Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘acl’

The Expense of Early Sport Specialization

My role in the horse world to date has been little more than loyal supporter. This includes my posts as head cheerleader, financier, and klutzy outsider comic relief (for example, I always seem to be over- or under-dressed). My ROI is measured in the smiles on my girls’ faces over the years. They have seemed to truly enjoy the process, the journey, sometimes with little regard to the outcome or the score.

Everything about the horse world is expensive. Really expensive, actually. There are lots of expensive sports out there to be sure. Golf, tennis, and hockey come quickly to mind. All have in common expensive equipment, coaching, and venues, even at the lowest levels of participation. Most other sports only become expensive when you add in the effects of higher level competition with the new burdens of professional coaching and travel. Think AAU anything, gymnastics or swimming.

One thing that sets the horse world apart is the Sugar Daddy or Sugar Momma, a usually over-monied individual whose sole role is to write checks. Big checks. Lots and lots of checks. Most whom I’ve met don’t really seem to enjoy hanging around horses, actually. Kinda like someone who owns a big boat but gets seasick in the bathtub. The other essential difference between a Sugar Daddy/Momma and a “Little League Parent” is that the Sugar Daddy/Momma doesn’t care a lick about the outcome of the event.

In a funny, very roundabout way this makes me think about youth sports, high school sports, and the behavior of parents in that world. Unlike the Sugar Daddy/Momma the youth sports parent is highly invested in outcomes, not only game by game but also in terms of reaching the next level. As in that level to which the ridiculously large percentage of participants never get. You probably think this is about going pro, about making a living at your sport. Nope. That number is so tiny and has been parsed so many times and so many ways that it’s not worth spending the electrons thinking about how few college athletes or minor leaguers make it to The Show. I’m not even talking about getting a scholarship to play a D1 sport.

What I’m thinking about is some fascinating facts about how few high school athletes go on to play a sport at any level in college.

Seriously, the numbers are comically low. Cut and past this for a look: http://www.ncaa.org/about/resources/research/estimated-probability-competing-college-athletics. For boys, only lacrosse and hockey are above 10%. More boys go on to swim in college (7.1%) than play football (6.8%). The statistics are similar for girls led by Ice hockey (24%), lacrosse (12.9%), and field hockey (10.1%); all other sports are in the low to mid-single digits. I don’t know about you, but with all of the teams sponsored by Division 3 colleges out there, along with the dearth of multi-sport athletes taking up more than one slot, these figures are really shockingly low.

How, then, can we justify the expense of early sport specialization, both in real financial terms, and in terms of the epidemic of injuries suffered through over-use and under-preparation?

On my most recent foray into the horse world I met a  youngster who plays on a volleyball team that uses CrossFit to enhance their fitness.  She no longer does her first-love sport, tumbling, because of a repetitive use stress fracture in her back suffered before she started to play other sports. All tumbling all the time wrecked her. How many young arms must we scar with a Tommy John “autograph” prior to obtaining a driver’s license before we suggest adding in a little winter reprieve from pitching? Isn’t it just a bit disheartening to think that the ACL tear rate in young female soccer players is higher than the overall NCAA participation rate for girls who played that sport in high school? Mind you, these are TOTAL participation rates, not the percentages of kids who got a scholarship to play D1. The list goes on and on.

Says here that the kids would be far better off playing more sports with their buddies in their hometown schools, both physically and mentally, than they are now joining elite travel programs and chasing after such a small number of slots at the next level. Probably have a better relationship with Mom and Dad, too. For sure Mom and Dad are likely to be better behaved. Throw in a little bit of fitness training that emphasizes proper mechanics in functional movements and maybe we can start a trend.

No Sugar Daddies or Mommas necessary, either.

An Open Letter to Parents and Coaches of Girls Who Play Sports

Dear Coaches and Parents,

For more than 30 years I have had the good fortune to be a volunteer assistant coach for boys and young men playing football, basketball, and lacrosse, sports I played in high school and/or college. In this capacity I became very familiar with the particular dangers of concussions suffered while playing these contact sports. Indeed, one of my sons suffered a severe concussion as a high school lacrosse player, effectively ending his competitive career. I applaud the recent efforts being made at all levels of competition, especially in the area of gratuitous headshots in football, lacrosse, and hockey.

As a fitness coach for the last 10 years or so I’ve learned of another, all too common injury in sports, one that is disproportionally concentrated in the younger athletes: ACL tears in girls and young women. There is a veritable epidemic of ACL injuries in soccer, basketball, and volleyball. Girls are 4-6X more likely to tear their ACL playing these sports than boys. The numbers are quite simply appalling, and yet I hear not a word about this from any media source. Girls are being felled by this injury in droves but it seems no one is talking about how to prevent it.

Can anyone tell me why that is?

It’s not like this is a new phenomenon. A brief Google search turns up academic articles published in 1999. It’s also not as if these injuries are only of historical importance. The daughter of a friend was the third girl playing the same position for the same U17 soccer team for the same coach to suffer a non-contact ACL tear in 2015. Nor were they the only girls on that team so afflicted. When asked what changes had been made by the team or the coach in response to these injuries my friend shook his head. Crickets.

Can anyone tell me how this is OK?

The answer, of course, is that it is not OK. Not even a little bit. The causes underlying the increased risk to suffer an ACL tear in which a female athlete does not come into contact with another player are relatively well known. Studies have been done examining the way girls jump and land. As it turns out, girls tend to change direction and land with an outstretched, straight leg. Boys, on the other hand, do so with a flexed leg, reducing tension on the ACL.

If you watch girls running you can’t help but be struck by the valgus position of the knee when their foot lands on the ground; the knee is markedly inside the foot.  Girls tend to have stronger anterior muscles and therefore tend to be quad-dominant runners. They pull their upper leg forward through the contraction of the thigh muscles. Boys, on the other hand, are posterior chain-dominant runners, pulling their legs up through the contraction of their glutes and hamstrings. Without a strong posterior chain to counteract the effect of the quadriceps, the ACL is again under increased tension, magnifying the risk caused by knee position.

We know why the injuries occur, and as it turns out we also know how to prevent them, or at least reduce their frequency: teach young female athletes safer movement patterns, and put them in strength and conditioning programs that specifically train their posterior chain. If you see this type of training you will recognize it immediately: it’s how we train boys.

Can anyone explain to me why this is not occurring with young female athletes right now?

Even at the highest level of women’s sports we still see non-contact ACL injuries. For example, in 2011, 6 of the 21 members of the U.S. Women’s National Soccer Team had suffered an ACL tear at one point in their careers. However, in more recent years there has been a decrease in these injuries at the professional level because teams are training their female athletes in better neuromuscular recruitment patterns, which creates sounder movement. Athletes are doing strength and conditioning programs that emphasize strengthening their glutes and hamstrings. Hence, we are seeing dramatically fewer ACL tears at the highest levels of women’s sports. There is no way to justify not doing the same thing for girls early in their careers.

Proven templates already exist to do just this. Simply utilizing the off-the-shelf PEP program of stretching and plyometrics has demonstrated meaningful decreases in the incidence of ACL tears. Rather than use such a basic program when it comes to high quality movement patterns, why not look to someone like San Francisco’s Dr. Kelly Starrett? The founder of Mobility WOD and author of “The Supple Leopard”, Dr. Starrett is a consultant to dozens of collegiate athletic departments. He recently took over training for an elite 150-member girls volleyball program with the specific aim of reducing ACL injuries in those athletes. His teachings on proper movement mechanics are peerless, as a quick perusal of his book will attest. Perhaps we should be looking at what he is doing.

Jeff and Mikki Martin have been training kids in Southern California, the epicenter of youth soccer, for well over a decade. Their protocols include meticulous attention to the type of mechanics taught by Kelly Starrett and emphasize the importance of strengthening the posterior chain beginning around age 10. As the developers of the original CrossFit Kids program and more recently founders of The Brand X Method™, they have trained hundreds of young girls who play soccer without a single one of their athletes suffering an ACL injury while under their care. They arguably have the longest track record of successfully and safely training youngsters. Perhaps we should be looking at what they are doing.

One thing is for sure: it is not OK to continue with the status quo. Simply doing what you have always done is nothing less than condemning a high percentage of your girls and young women to suffering an ACL tear and all that goes along with it. The nature of the sports in which we see an epidemic of concussions is such that the only way to prevent them is not to play those sports. This is not the case with non-contact ACL tears in soccer, basketball, volleyball and other sports played by girls. Prevention is possible through the institution of training programs that emphasize the teaching of new, safer movement patterns, as well as strengthening the muscles of the posterior chain.

I’d like to propose a 3-part solution to this problem. First, we would like to offer training to coaches in how to teach better basic movement patterns. One of the most fundamental goals for those of us who utilize The Brand X Method ™ to train kids and teens is to create a cadre of coaches who can do this. We hope that this can become a core part of in-season team training. Secondly, we wish to make available our coaches, and coaches who share our concerns and philosophy, to train your athletes to have a stronger posterior chain. The data supporting the inclusion of weighted squats, deadlifts, and power cleans both in season and out of season is compelling. Our coaches are experts in teaching the proper mechanics involved, and our athletes progress in a safe and measured fashion.

Lastly, the data supporting the inclusion of full-body functional movements executed at relatively high intensity is equally compelling when it comes to not only injury prevention, but also in developing stronger, faster, more durable athletes. The Brand X Method ™ is a proven program that emphasizes proper mechanics and safety. It is the latest version of a program that has been creating highly athletic youngsters and teens for more than 10 years. This type of physical fitness directly translates to more capable and confident athletes in all of the sports mentioned. At CrossFit Bingo our Alpha X Youth Athletics program is available to train your athletes all year round, either individually or in team settings.

It’s time we all start talking about these non-contact ACL injuries in girls’ sports, just like we have been talking about concussions in boys’ sports. Parents should be asking what is being done on behalf of their daughters. Coaches should be committed to stopping the epidemic of non-contact ACL injuries in their female athletes.

We can help.


Darrell E. White, M.D.

Co-Founder, CrossFit Bingo

Co-Founder, Alpha X Youth Athletics



Sunday musings 11/1/15

Sunday musings…

1) Fall Back. Needed that.

2) Pharoah. A champion goes out on top. Not a dry eye chez bingo. Google “Tim Layden” for a great review.

3) Jacket. The motorcycle jacket has been alternately called an iconic male look, and a caricature of masculinity. I do not own a motorcycle jacket. Am I somehow not masculine, or am I subtly making a statement about inclusivity?

Or do I just look stupid in a leather motorcycle jacket?

4) ACL. There is a veritable epidemic of non-contact ACL tears among young female athletes. Unlike concussions in young male athletes, the collective response from media sources of all kinds to this: crickets. Also absent, any hint of a change in how girls are training for their sports.

Why is that? How is that OK?

5) Relative. “Constantly varied functional movements performed at relatively high intensity.” What exactly does that mean? For whom does this apply? I’ve been perusing the programming of some CrossFit Affiliate (and a couple of recently de-affiliated gyms still programming CrossFit-type WODs), watching videos and looking at pics of their athletes, and it looks like there’s a bit of confusion out there.

The “relative” in that definition of CrossFit speaks to the universal scaleability of the physical part of the CrossFit prescription. Load can be moved up or down. Duration can be increased or decreased. Movements that maintain the desired stimulus of the posted WOD can be substituted where a particular skill has yet to be acquired. Intensity is relative to the individual athlete in question, and in the classic application of the CrossFit prescription it is only “high” after that athlete demonstrates mechanical proficiency on a consistent basis.

Watching last year’s Games and Regionals footage one of the things that impressed me was the tight correlation between the virtuosity of movement and the resulting work performed in the more accomplished athletes. One cannot help but notice at all levels of competition the movement flaws seen in athletes who could not sustain enough intensity to place highly in an event. If you go back in time and watch videos of the early days of CrossFit you are struck by the emphasis on proper mechanics as a vehicle to increased efficiency and therefore more work or power output. Form is the gateway to intensity.

At my Alma Mater there is a saying about teaching that goes like this: the perfect classroom is Mark Hopkins on one end of a log, and a student on the other. I always had that image when I watched videos of Coach at the original CrossFit Santa Cruz, when I read his earliest writings in the CFJ. You know, the perfect gym is Greg Glassman on one side of a barbell and a CrossFitter on the other. CrossFit, at least the CrossFit I learned from Coach, is more than just writing a WOD on the whiteboard and opening the garage door. Every solo CrossFitter I’ve ever met, even those doing Coach’s own programming, was better after being actively coached.

“Relatively high intensity” is both a highly personal, individual metric, and a constantly moving target. It requires a shared knowledge of an athlete’s mechanics and consistency by both athlete and trainer. Programming must not make high intensity either unobtainable or unavoidable. There is only one Greg Glassman, just as there was only one Mark Hopkins. Williams College today is much larger than that single log, and Heaven knows CrossFit is much larger than CrossFit Santa Cruz ca. 2003. There is, however, a lineage that we should be able to trace back to both men.

If a gym is training people according to the CrossFit prescription, shouldn’t we be able to look at that gym and see that lineage?

I’ll see you next week…


Lessons from a CrossFit Athlete Moving On

Gutted. Just a deep, sickening sadness when I heard the news. I confess, I wasn’t watching the Regionals feed, just reading and studying and occasionally glancing at various SM feeds. They all blew up at the same time, precisely 5 minutes after Julie Foucher’s achilles tendon did the same.

I wanted to throw up.

To be honest, while I would be saddened by any injury to a Regionals competitor, Julie is a friend, someone I know face-to-face. Seeing her hurting was a more personal thing for me and for all of Clan bingo. We know her story and we know her people. It felt like watching my neighbor’s kid get hurt, the one who always made you smile when you saw her outside playing. Her tears brought ours.

There is some anger out there in CrossFit land about this, and we will soon be hearing condemnation of not only the movement during which the injury occurred, but also by extension the entirety of CrossFit itself. Julie does not seem angry (we’ve not yet spoken; I’ve seen the same videos you have), and for whatever little it’s worth I’m not, either. I think this is misplaced, this anger, and that it speaks to a continuing and fundamental misunderstanding of the differences between training and competing, between CrossFit and The Sport of Fitness®. As such it bears examination and illumination. Again.

Julie Foucher, and competitors at her level, is a professional athlete. She is paid for her outcomes. Paid for performance. As such, like every other professional athlete, she accepts a higher degree of risk in both her training and her competitions. This is a fact of life in every athletic pursuit. Full stop. As sports evolve one hopes that leaders strive to make essential aspects of those sports safer, but at some point it becomes impossible to increase safety without removing essential.

Smaller engines and slower speeds would certainly reduce crashes at Indy, but then it would be a commute, not a race.

Being injured in the heat of competition is very disappointing; being injured in training more so, because that which you do to become better has made you worse. The safety bar is therefore raised higher in the gym than in the arena. Indeed, the further we are from the pinnacle of performance in any competitive endeavor, the more important it becomes to emphasize safety.

Regarding the movement in question today, the Box Jump, this is rather straightforward: step down in training, and step down in competitions entered for your own entertainment and enlightenment. Again, Full Stop. You are not Julie Foucher. I am not Julie Foucher. It is folly to conflate a competition in which you perform functional movements at relatively high intensity against a clock and fellow recreational athletes with the CrossFit Games.

This, in turn, illustrates the folly and fallacious thinking of extrapolating a ruptured achilles tendon in an elite athlete at the highest level of competition to the conclusion that CrossFit is dangerous. Poppycock. Constantly varied functional movements performed at relatively high intensity is as safe as any other fitness methodology. It is especially so if you adhere to the classic progression, still taught at every CrossFit seminar: technique, then consistency, then–and only then–intensity.

The Sport of Fitness is also as safe as other sports. Injuries to women? How about the epidemic of non-contact ACL tears in young women playing soccer? The higher the level of amateur soccer played, the greater the number and higher the percentage of girls and women who blow their ACL. Not at the pro level though, because they train differently. Where is the outrage here? Achilles tendon injuries, you say? Ask your buddy the orthopod about middle-aged men who play basketball and racquet sports. It’s so common it’s a cartoon.

No, anger is misplaced here if it is directed toward either CrossFit or The Sport of Fitness. The best example of why? None other than Julie Foucher. What makes Julie such a special person is what she did and is doing after her injury: moving on. There is sadness to be sure. A sense that the journey ended too soon. A quest not quite fulfilled. After the tears, though, came a smile. Perspective. There was talk of fun. CrossFit with CrossFitters as fun.

We welcome Julie back to our world of training to be better at life. As she now steps down like the rest of us she has offered us one final gift as she moves on from competition: a smile and a hand up to each of us, a reminder that what we do is fun because we do it together. For that, and for the joy of watching her compete these many years, we in turn should holster our anger, dry our tears, and smile back at her in thanks.