Dr. Christian Balldin on Knee Dislocation

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WARNING: Video Contains Images of Graphic Injury


Marcus Lattimore sustains a knee dislocation in this past weekend’s game.  
Video courtesy of ESPN.

The term knee dislocation is not to be taken lightly.  The clinical definition of a knee dislocation is injury to three of the four major ligaments surrounding the knee.  The four major ligaments are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL) and the fibular collateral ligament (FCL) occasionally called the lateral collateral ligament.  Of course there are many more stabilizing structures of the knee including the separate bundles of the individual ligaments and the structures in the postero-medial and postero-lateral corners (PLC/PMC). 

When knee dislocation is suspected, emergent evaluation by a physician is a must.  There can be an injury to the nerves and blood vessels to the lower leg necessitating emergent surgical intervention.  The energy required to cause a knee dislocation is very high and often times there are other associated injuries. An example would be a motor vehicle accident with direct forceful blow to the knee or significant twisting event.  They can also be present in sports such as football or speeding down the hill and hitting a tree while skiing.  An example of a knee dislocation happened this past weekend during the University of South Carolina vs University of Tennessee football game when highly regarded NFL prospect Marcus Lattimore sustained a knee dislocation.  

Many of these ligament injuries are diagnosed using the clinical exam.  However, x-rays are a must and a magnetic resonance imaging (MRI) study is needed as well.  The x-rays provide information regarding the status of the bone in regards to any fractures, the position of the bones, and overall bone quality.  An MRI on the other hand provides much greater detail in regards to the soft tissue structures such as the cartilage surfaces on the bones, the medial and lateral menisci, and the ligament and muscle condition surrounding the knee. 

At times, the MRI will show that the MCL or FCL is intact and without an abnormality but clinically during the exam there is laxity to these ligaments.  This is especially so in chronic cases.  Stress x-rays with a manual force provided to the knee will then give objective evidence to any increased laxity as you compare the normal side to the injured side.  These types of techniques can be of utmost importance to determine injuries to these areas of the knee.

Unfortunately, knee dislocations the vast majority of the time require surgical intervention.  The type of reconstructive surgery required would depend on the severity and type of knee dislocation as well as associated knee injuries.  Anatomical reconstruction would be the goal in most cases.  The subtle injuries to the posterolateral corner can often be missed if a careful clinical and diagnostic workup is not performed which would set any reconstructive surgery of other ligaments up for failure if not recognized and dealt with.  These injuries can be devastating and not only end the career of an athlete but if there are injuries to the blood vessels at the time of the injury they can at times even lead to loss of the limb.  Thus, these injuries should be taken very seriously.

Dr. Christian Balldin is an orthopaedic surgeon, fellowship trained in sports medicine, with The San Antonio Orthopaedic Group.  He treats patients aged 3 years and up for all orthopaedic conditions with the exception of the spine.  To learn more about Dr. Balldin, visit his web page here.  To schedule an appointment with Dr. Balldin, call 210.281.9595.

Dr. Philip Jacobs Serves as Medical Director at AT&T Championship Golf Tournament

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This weekend marks the 28th Annual AT&T Championship Golf Tournament in San Antonio. The tournament begins today and runs through Sunday, October 28th at the TPC Canyons Course at the JW Marriott.

TSAOG’s own Dr. Philip M Jacobs has served as Medical Director for the tournament for 16 consecutive years so, if you’re headed out to the tournament this weekend, keep an eye out for him!  Providing professional orthopaedic care for pro and amateur athletes alike is one more way TSAOG makes your health our mission!

Dr. Philip M. Jacobs is no longer a member of The San Antonio Orthopaedic Group, effective 9/30/2016. To schedule an appointment with a different sports medicine specialist, please call 210.281.9595.

Dr. Christian Balldin Becomes Team Physician for OLLU Athletics

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TSAOG is pleased to announce that our own Dr. Christian Balldin is the new team physician for Our Lady of the Lake University (OLLU) Athletics.  This new relationship means that Dr. Balldin will be in direct contact with OLLU Athletic Trainer Christine Ramirez, on call to treat OLLU student athletes, and holding weekly meetings with the OLLU Athletic Department to evaluate any injuries.  You may also see him on the sidelines at home games.

According to Dr. Balldin, “I am very excited about the opportunity to work with OLLU Athletics.  Christine Ramirez, the only Athletic Trainer at the University, is very busy and needs to have quick, direct access for her athletes to be seen by an orthopaedic sports medicine surgeon.  The relationship between TSAOG’s Sports Medicine Institute and OLLU Athletics is something that will allow that to happen.  I look forward to working closely with Christine and OLLU Athletics in order to make sure their athletes get the access to care and professional service they deserve.”


Dr. Christian Balldin is an orthopaedic surgeon, fellowship trained in sports medicine, with The San Antonio Orthopaedic Group.  He treats patients aged 3 years and up for all orthopaedic conditions with the exception of the spine.  To learn more about Dr. Balldin, visit his web page here.  To schedule an appointment with Dr. Balldin, please call 210.281.9595.

Dr. Frank Garcia on Training for a Marathon

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If you look into the origin of a marathon, you would likely think twice about participating.  The modern marathon commemorates the run of the soldier Pheidippides from a battlefield at the site of the town of Marathon, Greece, to Athens in 490 B.C., bringing news of a Greek victory over the Persians. Legend has it that Pheidippides delivered the momentous message “Niki!” (“victory”), then collapsed and died, setting a precedent for dramatic conclusions to the marathon.  However, considering in the modern day that there are over 500 marathons held throughout the world each year, a marathon (26.2 miles, approximately 25,000 steps) is an achievable goal.  Unfortunately, a significant number of runners sustain some form of injury.

Through the use of a training plan, proper equipment, and discipline the modern marathon is well within grasp of the average, motivated person, while minimizing the risk of injury in the process.

Technology can be a significant help in training.  The use of a heart rate monitor is recommended by most experienced coaches.  It is common for inexperienced runners to use “how they feel” or “rate of perceived exertion (RPE).”  RPE can be a good guideline for the experienced athlete, but most newcomers tend to underrate their RPE, sometimes with disastrous consequences.  Still, a large majority of athletes still use a combination of RPE and the heart rate monitor.  Heart rate monitors, when used correctly, will allow you to better train in the proper zone which not only helps to improve your fitness, but also reduces the risks of an overuse injury.  This, in combination with a proper training plan, is the most effective way to achieve your goal.

Another tool that is important to helping you achieve your marathon goals is choosing proper running shoes.  It seems simple enough, but more often than not, people run in improper footwear.  Training places significant stresses on the body and improper footwear can increase your risk of injury. Consider the fact that while running, patella tendon forces have been calculated at 5 to 7 times your body weight and patella femoral forces at up to 10 times your body weight.  Wearing “good-looking shoes” won’t make you faster, so it’s imperative that you spend the time to have a gait evaluation by a qualified person.  This can typically be done by employees (which are typically runners/athletes themselves) in reputable running and fitness stores.

If you are new to marathon training, it is an absolute must to have a proper plan along with adequate time to train. Without it, you are more prone to overtraining, increasing the risk of injury.  The best training plans use what is called “periodization.”  Joe Friel, a well-known author and coach of professional athletes for over 30 years, describes periodization as a widely accepted training approach in which you manage your resources – time and energy – to achieve your goals.  It is often broken down into various periods including prep, base, build, peak and race phases. 

The primary purposes of each phase are as follows:

  • Prep – Preparing for training which can include cross training, weight lifting etc.
  • Base – Developing basic abilities with a focus on technique and duration, not speed.
  • Build – Developing advanced abilities with an emphasis on intensity.
  • Peak – This is of short duration, typically referred to as “tapering.”
  • Race – Rest and preparation for your race.

All phases include a steady build up of intensity and duration and you should always have a recovery week prior to moving on to the next phase.  The recovery week is expected to be EASY!  Active recovery tends to improve a person’s economy greater than doing a rest week where no exercise is done by allowing the body to flush out excessive waste products from muscles.

You must also set realistic expectations based on your training goals and the time you are willing to dedicate to running.  Risks of injury are significantly higher with less training time, especially if you have little or no base fitness.  For this reason, running groups or a personal coach can often help you in keeping on task and keeping your fitness goals in check.

Lastly, I want to touch briefly on overuse injury.  As I’ve mentioned, training for long distance races poses significant risks for injury, particularly as you start to build intensity.  Newcomers and seasoned athletes alike are at risk.  What often differentiates them is what is done when an injury occurs.  Inexperienced athletes are more likely to work through an injury rather than rest and allow the injury to heal.  An experienced athlete is more likely to rest until fully recovered.    Obviously, as race day gets closer, resting an injury becomes much more of a mental challenge because the athlete feels pressured into achieving their set goals.  Regardless, injury recovery is important to minimize the risk of an acute injury becoming a chronic and long-term problem. In summary, injuries occur when athletes exercise too often, too hard, too much, or too soon after an injury.

Training for a marathon can be a daunting task.  However with the proper training plan, tools and time, completing a marathon is an achievable goal. In 2011, there were approximately 520,000 runners who went the distance in the US. That would place you in an elite group of less than one-one thousandth of the population of the US!

Dr. Frank J. Garcia is a board-certified orthopaedic surgeon with The San Antonio Orthopaedic Group.  He treats patients aged 14 years and up for all orthopaedic conditions.  To schedule an appointment with Dr. Garcia, please call 210.281.9595.  To learn more about Dr. Garcia, visit his web page here

Dr. Christian Balldin on How to Tell if Your Shoulder Pain is a Snapping Scapula

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Most people have aches and pains that come and go.  Pain behind the shoulder blade (the bone known as the scapula) is quite common, but can be debilitating.  There are a number of possible causes, so a careful physical examination and detailed information from each individual patient is vital for me to be able to make the correct diagnosis.  A crunching sensation and sometimes an audible noise (aka crepitus) is often present in a diagnosis of snapping scapula, also known as scapulothoracic bursitis with crepitus. 

With a diagnosis of snapping scapula, pain will be present in the back along the border of the shoulder blade closest to the spine and midline and will present upon movement of the arm.  When we move the arm from the side of the body to a position above our head, 2/3 of that motion comes from the shoulder but the other 1/3 actually comes from rotation of the shoulder blade.  Therefore, if you have inflammation in the scapulothoracic bursa (a bursa is a fluid filled sac normally present to decrease friction in an area of movement) that exists between the shoulder blade and the rib cage, it will cause pain and potentially the crunching sensation upon movement of the arm.  Sometimes, patients can also develop bone spurs in this area which can aggravate the situation. 

Most of the time, treatment for snapping scapula is non-surgical and I generally approach it using anti-inflammatory medication, injections into the bursa (which really helps and also can be of diagnostic value), and physical therapy.  Physical therapy is of the utmost importance in treating this condition as it focuses on your posture, making sure the kinetics for the shoulder is correct, and strengthening the muscles around this area. 

Other conditions, including neck pain radiating to the shoulder, shoulder pain radiating to the area, compressed peripheral nerves, and very rarely musculoskeletal tumors can mimic the symptoms of snapping scapula. A thorough physical examination and history of the complaint will rule the other conditions out. 

If conservative measures have been exhausted, a minimally invasive procedure using a small camera and instruments can be used to remove the inflamed tissue and any bone spurs.  This is called endoscopic scapulothoracic bursectomy and partial scapulectomy.  It can be done as an outpatient procedure in the vast majority of cases. Most people recover within a few weeks, but many feel better after only a few days.  Even after surgery, though, physical therapy is of the utmost importance to ensure the musculature around the shoulder and the posture is corrected so that the shoulder area remains healthy.

Dr. Christian Balldin is an orthopaedic surgeon, fellowship trained in sports medicine, with The San Antonio Orthopaedic Group.  He treats patients aged 3 years and up for all orthopaedic conditions with the exception of the spine.  To learn more about Dr. Balldin, visit his web page here.  To schedule an appointment with Dr. Balldin, please call 210.281.9595.

Dr. Christian Balldin on Causes and Treatments of Hamstring Injuries

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Hamstring injuries are very common in sports and can involve any part along the entire length of the muscles and tendons from the hip to the knee.  The hamstring origin is found on the part of the pelvis called the ischial tuberosity, which is easily felt as it is the hard bone that we all sit on in our buttocks.  The majority of the muscles form a common tendon that attaches in this area.  The muscle bellies considered the hamstring muscles are found on the back of the thigh.  The hamstrings attach below the knee on the upper tibia and fibula – the two bones that make up the lower leg. 

Injuries can happen at any point along this course, but hamstring injuries involving the tendons attaching to the lower leg are quite rare.  When they do occur, these injuries usually involve the tendon from the biceps femoris muscle that attaches on the upper fibula. Injuries to this tendon are mostly associated with high energy injuries such as a knee dislocation or a significant ligament injury to the knee.  As you can imagine, there is often additional damage found alongside this type of injury.  Unfortunately, these types of injuries commonly need complex surgical repair and other reconstructive procedures.  The tendons that attach to the inside part of the lower leg are usually not injured significantly but can be involved with bursitis (when the fluid filled sac that envelops the tendons gets inflamed).  This can be treated with conservative means in the majority of cases.  

Injuries to the muscle bellies themselves are the most commonly seen hamstring injury.  These are often the easiest to recover from, but are also known for sticking around and being nagging injuries throughout an athlete’s season.  This has been the case with numerous professional athletes, including Miles Austin of the Dallas Cowboys.  These muscle belly injuries almost always heal without any need for an invasive procedure but they need time, something many athletes can be reluctant to allow for.  Not allowing enough time for this type of injury to heal can lead to chronic problems and reinjury.

Another location of injury to the hamstring complex is at its origin on the ischial tuberosity on the pelvis.  With explosive maneuvers, such as the beginning of a sprint or during the start of water skiing, this area sees a tremendous amount of stress.  The entire hamstring complex origin can pull off the ischial tuberosity with or without a piece of bone.  If it does so and retracts away from the ischial tuberosity it will most likely require surgical repair.  There are numerous studies to indicate that patients that have it repaired do better than those who do not.  One of the major nerves to the lower leg – the sciatic nerve – travels very close to the ischial tuberosity and can be involved in the scar that forms if these injuries are not treated surgically relatively soon after injury.  If this is the case it can be a significant source of ongoing pain.  Patients with chronic tears and sciatic nerve irritation also do well with repair and removal of the scar tissue in this area although the surgery is slightly more complex.

If you have acute injury with weakness and significant bruising or simply a nagging discomfort that is present in this area, I recommend you have it evaluated by a physician.  Hamstring injuries are often accompanied by a significant amount of bruising and pain.  At times the entire back of the thigh and groin can be black and blue due to the bleeding that occurs.  Consulting with a physician will help you understand the extent of your hamstring injury and your best options for treatment and rehabilitation.

Dr. Christian Balldin is an orthopaedic surgeon, fellowship trained in sports medicine, with The San Antonio Orthopaedic Group.  He treats patients aged 3 years and up for all orthopaedic conditions with the exception of the spine.  To learn more about Dr. Balldin, visit his web page here.  To schedule an appointment with Dr. Balldin, call 210.281.9595.

Dr. David Schroder on the Popularity and Increasing Availability of Urgent Care Centers

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An issue getting some coverage in the press lately has been the increase in availability of and visits to urgent care centers, ranging from small “doc-in-a-box” clinics to larger facilities affiliated with hospitals or multi-location chains.

The increase in consumer demand for urgent care centers has been largely driven by the frustration of the average patient at having to spend hours waiting in an emergency room and pay a hefty fee to get treatment for lower level injuries and conditions, simply because the hospital is what is open when the patient is available to be seen (walk-ins, after hours and weekends).  Most people would much rather pay a small amount of cash to be seen in a reasonable amount of time and get going on their way.  From a convenience standpoint, I do believe urgent care centers are useful and that the average patient will be more efficiently granted medical care.

However, a major downside of urgent care centers, particularly from a subspecialty perspective, is that a patient may have diagnostic tests performed that may not be what the subspecialist (the next physician to provide treatment) needs to see.  As an orthopaedic surgeon, I often have specific requirements for how a radiographic test (x-ray, CT scan, MRI, etc) should be performed to be useful for diagnosis and preoperative planning.  For example, if an inadequate MRI is obtained prior to an orthopaedic consultation, I may not have the images that I need to properly diagnose and treat your complaint.  In this case, a replacement MRI would need to be ordered and it can be very difficult to justify the cost of repeat imaging to an insurance company or to a patient who is paying out of pocket. 

The growing trend of subspecialty practices providing an urgent care option is useful in combating this issue.  When a patient is seen in an urgent care environment that only deals with a specific subspecialty, it leads to a better directed effort in getting a proper patient workup performed.  Urgent care options like our OrthoNow Urgent Care Clinic offer more efficient delivery of care to orthopedic patients with acute injuries by providing a timely and appropriate workup.  They also lower costs by avoiding emergency fees and the price of repeating radiographic tests.

In an age with projected physician shortages and crowded emergency departments with high fixed costs, the spread of urgent care facilities is inevitable. We, as a community of healthcare providers, have to work together to ensure the proper flow of information between providers to allow for comprehensive and consistent medical care. For instance, even with access to electronic medical records, it can be difficult to allow for continuous documentation of care for a patient, as that patient will often arrive at a subspecialty physician’s office without documentation from the urgent care center. We have to ensure that trying to provide medical care as efficiently as possible does not interfere with providing medical care as comprehensively and accurately as possible.

Dr. David T Schroder is an orthopaedic surgeon, fellowship trained in total joint replacement, with The San Antonio Orthopaedic Group.  He treats patients aged 11 years and up for most orthopaedic conditions, with the exception of spinal surgery.  To schedule an appointment with Dr. Schroder, please call 210.281.9595.


Dr. Christian Balldin on Recognizing Concussions in Athletes

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The awareness, evaluation and treatment of concussions are a hot topic lately. In the sports world especially, we are hearing about it more and more.  The NFL is attempting to limit the exposure of its players to violent hits and fining (or even suspending) the players that do deliver these types of hits.  Pee wee football coaches are trying to teach better tackling and not to lead with the helmet to not only protect the brain but also the spine to avoid catastrophic injuries such as spinal cord injury. 

However, concussions are not only present in football.  In almost every sport there is a chance for head injury and thus concussions.  The sport with the highest rate of concussions is actually women’s soccer. 

Concussions are common with the CDC estimating 1.6 – 3.8 million occurring annually.  In 90% of these, loss of consciousness does not occur.  The symptoms of concussions include:

  • Headache
  • Difficulty concentrating
  • Dizziness and problems with balance
  • Fatigue
  • Blurred vision
  • Light sensitivity
  • Memory difficulties
The cumulative effects of concussions are really dangerous and not to be taken lightly.  Having repeated concussions throughout an athlete’s life can predispose them to Chronic Traumatic Brain Injury (CTBI).  It is the most common effect from repeated brain injury.  It can have serious vocational, persistent cognitive deficits and personal effects.

The so called “Second Impact Syndrome” (SIS) is when an athlete sustains a second concussion while still not recovered from the first.  During the recovery period of a concussion, even minor trauma, such as a trivial hit to the head, can cause significant increases in intracranial pressures and devastating consequences. 

The best way to manage concussions is to treat them appropriately when they do occur.  A coordinated effort between the athletic trainer, physicians involved, neuropsychologist, the athlete, the athlete’s family as well as the coach should be undertaken in order to have a safe return to play and/or to exertion.  A recent article in the Journal of Bone and Joint Surgery discussed the matter and made the following points:

  • Acute concussion symptoms are mostly self limited with resolution within two weeks
  • Athletes should rest physically and cognitively until symptoms have resolved at rest and with exertion
  • Neuropsychological testing should be used as part of overall evaluation when attempting to decide when an athlete is ready to return
  • A history of multiple concussions or a history of prolonged symptoms might necessitate retirement from collision/contact sports
  • Additional research still needed on long term consequences of concussions
The treatment of concussions is evolving, as it should, since we still do not fully understand the complex neural pathways that are affected.  Recognizing when a concussion has occurred is one of the most important steps.  This can only happen if we continue to educate those involved in sports on how to recognize the signs and symptoms of concussions.  A goal for the near future should be to have all young athletes involved in contact/collision sports baseline tested for concussion using objective computer programs.  Baseline readings taken prior to play would then be available to compare against if an incident occurs during the season.  This data would be part of the overall examination when attempting to treat and return an athlete to play.  This of course requires an organized effort on all parties involved.

Dr. Christian Balldin is an orthopaedic surgeon, fellowship trained in sports medicine, with The San Antonio Orthopaedic Group.  He treats patients aged 3 years and up for all orthopaedic conditions with the exception of the spine.  To learn more about Dr. Balldin, visit his web page here.  To schedule an appointment with Dr. Balldin, call 210.281.9595.

To link to the study that Dr. Balldin is referencing, click here.

Dr. Christian Balldin on Hip Pain in the Active Adolescent and Adult

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There are numerous causes of hip pain in the active adolescent and adult population, including but not limited to:

  • A loose body, like a piece of cartilage, inside the hip joint itself.
  • Impingement of the femur bone and the hip socket.  This is when there is extra bone that forms on either or more often both locations in response to stress which can result in pain as well as decreased range of motion.
  • A tear of the labrum (the elastic tissue surrounding the socket of the hip joint) which is very commonly seen in combination of impingement.
  • Snapping of tendons over the hip joint capsule itself or occasionally more on the outside of the hip involving the iliotibial (IT) band
  • Greater trochanteric bursitis which is inflammation in an area on the outside of the hip that is normally present to decrease friction of the surrounding tissues
  • Strains of the muscles surrounding the hip joint, including the hip flexors and groin.
  • Pain actually generated in the lower back, which radiates to the hip area.

The vast majority of these conditions can be treated non-surgically using methods like rest, anti-inflammatory medication, occasionally local injections as well as physical therapy.

However, when you are dealing with a loose body floating around in the joint time can be of the essence.  The longer it is left unattended, the more damage it may do to the remaining healthy cartilage.  In these cases, the loose body should be removed sooner rather than later using a minimally invasive procedure called hip arthroscopy (“What is Arthroscopy?”). When appropriate, hip arthroscopy can also be used to repair tears of the labrum or to correct impingement by removing the excessive bone.

In cases where hip pain cannot be resolved using non-surgical techniques, hip arthroscopy offers a great, minimally invasive alternative to open hip surgery which allows for a smooth and speedy recovery in the majority of cases.

Dr. B. Christian Balldin is an orthopaedic surgeon, specializing in sports medicine, at The San Antonio Orthopaedic Group.  His fellowship training at The Steadman Clinic in Vail, CO included training in hip arthroscopy.  To learn more about Dr. Balldin, please visit his web page here. To schedule an appointment with Dr. Balldin, please call 210.281.9595.

Dr. Deborah Bergfeld on the Relationship Between Football and Neurological Disorders

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As a sport, “American Football” has long been celebrated as an entertainment spectacle, from Friday nights to Sunday afternoons. Annually, the sport offers tens of thousands of youth athletes a venue to learn leadership and teamwork, while helping to develop their physical abilities. For years, the medical community has scrutinized football from a standpoint of neurologic trauma and injury, particularly where concussion and spinal cord injury are concerned. More recently, such concerns have come to the forefront at the urging of past professional players and through more intense media coverage. Through recent medical research, the lasting effects on football participants is becoming more understood and more alarming.

On September 5, 2012, the American Academy of Neurology released a study confirming some long held suspicions about the susceptibility of football players to long term consequences of the sport in regards to neurologic illness.

This study looked at 3,439 former National Football League (“NFL”) players who had played for at least five (5) seasons. These players were categorized as “Non-speed” (linemen) and “Speed” players (all other positions excluding punters and kickers).

This study found that death from neurodegenerative disorders like Parkinson’s disease, Alzheimer’s disease, and ALS (Lou Gehrig’s disease) was 3 times higher in this study group as compared to the average American. In particular, mortality for these football players was 4 times higher from Alzheimer’s disease and ALS. Furthermore, Speed players were at greater risk than Non-speed players.  

Certainly, most young men and women who play football will not become NFL players. But, the results of this article certainly have implications for players and their families. Contact football is promoted prior to middle school and greater restrictions on such contact may need to be considered. In Texas, where football is ingrained in our culture, noncontact regulations may be a tough pill  for coaches, players and parents to swallow but conversations about age limits for contact and stringent adherence to concussion guidelines should take place to protect these players. Parents may want to consider encouraging their child to play ‘nonspeed’ positions or, based on these results, may want to consider involvement in non-contact sports with lower rates of head injury like baseball, swimming, etc.

Dr. Deborah A. Bergfeld is no longer in practice with The San Antonio Orthopaedic Group.  To schedule an appointment with another physical medicine & rehabilitation physician, please call 210.281.9595.

To link to the study that Dr. Bergfeld is referencing, click


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