate with your muscles in order to perform movement. With neuromuscular injury prevention training, you focus on correct muscle firing patterns when performing movements. (For example: One exercise might have you work to make sure your quads and hamstrings co-contract).

When we move, we need muscles to fire equally to control our dynamic movements. We need to ensure the muscles have the proper strength to do so. Often, a person’s quads are much stronger than hamstrings. When they contract at the same time, the quads always win the tug of war. A dominant muscle creates an imbalance that makes us more susceptible to injury. A good prevention program will focus on strength training from the core all the way to the feet.

How Long is the Program?

Research shows that the most effective ACL prevention programs are performed at least 3 times per week for 6 weeks. Start the program in pre-season. Continue some of the components during your sport’s season. Plan to spend 20-30 minutes in order for each session. Don’t rush it.  

Devote enough time to each piece of training. Blowing through the program, just to say you’ve completed it, will be ineffective.

Prevention programs are great for people of any age, but research has seen the best results with kids who start at a younger age, usually around 12. They should then continue the program yearly until they are skeletally and muscularly mature. There are several ACL prevention programs out there. We recommend two programs scientifically proven to reduce the risk of ACL injury – Sportsmetrics and Prevent Injury and Enhance Performance (PEP).

Skiing in Colorado – How to Prevent Ski Injuries

Many say that Colorado is home to some of the world’s best skiing and snowboarding, which also means our state sees a tremendous amount of ski injuries. Heavy snowfall and a vast variety of mountain terrain make Colorado ski resorts a terrific choice for skiers and snowboarders of all levels. Colorado also offers unparalleled ski schools, sunshine, and historic ski towns.

Being active in sports has many positive health effects. It can help prevent cardiovascular disease, diabetes, cancer, hypertension, obesity, depression, and osteoporosis. Besides the beneficial health effects of being active, sports participation is of course also associated with a risk of injuries. Being aware of the risk of injuries while skiing and snowboarding is important, as well as making sure that you are protecting yourself, whether it is a knee brace while skiing or wearing a helmet on the slopes.

Do you have knee pain while skiing? Should you use knee support?

A lot of people ask whether they should use a brace when they ski, much like some football players are urged to use a knee brace to prevent injury. After conducting further research on knee pain while skiing, we were surprised with our findings

For skiers with prior ACL injuries, there was a significant reduction in re-injury rate when using a functional, hinged knee brace. So, if you have ever hurt your ACL, stop by and we will evaluate your degree of laxity and what specific braces would be the best for you.

At Integrative Sports Medicine, we stock but do not sell knee braces, and we have no financial interest in bracing, so our advice is objective. From personal experience, I have chosen to use a knee brace while skiing after a football injury and have seen improvements in my ability to maneuver on the slopes. In addition to that, it drastically reduces the risk of re-injuring my knee due to the stability that knee braces can provide.

Human joints need stability. If you are concerned about the impact skiing or snowboarding may have on your knees, or other joints, come visits us. At Integrative Sports Medicine, we will be able to evaluate your joints and help you make the best decision to enjoy your time on the slopes.

Potential of Concussions from Skiing

In snow sports, helmets really do matter. As a fairly late adopter of helmet use while skiing, I was lucky enough to leave the slopes without any severe injuries. After seeing my navigate down Big Chute at Crested Butte, my wife mandated I purchase a helmet. As we’ve seen, many skiers and snowboarders choose not to wear a helmet, for various reasons. At Integrative Sports Medicine, we recommend all skiers and snowboarders wear helmets on the slopes, regardless of your skill level.

We tend to see the majority of concussions stemming from two groups, males and snowboarders. This statistic can be explained easily by their behaviors, and their lack of desire to change them. Over the past four decades on the ski slopes, we have noticed a slight improvement in the amount of males and snowboarders adopting helmets. An injury on the ski hill is capable of causing a traumatic injury to your brain, including concussions or even worse.

Interesting Ski and Snowboard Injury Facts

• In the terrain park, the number of turns or spins made correlates with injury more so than the distance traveled.
• Landing on a flat surface or the knuckle of the pipe increases the rate of falls.
• Staying within your ability level will reduce the risk of injury while skiing/snowboarding.
• Collisions are a major cause of ski and snowboard injuries. Find runs that are not as crowded, and are less likely to have multiple riding styles can reduce that risk.
• New ACL-Preventing bindings compliment your body’s biomechanics and can be a potential way to reduce ski injuries.

Overall, when skiing or snowboarding, it is important to be aware that a major injury can always happen. Be mindful of various risks on the slopes.

So, have a great and safe day on the slopes! Brad Abrahamson, MD

Brad Abrahamson, MD is the designated Northern Colorado Affiliate of Stop Sports Injuries. Here are some additional tips from them.

Is Bursitis a Real Diagnosis? A Functional and Integrative Medicine Approach

Diagnosis is the first step in getting better treatment plans. A Functional approach assesses the whole patient, considering underlying causes in a serious way. Functional medical thinking refuses to accept the presenting symptom as the entire picture. It leads to a diagnosis that is more holistic and more specific. The integrative approach then utilizes several treatment approaches to get a much more comprehensive set of treatment options. Integrative sports medicine asserts a true team approach, where the team synergistically employs the available skills, techniques and treatments, utilizing any or all parts of my skill-set, and most importantly any and all of the therapeutic community.

Bursitis

A bursa is a friction-reducing structure between two things in the body that move. It is a “potential space,” like a water balloon with just a tiny amount of lubrication inside so that whatever is attached to one side can freely glide against whatever is attached to the other side. I’ll give two examples. First, the subacromial bursa. This sits between the rotator cuff and the acromion bone at the top of the inside of the shoulder. It allows the rotator cuff, which moves a great deal, to glide by overlying structures such as the acromion bone, the end of the collarbone (clavicle) and the deltoid muscle, do not move much compared with the rotator cuff tendons.

Figure 1: Subacromial bursa of shoulder, Courtesy AAOS (see above)

A good second example would be any of the bursae around the greater trochanter, which collectively are called the “trochanteric bursa.” These bursae allow movement of the muscles overlying the greater trochanter against themselves and against the bone. The tensor fascia lata, has to glide against the iliotibial band, and both of these structures are muscles with a big, wide band of tendon. All the muscle-tendon units have to be able to glide over the greater trochanter. The trochanteric bursa allows this by greatly reducing the friction.

All bursae are subject to becoming inflamed, and typical medical advice includes icing, taking NSAIDs, and sometimes progression to corticosteroid injection and even surgical bursectomy.

My take is that all these therapies miss the point. They miss it because they assume that bursitis is the entity. To the contrary, bursitis is a side-effect. To get a diagnosis that can lead to a cure rather than a band-aid approach, integrative and functional medicine need to be employed.

Functional Medicine as the Basis of Diagnosis and Integrative Medicine as a System of Treatment

If you are reading this, I am guessing that you have a sense that there is something terribly wrong with how traditional medicine is being presented to you. You are right. It is not just the money machine, not just “Big Pharma” and not just the unreasonable time pressure your doctor faces. Traditional medicine is at times fundamentally flawed by cognitive errors which are sometimes intertwined with the system errors within medical bureaucracy. There are many cognitive errors in medicine (see https://www.jround.co.uk/error/reading/crosskerry1.pdf). Functional medicine is a step towards correcting some of these cognitive errors that lead to superficial or spurious diagnoses.

Functional medicine looks for underlying causes in a serious way. It’s not just “you contracted bursitis from overuse.” It is more like, “you contracted bursitis because the adjacent tendon/muscle use is under chronic strain due to an adverse biomechanical pattern, under-recovery, sub-optimal nutrition and other specific factors.” This gets to why bursitis should not just be squelched by a steroid injection, but the underlying reasons it happened in the first place should be addressed. Here is an example of how Functional thinking might occur in a certain patient with a subacromial bursitis.

  1.     The patient has gotten “out of shape,” leaving the tendons adjacent to the bursa unhealthy.
  2.     The person got “out of shape” because of work and life stressors that reached a breaking point, leading to the patient taking less time to rest, sleep and exercise;
  3.     Because of time pressure and a shift of priorities from good health to making deadlines, good nutrition such as an exuberant intake of vegetables and a control on calorie intake went by the wayside.
  4.     Because of the inadequate intake of micronutrients (vitamins in food) and rest, tendons are not able to heal from day to day.
  5.     Because the tendons are under stress, the patient takes NSAIDs (non-steroidal anti-inflammatory medications) to deal with the pain. The NSAIDs compound the problem by blocking an “inflammatory” biological pathway in connective tissue healing. This compounds the underlying tendon healing problem.
  6.     Because the patient realizes they are “out of shape” they start exercising, but not with good form and beyond their current ability level, thinking about an earlier era in their life when certain effort and repetitions did not lead to problems. They do military overhead presses which stress the rotator cuff tendons in the shoulder and mechanically damage them by impinging on the acromion bone.
  7.     Because of the impingement, under-nutrition and under-recovery, the rotator cuff tendons begin to develop micro-tearing.
  8.     Because of the micro-tearing, the rotator cuff tendons develop micro-tearing of their collagen sub-units, the collagen fibrils. If I am lucky enough to see the patient at that point, I can see these small injuries on in-office diagnostic ultrasound and address the problem before it progresses to a rotator cuff tear.
  9.     Because tendon micro-tears don’t hurt badly at first, all the above processes continue unabated.
  10. Because the patient is un-aware of an impending problem, they continue to do military overhead presses, and the impingement problem is ever-worsening due to the progressively bad biomechanics that results from a sub-optimal rotator cuff.
  11. Eventually micro-tears of the rotator cuff release enough inflammatory mediators that the sub-acromial bursa becomes inflamed.  In addition, by this point, there is likely a partial tear of the rotator cuff.
  12. The point of this is that the “bursitis” is not an isolated inflammation of the bursa that came out of no-where. It is a result of the adjacent tendons trying to heal from chronic micro-tearing.

At this point, most clinicians are trained and time-pressured to identify and “treat” the bursitis. They are using System 1 thinking, the immediate, emotional response of what seems right (see https://bigthink.com/errors-we-live-by/kahnemans-mind-clarifying-biases for a quick look at that).  Then the doctor might jump right to “inject the bursa with steroid” (unintentionally by often harmful) and move on with the day. In contrast, the Functional approach is to consider all 11 (and more) of the above factors causing the bursitis and deal with each one. This is System 2 thinking.

As you can see, bursitis is not a self-explaining entity and is not a satisfying diagnosis that can be treated with corticosteroids or surgery. Corticosteroids mask the underlying problems and shut down healing processes.  Surgery removes an essential structure. This is where functional and integrative sports medicine comes in. Now, we can think about biomechanical causes while we watch the patient walk, thrown or run. We can find out if they need nutritional help, and we can find out what type of physical therapy will help solve the underlying problems. Sometimes, as in my last published case of the youth pitcher, all we needed to do was link the existing coaching information for the patient into a single pitch, and the stress on the painful joint is relieved. Occasionally biologic and cutting-edge therapies may have a role. Integrative medicine takes a multi-disciplinary approach, for a more permanent and natural solution.

To summarize, a functional approach assesses the patient, adds up the underlying causes, and refuses to accept the presenting symptom as the entire picture. It leads to a diagnosis that is more holistic and more specific. The integrative approach then utilizes several treatment approaches to get a much more comprehensive set of treatment options. Integrative sports medicine asserts a true team approach, where the team synergistically employs the available skills, techniques, and treatments, utilizing any or all parts of my skill-set, and most importantly all the therapeutic community.

Did my 9-year-old throw his shoulder out playing baseball?

Did my 9-year-old throw his shoulder out playing baseball?

A baseball parent recently came into our clinic with his son. The 9 yr-old pitcher was experiencing shoulder pain in the top and back of his dominant throwing arm, but only when he was throwing a ball. Because he played on an active club team,  his arm had few days off from throwing and catching.

While playing the battery makes you an effective baseball player, it can be hard on the body. That’s because this position combines both pitching and catching, resulting in the most throws per week of any position combination in baseball.

To figure out what was going on, we brought the young ball player into the Integrative Sports Medicine office for a throwing and pitching analysis using his own baseball equipment. Our analysis led us to some very interesting observations.

Throwing and pitching analysis

We asked the young boy to bring his baseball gear and demonstrate an authentic throw and catch that he may do during a game or practice session. During the assessment we asked him tons of questions so we could understand the full context to his situation.

What was uncovered:

  1. Muscle overcompensation
    Lackluster power generation in the thigh, butt and back muscles led to an overcompensation in the shoulder. He also tended to drop his elbow and throw with more displacement of the elbow when tired or unfocused. This was creating increased stress on the shoulder and elbow. An imbalance of arm velocity is developmentally normal for a 9/10-year-old and is fixable in a gifted and coachable student-athlete.
  2. Chronic shoulder pain and problems
    Physical exam findings consistent with mild, chronic and repetitive shoulder impingement, likely as result of sloppy arm control during follow through set up by imperfect mechanics from cocking phase through delivery. He also has congenital shoulder laxity (multidirectional instability or MDI). This is consistent with his mother being a hitter in volleyball and also consistent with his ability to put his shoulder through a large range of motion, which in part correlates with arm and ball velocity.
  3. Regular ultrasound results
    A basically normal ultrasound showed mild fluid in the joint but nothing severe. There were no torn structures.
  4. Back to baseball basics
    By asking lots of questions about his past training, we could tell that he knew the basics of how to throw a ball. Due to his age-appropriate brain development, he did not actually realize that he had already gotten pitching coaching but had not consciously linked the throwing elements into a sequence during his pitching motion. He didn’t realize that the purpose of his coach’s drills were for which is completely normal for a 9/10-year-old kid. In fact, when he followed the fundamentals that his coaches had already taught him and put them all together, he had a very good to excellent motion and no pain at all.

The most interesting part of the throwing analysis was that the patient was able to correct his throwing “errors” simply by getting him to remember his deliberate coaching. His coaches have come up with cleverly worded drills to get players to use other muscle groups that activate supportive muscle groups, such as the gluteals, to throw from the lower extremity and back.  For example, when the player incorporated “fart and flush” and “towel drill” together within the same pitch, there was less force on the shoulder and elbow and yet the pitch came in with excellent pace and accuracy. Another observation is that the patient reported a history of throwing for a radar gun, which is common, but in modern Sports Medicine is recommended for all student-athletes at all times.

Raising student athletes

This is a student-athlete who is lucky enough to play in a very sophisticated system of baseball. By dissecting his coaching tips, linking them into a single throw and correcting a tendency to drop his elbow when fatigued or not paying attention, his throw was completely fixed (for now) and he threw better and with less shoulder pain.

It is difficult for a coach to have time to spend large amounts of time with every individual thrower on the team to assess where the player is cognitively in understanding what he is being taught and how to use it.  There are literally not enough hours in the week when dealing with schedules, rosters, parents, and leagues, not to mention the other jobs and family responsibilities coaches have.  However, it is possible for a 9/10-year-old to understand and correct a throw when the coaching base is there and a thorough examination and analysis are turned into a conversation with the student-athlete coupled with actual throwing in real time.

Our success this time had everything to do with having a well-coached student-athlete with very supportive parents with great communication skills and not excessive pressure on the child.  All that made my job a lot easier. It’s important to keep the long-term in mind and not this year’s radar ratings and winning percentage/ERA and championships at the forefront.  I struggle with this myself as a parent.  These are children, not professional athletes and it can be hard to remember (just not in this case) how young they are at times.

From our research-filled and parent and coach friendly website, https://www.stopsportsinjuries.org/ with which I am the official affiliate for Northern Colorado, the max pitches you are allowed to throw per day at this age is 75 pitches, with outings being 4 or more days apart.  This is based on a lot of guesswork and common sense about what we are seeing, admittedly, and not particularly rigorous, hard data.  Despite our shortcomings as scientists, it is fair to agree with the book The Arm by Jeff Passan.  We are in an epidemic of shoulder and elbow injuries occurring at younger and younger ages.  Jeff Passan’s book mainly deals with the epidemic related to Tommy John surgery, so it can be more featured in a future article about the ulnar collateral ligament, but the epidemiology of injury also applies to shoulder overuse injuries in throwers.

Further commentary: there is no role for corticosteroid injections.  These student-athletes need healing time and activity modification, not a drug that shuts down healing, weakens connective tissue of the body and masks injury.  For an older player, regenerative medicine could be appropriate.  A 10-year-old has plenty of growth factors and stem cells in the area of any injury, so changing the biomechanics of the throw and allowing time for healing should be completely sufficient and no medical procedures should be needed.

This player was returned to play on a limited but increasing schedule to be supervised by parents and coaches, including the use of pitch counts and frequent check-ins with the player as to whether he is experiencing discomfort.  If we have learned nothing else over the past 100 years of baseball in this country, it is that injuries can start with minor discomfort, which if ignored can become major injuries with just a few more pitches.  Communication between players and coaches needs to be nurtured into an environment of comfort, honesty, and complete transparency.  We all know that is a major feat when dealing with pre-teens and teens, but it might be the best thing we have to prevent minor injuries from becoming life-changing injuries.

Check out:

https://www.stopsportsinjuries.org/STOP/Prevent_Injuries/Baseball_Injury_Prevention.aspx?WebsiteKey=22144c04-3260-4510-b318-8b5768345a42