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Reprint from Orthopedics Today March 1998

An ounce of prevention is more than a pound of cure in sports medicine

Orthopedic surgeon leads one-of-a-kind institute in sports injury prevention research and advocacy efforts

by Robert Trace
ORTHOPEDICS TODAY associate editor

Janda.jpg (5998 bytes) David H. Janda, MD, has a mission. He and his staff at the Institute for Preventative Sports Medicine, located on the campus of St. Joseph Mercy Hospital in Ann Arbor, Mich., are waging an all-out effort to help coaches, parents, league officials and players prevent sports injuries.

    It also doesn't hurt that Janda and his colleagues are helping take a bite out of national health care expenses through their injury prevention efforts.

    The institute conducts seminars for the lay and medical communities on injury prevention, and is currently the only health cost containment organization of its kind in North America. Just one of the research team's findings provided keys to preventing a proposed 1.7 million injuries annually in the United States, with a savings of $2 billion in health care costs per year.

    Injuries caused by sports, falls, motor vehicle accidents and the unintentional discharge of firearms remain the leading cause of death for individuals between the ages of one and 44, and these accidents cost the U.S. more than $133 billion each year in health care costs, according to Janda, who is director of the institute. He is also an orthopedic surgeon specializing in sports medicine at Orthopaedic Surgery Associates, a nine-physician orthopedic practice in Ann Arbor, Mich.

    "Injury remains the most under-recognized major public health problem in this country," he said, "and still we don't hear much about it in the media. The public needs to understand that there are many potential solutions to this problem."

    He continues to field occasional inquiries from persons wondering whether a proactive preventive approach would cut into an orthopedist's business. "As an orthopedic surgeon, my job is to do what's best for my patients, period," he responded. "There will always be patients who need our specialized care. But I think one of the problems we've run into in this country is not focusing enough on the prevention issue. Health care needs to be made more affordable, and the way to help do that is by preventing need."

A labor of love

    Janda volunteers 10-20 hours a week conducting research in his lab at the institute, or touting the cost and health benefits of proper sports injury prevention techniques to various groups.

    Organized recreational softball-which attracts over 40 million participants nationally each year-is a particular area of interest for Janda, who claims 710/o of all injuries from recreational softball and baseball result from sliding. While some of these injuries are attributed to poor musculoskeletal conditioning, shoddy sliding technique, and occasional alcohol consumption, the primary cause for these foot and ankle injuries is a late decision to slide, he said.

    A baserunner's risk for injury is also determined in part by the type of base he or she slides into, Janda acknowledged. Standard stationary bases are bolted to a metal post that is sunk into concrete in the ground. "Breakaway" bases utilizing a rubber mat fixed to the playing field by several low-profile rubber grommets can be displaced at a fraction of the more than 3500 foot-pounds required to dislodge a traditional stationary base. The breakaway bases, he added, differ from bases which are secured to the mat via a magnetic or Velcro strip, which can become ineffective when exposed to dirt or water.

Benefits of 'breakaways'

    In their observations of more than 8500 players in a softball league at the University of Michigan where half the games were played on fields using stationary bases and the other half were played using breakaway bases, Janda and his colleagues identified 45 sliding injuries involving stationary bases. Only two sliding injuries occurred on the fields equipped with breakaway bases. The total treatment costs to these 45 injured players came to over $55,000, an average of more than $1220 per injury, excluding lost work time and related costs, Janda said.

    In the two injuries occurring on the fields using breakaway bases, including a non-displaced medial malleolar ankle fracture and an ankle sprain, the total medical costs for both injuries was only $700, or $350 per injury. The ratio of injuries occurring on the stationary bases was 22.7 times higher than that for the modified breakaway bases, Janda pointed out.

    These findings were replicated in another phase of the study, in which all fields were equipped with breakaway bases. Again, just two injuries occurred in the more than 1000 games monitored, with the median costs totaling only $400. This represents a reduction in injury occurrences (compared with games played on stationary bases) of 98.70/o, Janda said. The corresponding reduction in related medical treatment costs exceeded 990/o.

A congressional matter

    Following Janda’s testimony before the House Appropriations Committee on Labor, Health and Human Services, House officials developed federal recommendations for the use of breakaway bases on recreational baseball and softball fields in all federally operated facilities. These include all U.S. military facilities worldwide, as well as federal correctional institutions.

    Although Janda is advocating for mandatory use of breakaway bases at both the amateur and professional baseball levels, he is pleased, for now, that federal institutions are taking a proactive approach to prevention. "According to the Pentagon, the No.1 reason for missed days in the military is sports injuries," said Janda. "Hopefully, efforts like these will help eliminate lost work time and the added costs of treatment and rehabilitation."

    Still, a majority of Little League baseball fields and office recreational softball leagues use the traditional stationary bases.

    "It's a shame because we spent less than $1000 on this series of studies, and according to the government, we found a way to save $2 billion in health care costs," Janda said. "when it comes to prevention, this is not the exception; it is truly the rule. A very small outlaying of expenditures can have a huge ramification on the prevention of injuries, as well as a huge ramification in the prevention of health care costs."

helmet tester.jpg (10953 bytes)Financial support

    As a policy, the institute does not accept financial contributions from the government or from sports product manufacturers in order to best serve the public without a conflict of interest.

    "Funding continues to be an ongoing area of contention for us," he added. "Unfortunately, the insurance companies haven't shown much interest in funding our projects, even though we have demonstrated, through scientific research, the steps coaches and players can take to prevent injuries and save medical costs."

    Instead, the institute must rely on tax-deductible contributions from individuals, foundations, corporations, and by grants from public and private agencies to support its research and operations. The institute's annual budget is approximately $200,000.

    The institute's pursuit of better safety measures has not been limited to breakaway bases, either Janda and his group recently studied the fatalities of 34 children over the past 17 years who died after being struck in the chest with a baseball during an organized baseball league game, causing fatal arrhythmia.

    The researchers compared the different chest protectors and softer, heavier baseballs currently on the market. "what we found was that even through many of the manufacturers made claims about how well their product worked, they had no scientific data to back up them up," Janda said.

head model dummy.jpg (8416 bytes)Working with auto industry

    Janda teamed with David Viano of General Motors, whose company contributed crash test dummies and the Hybrid III Crash System-a sophisticated computerized modeling structure used by the Justice Department for ballistics testing and auto manufacturers for crash testing-to measure the force of a fatal chest impact. The researchers then measured the potential for injury resulting from the impact, even when the child was wearing a protective device.

    The researchers also measured the intensity of the impact using traditional baseballs compared with softer, heavier baseballs claimed by manufacturers to be safer for children. "We found the softer baseballs and the chest protectors afforded no statistically significant benefit to the players, and in some cases made the injuries worse," observed Janda, whose findings appeared in the Clinical Journal of Sport Medicine.

    He said the soft baseballs were too heavy to be effective. "When we did our high-speed photographic work, we found the softer balls actually stuck to the chest longer, posing a greater risk to damaging the internal organs," Janda pointed out. "It enabled more energy and force to be driven into the heart. The softer but larger-mass balls also pushed off with greater force on the rebound, and we found the force of that 'double-hit' to be additive."

    Janda also reported the special chest protector for batters and pitchers acted like a conductor, funneling the energy into the heart over a shorter time period.

    One important byproduct of the institute's research was the introduction of softer, lighter baseballs. In a study to be published this spring in the Journal of Trauma, Janda and colleagues detail their findings on the effectiveness of these new lighter, softer baseballs.


Teach the fundamentals

    The simplest, and often most efficacious preventive measure, Janda believes, is teaching young athletes the fundamentals of their sport. "We can't overemphasize the importance of instructing players on the proper techniques of their sport, such as sliding in baseball or heading the ball in soccer, so they can play safely."

    For example, some children playing in leagues using the softer, heavier baseballs are not instructed on how to get out of the way of a pitch coming right at them. Many of these children are also assured by their coaches that because the baseball is softer, the risk for injury is much less. "Many of these children panic and step right into the pitch, and the ball hits them in the chest," he said.

    Janda became particularly disgruntled when Ann Brown, director of the federal Consumer Product Safety Commission, recently recommended widespread use of the softer, heavier baseballs, based on information provided to her by the product manufacturers. "That kind of 'blind' recommendation gives folks a false sense of security," Janda said. "It's like claiming that, because a Cadillac and a Yugo are both cars, they are comparable in terms of performance and safety."

crash test dummies.jpg (20422 bytes)Soccer safety

The institute is also researching the incidence of fatalities among young soccer players who hit their head on the goal post, or had the goal post topple over and fall on them.

    After identifying the deaths of 18 children over a 13-year period, Janda and his colleagues began work on a softer, lighter goal post. "It took us about two years to design a goal post that was thinner and which didn't alter the goal dimensions or the rebound of the ball, yet still protected the athlete if he or she ran into it," he said. "We tested the goal post material and it reduces the force incurred by a player's head or neck by over 600/o. We also conducted a two-year field study on the effectiveness of the goal posts, and of 14 player impacts with the post, there were no injuries."

    In a related effort, Janda and colleagues observed soccer coaches as they led their young players in heading drills. He recommends children use a special helmet when first learning to head the ball.

    "We would watch the coaches line the kids up; one child would go first and head the ball a couple of times, and the coaches would commend him as he staggered away," Janda said. "The next thing we knew, we were seeing all these little children staggering around the field like little Muhammed Alis. When we asked the children afterward what they liked most and least about soccer practice, they would always say they disliked the heading drill the most. They said after the drill they felt dizzy, or heard ringing in their ears, or saw two of everything, or they felt like they would throw up. Actually, these are all signs of a mild concussion."

At risk for brain damage?

    Janda and his crew are conducting a longitudinal study of soccer players ages 11 - 13 in Ann Arbor to determine if several years' worth of heading a soccer ball in practice and competition has an effect on their information processing abilities. Janda's project is inspired by a Norwegian study conducted a few years ago of soccer players ages 19 and older who played soccer throughout their school-age and adolescent years. The researchers there reported that 85Wo of those studied demonstrated permanent information processing and memory deficits.

    "Most coaches we've approached about this lean toward tradition, and are not enthusiastic about having their players wear helmets, especially during the games," he said. "Many of them feel their players will be 'wimps,' or they won't learn how to head the ball properly. But by wearing the helmets at least during practice, or using soccer balls with less air during the heading exercises, the players might not leave practice with the kinds of concussive symptoms we've been seeing."

A busy agenda

The institute is also busy pursuing safety product evaluations and research in a number of other areas, including:

alternative coaching techniques in football;

the development and testing of a different type of cleated structure to reduce foot, ankle and knee injuries in football;

a study of non-lethal projectiles used at sporting events for crowd control;

a surveillance study assessing the prevalence and severity of recreational basketball injuries;

the prevention of cervical spine injuries in hockey; and

studies of shin guards and their protective capabilities in soccer

    Proposed projects include the development of future protective head gear for football and biking, improved surfaces for running, and a shoulder injury prevention program.

    As part of the institute's advocacy efforts, the Advisory Council will continue to extend the research findings of the institute to the public. Advisory Council members include leaders from amateur and professional sports-including notables like John Unitas, Oscar Robertson, Walter Payton and Bonnie Blair-as well as community and business leaders who lend their expertise on sports and health care cost-related issues.

Gaining recognition

    Janda said the institute's efforts are slowly gaining recognition throughout the world, and the institute has already assisted the House Subcommittee on Commerce, Consumer Protections and Competitiveness in its investigations of the ethical practices of manufacturers marketing sporting goods alleged to be safer Likewise, the American Academy of Orthopaedic Surgeons developed a position statement advocating the widespread use of breakaway bases, predicated on Janda's research findings.

    Janda has presented his research to the American Orthopaedic Foot and Ankle Society, the American College of Sports Medicine, the Canadian Academy of Sports Medicine, and the National Athletic Trainers Association. He also presented his findings to the French government, and he will be the keynote speaker on sports injury prevention at a meeting this November hosted by the Australian government and the Sydney Olympic Organizing Committee.

    "We all tend to think of sports injuries as being little bumps and bruises, and not having significant ramifications," he said. "But the medical and job-related costs that add up when someone misses work for several weeks and has to have surgery and rehabilitation can be very significant. Some of these athletes may never be the same after their injury, and that's what we want to avoid."

Copyright 2001 The Institute for Preventative Sports Medicine. All rights reserved.