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Scott Webb: While having our kids involved in sports is good for their health and wellbeing, it can also lead to injuries. This podcast will help parents and guardians know when it's time to head to the orthopedic walk-in clinic or to make an appointment to see a doctor for those sports-related injuries. And joining me today to help answer many of the questions that we all have is Dr. Brenton Bohlig. He's board-certified in Sports Medicine and Physical Medicine and Rehabilitation with Genesis.

This is Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. I'm Scott Webb. So doctor, it's so great to have your time today. As a dad of two kids myself who played a lot of sports over the years, this is certainly a relevant topic for me. And I'm sure it is for listeners as well. So I want to start by asking, should parents consider having their children seen by a doctor before they start playing sports, you know, even if a sports physical isn't required?

Dr. Brenton Bohlig: In terms of physicals, we just did hundreds of them for the upcoming fall seasons, but it can vary by age and activity level and if there's any prior issues or conditions that you might be concerned with. Generally, I'd say if your younger child, elementary level going into activity, if you're not really having any complaints or they're saying they're having issues or you notice difficulty with playing around with friends or at home, a physical is not necessarily needed, because most of the things we would identify or be worried about would be seen in like an annual pediatrician checkup or something of that nature.

So when it gets into like 7th grade to 12th grade, that's when, at least in Ohio, high school requires a pre-participation physical exams. So in that regard, then we would suggest you have them. And we do those here in our clinic and do them before the season, but we can also do them throughout the year as well, depending on when their season may be.

Scott Webb: Yeah. And as you say, obviously, most of our kids have yearly checkups with their pediatricians. So any of those types of issues can be brought up then. And then if they're about to play sports, but they maybe don't need a physical, you know, case-by-case basis, if you think your child needs to come in, then have them come in, have a physical, whether it's required or not.

And, you know, when we talk about our kids and trying to avoid muscle strains and pulls and things like that, I always used to tell my kids and still tell my daughter, "Hey, make sure you stretch," you know? And she says, "Sure." And then I see them not stretch and they just start playing. Is there anything we can do as parents to help them kind of avoid those muscle strains or pulls during sports?

Dr. Brenton Bohlig: So you're on the right track. You know, stretching, it's more like warm up, cool down. Those are types of things that can help get you ready for more intensive activity. And then after, as you say cool down, kind of get some of that lactic acid that might build up in the muscles, kind of let that dissipate and reduce some of the soreness and injuries that might come after.

Not just that though. I mean, big thing, especially with kids, is just general overuse, which we can get into a little bit here or maybe later. But hydration is another key fact, especially in the summer. It's humid, a lot of that. So if you're under-hydrated, you know, dehydrated state, increased risk for injuries, especially musculoskeletal.

So just a few things I wanted to bring up here. When I try to educate some patients, there's some good information out there on the web. One coming from TeamUSA and it was basic kind of rule of thumb for hydration, is take your body weight divide it by two and then that's the number of ounces of water you should have a day. Now that can seem like quite a lot, but especially if a kid's active, they'll need it. They're going to be burning through that and really need that for high level activity. So right before activity, good to have 16 ounces of water. During activity, they say every 15 to 20 minutes, few sips here or there. And then after, another basically like a small water bottle and that can help really provide the, you know, good situation, good environment for those muscles while incorporating some of that warm up, cool down.

And then the other thing, and I think, I would elaborate on it a little bit more is just overuse. If I could address that here, it's probably one of the biggest things that causes injuries in youth athletics, it's just they're doing too much. Of course, we want them to be active. You want to play sports, do things, all of that's great. But it can be too much at times.

So some of the general rules and some of these come from the National Athletic Trainers Association and the Journal of Athletic Training, there was a good article from October of 2019 that showed some recommendations for youth activity to avoid injury and burnout and things like that. One would be delaying specializing in a sport for as long as possible. So the younger they are, play more sports, you know, different things each season, get a good variety. Another one is try to only have one team at a time. So in the summer, maybe just playing one sport; in the fall, you know, another sport, but not two, three teams at a time. It just can kind of be a little too much.

Another rule of thumb there is try, especially adolescents, younger kids as they growing, try to limit activity to about eight months a year, so essentially one season off from sports. Don't want to overload them, have them go all year round, just not enough rest incorporated there. And a good thing I share with patients here is try to have no more hours per week than the age in years. So if you're a 12-year-old child, try not to participate more than 12 hours per week in an organized sport. And probably one of the most important things that can sometimes be tough is just having at least two days of rest per week, so two days where you're not having to practice a game or other competition. I think all those incorporated, that can really help limit the overuse injuries in muscles, those strains, the sprains, and anything else that can kind of limit their activity level.

Scott Webb: Yeah, those are great tips and suggestions. And I know it's tricky with travel sports. You know, that a lot of these sports have become year round. When they're not playing games, they're practicing, they're lifting, they're hitting, whatever it might be. And it can be really difficult when you have young active kids just to kind of reel them in, to hold them back a little bit. They're like these thoroughbreds, they just want to run. They want to go, you know, and we're all trying to do right by them as parents to avoid the strains and pulls and overuse and concussions as well. So I want to ask you, what are some of the signs of a concussion that children may experience while they're playing? Like, how can we tell that something's wrong? And, you know, we know from watching football and soccer and some of these obvious signs. But maybe what are some of the less obvious signs that a child, our child, might have a concussion?

Dr. Brenton Bohlig: Yeah, great point. So there are definitely those obvious ones, you know, the red flags. Loss of consciousness, maybe repeated vomiting, a very severe headache that won't go away, you know, they're not responding. Those things where you're like, "Okay, this is not right." That's more of a let's have them looked at in the emergency room type of situation.

But then there's a very small percentage of head injury and concussion, those are just the ones you can kind of hear about or remember, but the, you know, every day bang their head, maybe playing soccer or something, things you want to look for there, there's a whole list, but some of the stuff that I try to draw attention to would be, first off, nausea or vomiting pretty soon after. And then you look for dizziness, vision changes, whether it's blurry or double vision. Balance changes is another big tip-off, if they don't seem like they're walking quite right or feeling like they're going wobbling side to side, like they're on a boat or something. Feeling a little slowed down or foggy. Just not feeling right. I mean, these are questions we'll ask in an evaluation, like, "Do you feel off? Do you feel like things are just slowed or you're in a fog?" What comes with that is difficulty remembering, concentrating. And then also emotional changes, they're a little more irritable. Might be feeling a little more down or sad than normal. And these are things that may not appear right away. It could take a few days. So it's tough right on the spot to determine sometimes unless it's some of those more obvious symptoms.

But that's the thing, I mean, that's the tough part with concussion, is everyone's different, everyone's going to have a different recovery and their symptoms may not be the same even from one concussion to the next. So it does take some training to recognize that and kind of help guide through. But the good thing is, again, high percentage of these, you could have symptoms for only a few days and feel better later that week. Most people will be back to normal within that two to four-week time period. But again, severity and how you feel will decrease with time.

Scott Webb: Yeah. And it does sound like a sort of a case-by-case basis, maybe a sport-by-sport basis. And when do you recommend we would bring our kids in, if they're only maybe experiencing one of the symptoms? Do you recommend that they come in to the clinic, the orthopedic walk-in clinic, and be seen immediately, or give it a couple of days? What's your recommendation?

Dr. Brenton Bohlig: If you suspect a concussion and, you know, they're still obviously still conscious and able to be present and mindful of what's going on, all those things, first off, as I didn't mention before, but if you do suspect concussion, it's now mandated state law, basically every state in the country is you must come out of activity for the remainder of that day. So I think everybody's kind of familiar with that now. But that next night, the next day, if your child is still having some of the things I discussed, like maybe there's sensitivity to light, maybe the noise bothers them, maybe they're feeling dizzy or off, if it's more than that first 24, 48 hours, that's when maybe you'd like to be seen, I'd recommend probably call because we'd like to schedule you to have you set aside some time to really go through things. We also through Genesis offer a great concussion clinic where our physical therapists will be able to get you in within a matter of days to really assess and start working on the scoring and how we look at the symptoms, but then also physical therapy and what we call vestibular therapy, which is balance and recovery of coordination and vision and all those different aspects.

So I wouldn't necessarily say come into the walk-in right away because, initially, I'm going to want to have the patient rest for about one to two days. And then after that, if you're still having some problems with a lot of those symptoms we discussed, then it's okay I think to be assessed and we can kind of determine how severe this is, what kind of things we might need to do, what kind of modifications to make, because large majority of these will improve with just basic it's going to be rest, attention to some of the details of the symptom. And the golden rule with any concussion is don't do anything that's going to make symptoms worse. So if you do something, you're reading, you're looking at computer screen and you start to get a headache or blurry vision, then that's your brain, your body, telling you that, "All right, we're not really ready for this yet." You kind of got to kind of pull back and maybe give it another day. Maybe break it up, like if it's homework stuff, you just do maybe 15 minutes at a time, so you're not getting those symptoms. That just moves the recovery and kind of lessens the time.

Scott Webb: Yeah, definitely. And I know that it seemed to me like when I was a kid, if you suspected a concussion or diagnosed with a concussion, you know, the recommendation was to basically just do nothing, to just lay there and do nothing. But I know that there's more of a push these days to take a little bit of time off, sure, to rest, relax, close your eyes. But to start to slowly get back into things, to do things that you can do, as you say. But when it becomes a problem or your eyes are bothering you, whatever it might be, then you can pull back a little bit. And if the symptoms persist, then a phone call or walking in would be recommended.

Dr. Brenton Bohlig: There's research showing that rest more than three days is not any more beneficial than one or two days. So it's not lock yourself in a dark room and do nothing for a week. It used to be. Like when I was first in training, that was kind of the thought, but now, no. Twenty-four, forty-eight hours, then after that, you really want to start getting your brain active, which is doing first like school activities. So whether it's reading or trying to do some homework or something like that, see where you're at. And then if those symptoms come up, you back it off and we just kind of day by day work on that.

And then once that's better, then you get into the physical, doing light exercise, walking, take your pet out for a walk, just kind of go around the house or the backyard, do things at home that aren't contact-related or just really light cardio exercise. And then we're pretty familiar with the return to play protocol, which starts with that, and then works up day by day, more intensive things in your sport, and eventually getting back to normal gameplay. And that's usually about a seven-day process, but you can feel better sooner than that. It's definitely for precaution and we go through those steps, but a lot of people will start to feel a little better earlier.

Scott Webb: Which is good to hear, especially when it comes to our kids and they're going to want to, as you say, return to play as quickly as they can. And we want them to do it as safely as they can. And speaking of that, you know, ankle injuries are so common in sports. I mean, just, you know, pick a player and they probably have an ankle injury. So when do ankle injuries rise to the level where you'd want to see people in the clinic?

Dr. Brenton Bohlig: So this is one where, you know, you'll know usually immediately, although not always. So it's kind of tough where if you think you've sprained your ankle, yeah, a sprain or strain initially, there's going to be some swelling, maybe bruising, maybe not, so there could be a lot of pain, it can be tough to walk on.

First recommendation will come in with the RICE or rest, ice, compression, elevation. There's an updated version called POLICE, P-O-L-I-C-E. So that would be protection, and then the O and L are optimum loading, which is a change from just complete rest. We want to actually get things moving again because it improves recovery and speeds up that time. And then, ice, compression elevation.

So I start with that stuff. You know, if you hurt your ankle, you can walk on it, great. That's a good sign. This maybe a sprain, but things will get better. So bracing is good. Compression, whether it's ACE wrap or something of that nature. Icing it, elevating it. But then once you kind of do that initial phase, starting to do little ankle motion exercises, we often start with just trying to spell the alphabet with your ankle, so do all the different letters, so you're getting different motions, different muscles, different parts of the ankle used. Weightbearing status, you know, sometimes people need to use crutches for a few days and then that's okay until you can start to walk on it and move it a little better. But we start with those things.

And then what I say, if it's having some dysfunction, like things you don't feel like you can move it properly, it feels really weak one direction, or you just absolutely cannot stand on it, then that's appropriate to be seen in the clinic, maybe get an x-ray because sometimes fractures can happen with ankle injuries. And we want to check that out and see if it needs any additional casting or non-weight-bearing status for a while. But a lot of times I'd give it a day or two to see where it's at, because initially things are going to hurt, going to be pretty bad, but you'd be surprised the next day, "Oh, swelling is way down. I can actually walk on this. Maybe I can just wear a brace, ice, take some over-the-counter medications and be good." I mean, that is a large majority of the ankle injuries. But if you have more difficulty walking on it, there's a lot of swelling, a lot of bruising, then I think that's definitely worth a visit.

Scott Webb: Yeah, for sure. And the next question I have for you is something that's come up for me a lot with my kids where, as you mentioned swelling, so a lot of times they don't have any swelling. There are no obvious signs that there's a knee injury or an ankle injury, but they're complaining of something. So what do we do when there isn't any swelling, but they're complaining of pain? Is it POLICE again? Is that the standard protocol now? Is that kind of the gold standard? What do you recommend?

Dr. Brenton Bohlig: Yeah. I would definitely start with those things. If you don't notice swelling, that doesn't necessarily mean there's not an injury. Now most musculoskeletal injuries, whether it's the muscle, ligament and tendon, something like that around the knee or ankle, you are going to have a degree of swelling. That's just our body's process for healing in the inflammatory cascade. Things will start to swell. They might start to bruise early on and then they'll dissipate with time. But, if you don't see swelling, then I kind of go back to some of the things I brought up earlier. Is there dysfunction? Is there difficulty with weight-bearing, like walking around? Are you feeling or are they reporting that, "Yeah, there's just a lot of pain when I go up the stairs and it hurts in this part of my knee." But you're like, "Oh, it looks totally normal. You know, it doesn't look swollen." Well, that might not mean there's any musculoskeletal injury, but there are some internal structures, whether it's around the cartilage or just the alignment of the knee itself. There are other things that we can evaluate.

So just because there are no signs of swelling, it doesn't mean there might not be an injury. It may not be one of those acute injuries they suffered in like a sporting event or playing in the playground, but it could be more of a chronic issue and that kind of comes and goes or keeps lingering. So I would say, if there's not, then that's when you ask. If there's not swelling, that's when you ask about some of that, "How is it when you're walking? How was it when you maybe start to jog? Do you think this is stopping you from doing daily activities?" And if there's yes to any of those questions, then I think it's definitely worth the look and an evaluation because there can be more going on than just a musculoskeletal injury.

Scott Webb: Yeah, we all sort of look out for swelling as, you know, the telltale sign. But obviously, as you say, just because there is no swelling doesn't mean there isn't an injury, whether it's acute or otherwise. So this next one, as we get close to wrapping it up here. This has been really educational for me as a parent who deals with a lot of this stuff. Always the age old question, do we apply ice or do we apply heat to an injury? And there seems to be far too many experts near the playing fields about which is appropriate. So I'm going to leave it in the hands of an expert. How do we know whether to use ice or heat when our child is injured?

Dr. Brenton Bohlig: So go-to for any acute injury, something just happens or just in the last couple of days, I would always start with ice. Ice is going to help to limit some of the inflammation, some of the swelling, might help with some of the pain. So that's the first thing I would do in the first 48 hours, is kind of the time period where you want to ice. You don't want to do it too long. You want to ice for about 15 to 20 minutes. You could do it multiple times a day, but at least about an hour in between to let the tissue warm up and things to kind of neutralize before you apply that ice again.

And then another thing that can be helpful is ice massage. So rather than just having it sit in one spot, actually use that ice, you know, whether it's a large cube or sometimes let's say, you get like a paper dixie cup you can freeze and then kind of peel back the top part of the cup, so you have something to grab onto. Now, you've got this big block of ice that you can use to, you know, massage around the ankle, kind of help dissipate some of that swollen tissue and the fluid in the area, rather than just slapping an ice pack on there and let it sit.

So first few days, always icing. Now, after that, when it's more muscular injuries, like let's say you got a strain in your quad and that it's just feeling tight and achy. After the first couple of days, I would lean more toward heat. At that point, some of that acute inflammation has died down, hopefully the swelling has, and now you're dealing with more muscle tightness or achiness and the heat can help relax that and then allow you to do some massage or stretching to the area with some better results. So, ice or heat, I almost always start with ice first 48 hours. And then after that, you can try heat, but ice is still okay.

Scott Webb: That's all good to hear. And I can't wait to share this with all the would-be doctors and nurses around the ball fields, you know, who have very varying opinions about ice or heat. But immediately, ice; heat, later, especially if it's a more of a muscle type of thing. So, great information today. As we wrap up here, what are your takeaways when it comes to, you know, helping our kids prepare for sports, dealing with their injuries, when they should come in to be seen and x-rayed? What are your takeaways?

Dr. Brenton Bohlig: So I think the biggest takeaway is really doing activity in moderation. As I talked earlier, overuse injuries are a huge thing that, at least in the medical community. It comes up all the time at conferences and stuff like that. There's always lectures on it, but I think it's hard to get through. As you mentioned, kids just want to go. We want to allow that, but in a safe matter. So the thing I try to harp on are some of those kind of easy things to remember. No more hours per week than the age in years. So again, 12-year-old, just about 12 hours a week. You know, don't be practicing 18 hours a week. It's really not going to help. And they've shown that the more time you put in there doesn't necessarily improve the outcomes anyway. Most pro-athletes, when they're younger, they played three different sports. And then once they got older, maybe toward that high school level, they specialized. And that's really where they excelled. Rest is a huge factor. Two days per week is kind of the rule of thumb there. And then just try to maybe take a season off every now and then. Let them rest and kind of cool down after a season, not just jump. One day, they're doing baseball and the next day they jump into football. You know, let's take a couple of weeks off and let things just --

Scott Webb: Sometimes doing both in the same day, you know. It's crazy. You know, I've been at tournaments with my daughter where she played in a softball tournament, changed her clothes in the car, went and played in a basketball tournament, changed her clothes in the car again and we went back and played softball again. And I just thought to myself, "I'm a bad parent. I should not be encouraging this."

Dr. Brenton Bohlig: You know, in the short term here and there, I think it happens. Everybody experienced it, but when you're doing it year in year out for those kinds of really formative years and when they're growing, it can lead to some more injury-prone situations and just some further injury down the line. So it's just best to kind of not overdo it. That's kind of my biggest takeaway. Other than that, I think paying attention to some of those things we talked about with concussion, some of the signs initially, you know, rest, take it easy for the first couple of days. And if things still persist, then seeking medical expertise is definitely recommended.

Scott Webb: Yeah, definitely. Well, great speaking with you today. Great advice from an expert. Doctor, thanks so much for your time today and you stay well.

Dr. Brenton Bohlig: Thank you very much. Have a great day.

Scott Webb: For more information, go to genesis.hcs.org. And thanks for listening to Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. If you found this podcast helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.