There are significant discussions taking place daily around water company coolers specific to health care reform and specifically how it will impact Americans – rich and poor; insured and uninsured.

As an Athletic Trainer, and more specifically as an Athletic Administrator – I dealt with the administration of health care benefits of student-athletes on a variety of athletic budgets from a Division III school (Lenoir-Ryhne College) to a FCS school (Appalachian) to an elite Southeastern Conference school in the NCAA Division I (South Carolina). Further, the NCAA now allows member institutions to cover any and all medical benefits/medical services to student-athletes.

While Congress has not created this law to deal with health care specific to student-athletes, Athletic Administrators will now have to see how this will impact what they are providing as they are faced with the challenge to cover those portions of health care charges not covered by either primary accident insurance, excess accident insurance (purchased by the institution) or managed care programs negotiated by the institutions.

I certainly have enjoyed researching this subject as I prepare to present to the Mountain West Athletic Trainers and Team Physicians at their annual conference meeting in Las Vegas, Nevada May 1st, 2010. My challenge will be to interject my thoughts specific to “The Effect of Health Care Reform on Intercollegiate and Professional Sports”. How will this significant event impact the provision of care by Athletic Administrators, and will this reform increase the responsibility for institutions and professional sports clubs.

Back in the eighties, the Team Physician at Lenoir-Rhyne College questioned whether injuries sustained by high school football players caused more osteoarthritis. We engaged a study, to independently examine members of a local high school during their twenty-year class reunion. The subjects were examined independently by orthopaedic surgeons to determine any orthopaedic pathology which could be objectively assessed. Further, they were radiographically examined by a radiologist.

The findings were quite interesting. As one might expect, there was radiographic change merely due to the age of the subjects. However, those patients who had good medical care seemed to have less osteoarthritis. Further, patients who had undergone open surgical procedures had much more osteoarthritis than those patients treated arthroscopically.

Remember, this was about the time of the invent and advancing of the arthroscope in orthopaedics. However, the takehome message was clear – injuries were not the culprit for osteoarthritis, but possibly either the fact that grosser injury warranting open surgical intervention or the mere fact that the patient was treated with an open procedure.

The complete article is referenced below. I enjoyed working with these professionals on this article. While I learned a great deal from these peers, I probably gleaned ever more from the research and clinical process as I continued my career at other schools.

Moretz, A., Harlan, S., Goodrich, J., and Walters, R. (1984). Twenty year follow up of High School Football Injuries. The American Journal of Sports Medicine.

As an athletic trainer, I have always felt two places prophylactic braces can’t help: 1. around the ankle or 2. in the locker. Needless to say, if the brace is not comfortable, doesn’t fit, or just doesn’t feel right, the athlete is not going to wear it. I think that is one of the beautiful parts of the new functional custom-fit knee braces. They provide superior protection against knee injury as thigh and tibial cuffs have snugger, firmer fits. Donjoy has even changed the profile of the upper thigh cuff making it sleeker and conformed to the anatomicaol features of the thigh. The hinges are lower profile making the brace much sleeker than designs of the 80’s and 90’s. Braces covered athletes’ knees more tightly and provided more protection for soft tissue.

Functional Brace Use
Functional knee braces provide restraining influence to control abnormal displacements of the knee and decrease anterior tibial translation without associated contraction of the musculature of the lower extremity. With the ACL-deficient patient, brace use resulted in fewer episodes of giving way and utilization of the brace gave perception of stability in the knee.

Unilateral vs. Bilateral Hinges
When deciding on style of brace to use, Liu reported brace designs incorporating bilateral hinges and rigid shells were more effective than unilaterally hinged designs in transmitting loads8.
In the 2000 edition of Biomechanics, I reported on the comparison of knee injuries from the 1997 University of South Carolina football season when players used traditional lateral braces, vs. the 1998 season when we made the shift to custom fit knee braces that are now common. While the scope of this study is limited, the results are nonetheless very revealing as the data illustrated a substantial drop in the number and severity of knee injuries incurred. The use of the newer custom fit braces resulted in a drastic reduction in the amount of time loss (performance) by athletes as well as a drop in economical impact (medical expenses for knee injuries) for our football program.
Further studies on the subject have since supported my early findings on the ability of custom knee braces to help athletes avoid injury and the coaching and athletic training community has responded by making the use of knee braces by athletes common. In 2003, we conducted a survey to quantify prophylactic brace usage among NCAA Div I and I-AA institutions and found that over two-thirds of the institutions responding reported embracing prophylactic brace principles for their offensive lineman in their football programs. With the cost of major knee surgery averaging around $26,000, the cost of a knee brace is minimal in comparison, never mind the loss of time and eligibility by the athlete and the possible drop in performance level a major knee injury can present. In 2004, 24 of the top 25 ranked NCAA Div I football teams mandated the use of knee braces to avoid injury. This rise in popularity has not happened by accident. As an athletic trainer, I believe the increased incidence of bracing has evolved both due to increased awareness and primarily due to the superior design and construction of the braces. With research from functional knee braces following anterior cruciate ligament reconstruction, we know how the braces can minimize force production on the ligaments and further apply these concepts to functional activities in rehabilitation and activity.
I think physician and health care team members need to totally understand the concepts of prophylactic bracing when making recommendations to coaches, athletes and parents relative to this subject. Why else would these teams utilize this technology if it did not work? As I watch college football each year, the players at Florida, Ohio State, Oklahoma, Georgia, South Carolina, Florida State, Notre Dame – to name a few – have embraced prophylactic braces principles, and effectively utilized this to protect their player’s knees. Today’s discussion of prophylactic bracing is totally different that the bracing concepts discussed in the 1980’s. Those braces worn in sport were lateral braces and simply diffused the forces following lateral valgus blows to athlete’s knees. Today, the braces are functional kneed braces with double upright hinges with biomechanical design to vector force away from knee ligaments.
I have had several athletes bring their brace in to me following a practice or game and the brace is bent beyond belief, and may even be fractured! The design dissipates forces effectively and these players walked away from injuries with mild sprains. This scenario often is a heralding activity for the athlete and further substantiates brace usage. I must say, it is a sickening feeling when you examine an athlete and realize that their medical collateral ligament tear and possible anterior cruciate ligament tears which were received from a clipping injury, would have been minimized and probably prevented with prophylactic brace use as the force would have been dissipated laterally, and the double upright hinge would have also resisted the force medially. Today, coaches, parents and athletes in high school sports are realizing that spending $350 on a standard knee brace, or even $600 for a custom brace, can be a wise investment in the effort to protect young athletes from significant knee injuries – injuries that not only can hamper a promising sports career, but also adversely affect a wide range of activities and lifestyle in later years. And to do their part in supporting this trend, manufacturers are making it easier and more affordable for high school coaches and parents to outfit their athletes in prophylactic knee braces with programs such as DJO Inc’s “Join The Club” program.

The Future of Knee Bracing
The bracing industry is constantly seeking newer technologies to apply to the bracing needs. Just look at how materials which are introduced rapidly make their enterance into the industry. Further, as newer and more efficient hinges and brace composite materials evolve they product is every improved. Donjoy’s new dampening hinge has been well received in the Sports Medicine community, and is now even being fabricated in a lower brace profile. Athletes seek sleek, clean designs that work. Remember the two places braces don’t work: in the locker and around the ankle!

For some coaches and athletes the term “knee brace” conjures the unpalatable image of Joe Namath and his big, bulky Lennox Hill brace from the seventies. However, the reality is very far from that. Knee bracing in sports has rapidly evolved over the past twenty-five years with braces becoming comfortable, highly functional and commonplace in many sports – not only to help athletes return after injuries, but to protect against certain injuries in the first place. The progress that has been achieved in bracing is important for high school coaches, trainers and athletes to carefully consider.
This improved efficacy of the knee brace, particularly on a prophylactic basis, is well documented by research and very evident in the wide usage of braces among college athletes and sports programs today. As demonstrated by the studies and other data discussed below, braces today are an important and valuable piece of equipment that should be evaluated as early as the high-school level of athletics.
Back in 1984 the most common knee brace was the single hinge lateral brace used primarily in football and it was not really designed to help players avoid injuries. In fact the American Academy of Orthopaedic Surgeons didn’t even consider injury avoidance as a primary function of knee braces due to its construction and studies of the day were split on its ability to prevent injuries. Today, however, multiple studies now show that modern braces have the ability to effectively control rotational forces which produce injuries in knee ligaments. The most significant development in that evolution has been the introduction of custom fit function knee braces.

What We Find in Studies:
It is important for physicians and athletic trainers to advise athletes appropriately relative to protective equipment. Recommendations for protection require understanding of biomechanics and anatomy. Prophylactic braces were initially designed to restrain abnormal knee motions, and the knee braces have now progressed to provide functional stability.
Proper application has shown effective with the laterally applied prophylactic lateral brace as there was a decrease in valgus force application to the knee joint, often the culprit of injury to medial knee structures Physicians and athletic trainers commonly use prophylactic knee braces to protect the knee from impact forces. The principal factors that determine the impact response characteristics of a brace-knee composite are force distribution, energy absorption, and energy transmission. Material properties and the mechanical design of the brace are important factors in determining brace response to impact. The impact response can be quantified by applying lateral loads to cadaver knees and surrogate knee models. With the knee in full extension, prophylactic braces are limited in their capacity to protect the medial collateral ligament from direct lateral stress. Laboratory studies, using a surrogate knee model, concluded that preventive braces absorb 15-30% of the energy of a direct blow.

Various authors have reported on the positive effect of prophylactic bracing on the incidence and severity of knee injuries while Grace et al., and Teitz et al. reported bracing increased knee injuries. To validate the impact of prophylactic braces on this population a retrospective investigation attempted to control many of the known biases and utilized a large sample from a variety of institutions.

Flexibility training is just as important as strength training for the total development and conditioning of athletes. Especially in the injury phase, we encourage stretching before and after workouts. Flexibility is defined as range of motion at a joint. It is generally felt those athletes with loose joints are more susceptible to sustaining sprains of their joints, while those with tight joints are susceptible to strains of the muscles and tendons. This has been studied in the high school, college and professional ranks. Nicholas found flexibility to be a predictor of injury in professional football athletes, while Moretz et. al. found it not significant in high schools. Basically, the protocol identified five basic flexibility movements—each performed individually by patients. Those completing two or more tests were identified as “loose-jointed” versus “tight-jointed”. Flexibility training is a key ingredient to the total conditioning of the athlete.
Stretching can take on two types of looks. The traditional stretching technique is the ballistic stretch or bouncing stretch. This has been shown to be contra-indicated for flexibility as it actually causes muscles to tighten and can lead to more muscle strains.
The advocated type of stretching is the static stretching where muscles are held for a continuous stretch for six to ten seconds. This promotes elongation of the muscle fiber and the flexibility is maintained for two or three hours of a workout. Should you ever start to sustain more muscle strains with your teams, you should look at your flexibility program and modify things to promote a elongated elasticity throughout the workouts.

In addition, flexibility after exercise is as important as pre-workouts. Encourage athletes prone to muscles strains to stretch before, during and after workouts. When stretching following activity, they return muscles to their supple elongated state. Also it aids in post recovery muscle soreness and also promotes circulation in ridding the muscles of waste products.

In summary, flexibility can be an adjunct to conditioning and rehabilitation programs. Athletic Trainers, Strength Coaches, members of the coaching staff should all encourage aggressive approaches and compliance with flexibility exercises.

The news is replete the past few days relative to how coaches handle players. The firing of Kansas football coach certainly brought the topic to surface. More recently, the accusations by Texas Tech players and family fueled this fire.

My point is merely, there are different ways to handle injured athletes. I think it prudent to realize there are several issues worth reviewing/addressing here.
1. The physicians and athletic trainers should handle health care and the supervision of injuries and related matters.
2. The literature is supportive of rest following concussions. I don’t think the literature supports isolation in a room. The placement in a dark room would certainly make sense for a post-concussive event; but I think the application of this procedure could have been better implemented. From reports from the physician and athletic trainer involved; this request was mandated by the coach.
3. Administrators need to empower health care teams to care for injured athletes without influence of coaches. The NCAA put this into a rule relative to dealing with heat illness and conditioning activities. Funny that the NCAA had to make a rule for this autonomy to be provided to the health care team.

We cannot legislate or mandate ethics. Administrators need to make sure student-athletes are afforded a standard of care – and it is important administrators make sure that health care is objective and valid. The student-athlete does have a bill of rights!

Needless to say, I write this from the point of view of the health care team. Athletes have rights, and we need to make sure their safety is provided while they participate in a safe environment.

Athletic Trainers, Team Physicians, Coaches, and Equipment Managers need to warn players about the potential cataststrophic events which could occur using helmets and shoulder pads. The recommendations is to warn players about the potential of heat illness being exascerbated by protective equipment including helmets and shoulder pads. The article can be found at .

As I reflect on my career in Sports Medicine / Athletic Training, dating back to my college days studying Athletic Training in the seventies, there certainly has been a lot of evolutionary change in the area of management of health care data. I recall the early days when Appalachian’s Head Athletic Trainer Ron Kanoy filled out NAIRS forms weekly, and returned them to Penn State where the research was conducted. Those were the days of injury surveillance. Basically, these were data collection to look at the incidence of injury and researchers made scientific statements and recommendations relative to the prevention of injury and training and conditioning trends. Read the rest of this entry »

Over the recent years, interest has grown significantly relative to injury (especially of the lower leg) and sport surfaces. Are players getting injured due to changes in surfaces, are the infill synthetic turf leading to more injuries, or are there certain shoe types that are precluding injury?
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I’d like to share some thoughts on cost containment relative to the administration of health care in today’s collegiate athletics. As I reflect on my 28 years of service to this sector, the ability to provide the highest level of care in an economic means is a challenge. As a rule, institutions have been more willing to pay non-covered medical expenses of student-athletes at a greater rate in Division I, with less willingness in lower divisions. The financial ability is just greater to provide such services in the higher level divisions.

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