The High Ankle Sprain
By Dr. Don Kirkendall

Most players view an ankle sprain as a nuisance -- a few days off then back to play. I always say that a traditional ankle sprain needs to be treated with greater respect by players, as the consequences of returning to play too early can be considerable.

Most ankle sprains that are incompletely rehabilitated lead to another sprain (or something else far more serious), usually within the same season. The injured ankle can use support for six months or more.

There are other ligamentous injuries to the ankle and we seem to be hearing more about something called a ‘high ankle sprain.’

A typical ankle sprain happens when a player rolls the sole of the foot toward the other foot and damages the ligaments on the outside of the ankle. Like coming down from a jump and landing on someone else’s foot and rolling the foot inward.

The tibia and fibula of the leg are parallel bones that connect with each other at both ends. In between the bones is a special type of ligament (a syndesmostic ligament) that, among other duties, helps hold the two bones in parallel with each other. This seems to be the prime ligament that gets injured.

How this gets damaged can be hard to picture. The most likely cause is when the foot is fixed to the ground while the body above it is internally rotated over the planted foot. This then externally twists the uppermost bone of the ankle (the talus, which sits ‘pinched’ between the tibia and fibula) in comparison with the rest of the foot.

This pries the tibia and fibula apart out of parallel damaging that syndesmotic ligament in the lower part of the leg. If the force is strong enough, damage can happen to the medial side of the ankle, opposite that of a traditional ankle sprain.

The greater the force and the longer the force is applied can damage the ligament further up the leg meaning a more serious injury. Imagine running to the right, planting for a cut to the left and the opponent steps on your foot while you are twisting to the left.

This is not a common injury. We hear about these injuries mostly in sports with rigid ankle support like downhill skiing and ice hockey, but we are seeing reports in other ballistic cutting sports like football, basketball and soccer. When looking at all sports, this unique sprain makes up about only about 10-20% of all ankle sprains.

Players will complain about pain between the bones just above the level of the joint, either on the front or back of the ankle. Usually there is pain with weight bearing and pushing off during movement that can be lessened with specialized diagnostic taping (this taping method is not effective for play) .

The ‘tenderness length’ up the leg is indicative of injury severity. A doctor may perform a series of tests including a squeeze test (just what it sounds like), or externally rotate the foot under the leg, or others that evaluate the position of the fibula in relation to the tibia and foot.

There are others, but outside of the external rotation test, there is no definitive test or image that can be taken to clearly identify the injury. Most imaging is looking for possible fractures or changed relationship of the tibia to the fibula. Some recent MRI imaging methods have shown promise.

The time lost to this injury is very unpredictable. Some studies report only two and a half weeks out while others report two months or more. Many players report symptoms for a long time after the injury. Estimating time lost to this injury is very difficult. For most players and leagues, two months off effectively ends that season.

There is good data showing how to treat a common lateral ankle sprain. Not so for the high ankle sprain. No one can state with any degree of assurance if: the ankle needs immobilization, for how long, in what position, when to allow weight bearing, when to return to sport-specific movement, what specific sporting activities to be used and at what time in the rehab process and many more questions.

There are only 3-4 published papers on rehabbing this injury. Surgery may be required to improve stability of severe injuries. And the sports medicine community is not united in its opinion on early surgery versus non-operative rehabilitation.

The injury is not without the potential for complications, either from surgery or non-operative rehabilitation.

There is much known about this injury…how it happens, the incidence, and how to diagnose it. After that, things get complicated because the best course of treatment continues to evolve.

A player with an unstable ankle who tries to cut and avoid an opponent may be unable to evade contact and suffer a serious, high impact collision injury. For this reason, no player should return to play before the ankle is fully rehabilitated.

As always, never use columns like this to self-diagnose or treat. Always see a qualified sports medicine physician…they are the real professionals.

If you have access to a medical library, a recent detailed summary of this injury can be found in Williams GN. Syndesmotic ankle sprains in athletes. American Journal Of Sports Medicine, vol 35, pg 1198-1207, 2007.

Copyright 2007 Donald T. Kirkendall

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Using All That Oxygen
By Dr. Don Kirkendall
(Second In A Four-Part Series)

Last month, I introduced the topic of oxygen delivery. This month, I’ll talk about how this oxygen is used once it gets to the muscle.

How We Use Oxygen
Once oxygen is delivered to the muscles, the muscles need to make use of the delivered oxygen. Oxygen moves from one place to another by the process of diffusion – this is the downhill movement from a place of high concentration (blood) to a place of low concentration (muscle in this case).

Remember oxygen is carried by hemoglobin in the red cells. When blood enters the capillaries surrounding the low oxygen environment of muscle, oxygen leaves the hemoglobin, passes into the liquid part of the blood, pass through the capillary vessel wall, through the liquid surrounding the cells, then through the muscle cell wall, then into the muscle interior to a hemoglobin-like molecule called myoglobin.

From myoglobin, the oxygen moves to the real engine of the cell called the mitochondria where the energy is actually produced.

“Making Energy”
I use quotes because we don’t make energy. Our energy comes from the sun. What we do is transfer energy from the food we eat to be made available for biologic work. The body is pretty smart. Unlike a car that has one fuel and one way to use that fuel (I’ll ignore the newer hybrid cars), the body has options for fuel and different ways to use that fuel.

In the body, energy is located in a molecule called ATP (adenosine triphosphate). Adenosine is a molecule with three phosphates attached.

Most people think the phosphates are the energy. But the energy is in the ‘glue’ that holds these phosphates to each other and to the adenosine. We get energy when we split a phosphate off the ATP (three phosphates) releasing the energy leaving an ADP (diphosphate - two phosphates).

If needed, we can get energy from the ADP by splitting off a second phosphate, liberating the energy leaving a monophosphate (AMP).
I read one time that if you could put all the body’s ATP in one place, you might fill up a glass somewhere between the size of shot glass and a small juice glass (depending on who’s doing the calculation). So when ATP is used, we better replenish ATP fast because we can run out of the stuff real quickly.

So, when a phosphate is split off an ATP, there is all this energy around for work. Too bad that, the body isn’t a perfect machine. Only about 40% of the energy released is used by the cell, the rest is released as heat.

Ever wonder where your body temperature comes from? From the basal breakdown of ATP and the 60% of available energy released as heat. It doesn’t take much to see that during exercise more energy is needed (breakdown of ATP) and more heat is produced so you body temperature rises.

Anaerobic Energy
The methods of energy production fall under one of two headings: aerobic and anaerobic. “Anaerobic” means in the absence (an-) of oxygen (aerobic).

ATP-PC System
This is a quick, but limited way to get energy. The body constantly exchanges phosphates between molecules. Remember, ATP is a molecule (not the only molecule) where energy is stored between phosphate molecules. Phosphate, and the subsequent energy, also is stored when connected to creatine (the same creatine you’ve been hearing about as a supplement).

When the energy in an ATP molecule is used, a phosphocreatine (PC) molecule transfers its energy and its phosphate to the ADP. What’s left now is an ATP and a creatine. Soon after this transfer, energy and a phosphate must be put back on that creatine so that PC can feed the next ADP.

Energy is always in a state of flux. If things get really tight for energy, the body can use two ADP’s, transfer energy and a phosphate to one of the ADPs. What left is an ATP and an AMP (which may end up as ammonia). As you should see, the body is constantly transferring energy and phosphates around. The body is never in a state where these transfers cease.

The Lactic Acid System
There is a second anaerobic way to get energy. The starting point here is sugar…blood glucose or the storage form of glucose called glycogen. The chemistry of this is difficult for most people. So, I will try to make matters simple.

Glucose is a molecule that contains six carbons. This metabolic process breaks glucose into two 3-carbon molecules. When all the twisting and bending of these 3-carbon molecules is said and done, two new ATP molecules are assembled. At the end of this is a waste product called lactic acid.

Don’t worry about the chemistry of this process. Just accept it on faith. To experience what lactic acid production feels like, run up 2-3 flights of stairs and take stock of your quads.

You can’t make energy as fast through the lactic acid system as you can through the ATP-PC system (lower rate of production), but it can make energy for a longer period of time (greater capacity for energy). The problem with metabolic processes is a waste product that can upset the chemistry (the pH) of the muscle, in this case lactic acid. So the body better have a way to make energy that doesn’t potential damage the tissue with low pH.

Once lactic acid is produced, the body must work to get rid of it – and this is recovery which I always say is the key to success in ball games like soccer.

Next month – aerobic energy production.

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Where Do We Get All That Energy
By Dr. Don Kirkendall
(First In A Four-Part Series)

Most coaches don’t understand or chose not to understand where energy come for physical labor. And that is science, specifically biochemistry.
Exercise physiology is essentially two concepts: the DELIVERY of oxygen to the working muscles and the USE the delivered oxygen (I’ve just summarized eight years of college).

Everything else simply supports the delivery and use of oxygen. I personally think coaching books either go too far into physiology and biochemistry or just ignore it altogether. I’ll be gentle in my discussion in this four-part series.

Delivering Oxygen

To deliver oxygen, it has to be carried and most people remember from biology that oxygen is carried by hemoglobin in red blood cells. Sure, there are details about how oxygen is carried, but just understand that a red cell has only so much space to carry oxygen and blood can only have so many red cells before it becomes too thick.

Want to carry more oxygen? You need more red cells, thus the illegal attempts at blood doping where a very specific protocol is used to remove, store, then reinsert the red cells to increase oxygen carrying capacity sometimes used by hard core endurance athletes like cycling and cross country skiing.

I’ve never heard of anyone attempting blood doping in soccer. The other way is to use drugs that simulate red cells production (erythropoietin, nicknamed EPO). The point is that the blood will only hold so much oxygen, so there must be other ways to move more oxygen to the working muscles.

Appreciate that the heart is one remarkable organ. It works hard for a fraction of a second when it beats and only needs fractions of a second to rest, whether the heart rate is 50 or 200 beats per minute.

Let’s start at rest. When at rest, the body is at its “idle” -- the minimum to operate. You have a certain minimum energy requirement needed to keep things operating and your energy needs are met mostly through energy production with oxygen.

During exercise, the muscles (and other cells) must produce much more energy and they want to do this using oxygen. Now the body has two options. So the muscles just take all the oxygen out of the blood, right? Nope, muscle doesn’t suck the blood dry of oxygen; blood leaving muscle still has quite a lot of oxygen left in it.

The other option is for the muscles to take about the same amount of oxygen out of the blood, but in this option, more blood goes through the muscle and despite the shorter time in the muscle’s capillaries, the “same” amount of oxygen is taken by the muscles.

Increased blood flow is comes about by increasing both the heart rate as well as how much blood pumped is pumped with each heart beat and is called the stroke volume. The product of heart rate and stroke volume is a critical feature called the cardiac output.

Simply put, to deliver more oxygen to the body, you must increase the cardiac output. Now, during exercise, both the heart rate and stroke volume increase up to a point. But stroke volume increases only so much, up to about 40% of a personís capacity, then levels off.

Thus, in order to increase the cardiac output, heart rate must increase.
There are a many cardiac adaptations to training. Probably the most obvious changes are to the heart rate. At rest, you energy needs are roughly the same whether you are fit or not.

When you are fit, your resting heart rate is reduced. Oxygen consumption is very closely related to the cardiac output. So, at rest your oxygen consumption is the same after training (thus, cardiac output is also about the same after training).

Therefore, with cardiac output being the product of heart rate and stroke volume, with the resting heart rate lower, the stroke volume MUST be higher.

During exercise by the fit player, the stroke volume follows the same relative pattern (increase to ~40% of max, then plateau), just that this new pattern is at a much higher level.

One cardiologist I knew used to say the stroke volume of a fit athletes looked like a toilet flushing, so much blood was ejected each beat. After training, the heart rate at the same workload is reduced.

Let’s say, your heart rate before training for a 10-mile jog is 170. Now lets say, you heart rate is 150 at that same pace after training. The oxygen requirement for that 10-mile run is still about the same, so the stroke volume at this pace is greater, the heart isn’t beating as often, and your perception of intensity isn’t as high.

Your maximal heart rate is affected little and may actually drop by a few beats. This explanation is an oversimplification of a complex process.
Next month: Using that oxygen

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Injury Prevention
By Dr. Don Kirkendall

Regular readers of this column know that probably the best way to prevent injuries is simply to improve the level of fitness of the team. I’ve written about reasons why and how to improve endurance, speed, flexibility, proper methods of warm-up and strength training. I discussed ankle and head injuries, head and muscle injuries and more.

But I think what I could improve on is specific exercises for injury prevention. Enough with the concepts--GIVE SOME CONCRETE EXAMPLES!!

The research arm of FIFA is called F-MARC (FIFA Medical Assessment and Research Centre) and is based in Zurich. Last year, the F-MARC people got together to prepare a manual on sports medicine for soccer. This manual has a ton of soccer specific information on fitness, injuries, and prevention.

The centerpiece of the manual is the F-MARC 11. Ten exercises and the call for Fair Play that focus in on problem areas for soccer players that, if done as a part of their regular training, should be effective at preventing some of the more common non-contact injuries in soccer (no program will prevent injuries from that defender charging in full speed with spikes up).
Last month, FIFA had a press conference to announce the manual, the 11, and a nation-wide injury prevention program for youth soccer in Switzerland as the first wide application of the training and injury prevention principles. The F-MARC directors want this program publicized to the soccer community.

I’ve changed some of their grammar, but for this most part, this is as presented by F-MARC. Posters and tapes will soon be available. After a warm-up sufficient to break a sweat, perform these exercises as a team in about 15 minutes. It’s a small price to pay for keeping players unhurt and in the game.

While there is no guarantee that teams will be injury-free because of the 11 exactly as described, there is really good information that programs such as these are very effective. So, here is the F-MARC 11.

#1- The Bench
Purpose: Strengthening of the core muscles.
Starting position: Lie on the stomach. Support the upper body with the forearms. Place the feet perpendicular to the ground. (Looks a bit like a push-up only on the forearms instead of the hands)
Action: Lift stomach, hips and knees so that the body forms a straight line from the shoulder to the heels. Elbows directly under the shoulders. Tighten the abdominal muscles and buttocks. Lift the right leg a few inches from the ground and hold for 15 seconds. Return to the starting position, relax, repeat with the left leg. Perform 1-2 times each leg. Do more reps as fitness improves.
Important: Do not flex the hips or let your stomach drop. Maintain that straight line from the shoulders to the heels.

#2- Sideways Bench
Purpose: Strengthening of the lateral abdominal (core) muscles
Starting position: Lie on one side. Support the upper body with the forearm with the elbow under the shoulder. Bend bottom knee 90 degrees. When viewed from above, the shoulders, elbow, hips and both knees should form a straight line.
Action: Lift the top leg and hips until the shoulder, hip and top leg are in straight line and hold this position for 15 seconds. Return to the starting position, relax, repeat on the other side. Perform twice on each side. Do more reps as fitness improves.
Important: Do not drop the hips or tilt the upper shoulder or hips forwards.

#3- Hamstrings
Purpose: Strengthening the hamstrings.
Starting position: Kneel down (on a towel or shirt if needed) with a straight, upright upper body. Knees and lower legs should be hip width apart. Cross the arms in front of the body. A partner pins the ankles firmly to the ground with both hands.
Action: Slowly lean forward keeping the upper body and hips straight. Thighs, hips and upper body stay straight. Try to hold this straight body alignment as long as possible while leaning forward. When the position can no longer be maintained by the hamstrings then use both hands to control the fall. Perform five times. Do more reps as fitness improves.
Important: Do not bend hips. Perform the exercise slowly. Body control is important.

#4- Cross-country Skiing
Purpose: Strengthening leg muscles.
Starting position: Stand on the right leg and let the other leg hang relaxed. Flex the knee and hips slightly so that the upper body leans forward. From the front, the hip, knee and foot of the supporting leg should be in a straight line.
Action: Flex and extend the knee of the supporting leg and swing the arms in opposite directions in the same rhythm as in cross country skiing. Flex the knee as far as possible while keeping the weight balanced on the supporting foot. When extending, do not lock the knee. Keep pelvis and upper body stable and facing forwards. Perform 15 times on the right leg, then 15 times on the left leg. Do more reps as fitness improves.
Important: Keep pelvis horizontal and do not let it tilt to the side. Do not let knee buckle inwards.

#5- Chest-passing in Single-leg Stance
Purpose: Improve coordination and balance; strengthening of the leg muscles.
Starting position: Two players face each other at a distance of about 10 feet, both standing on their right leg. Knee and hips should be slightly bent. Keep the weight on the ball of the foot and lift the heel from the ground. From the front, the hip, knee and foot of the supporting leg should be in a straight line.
Action: Throw a ball back and forth with one hand; standing on the right leg means throwing with the left arm and vice versa. Catch the ball with both hands, and throw it back with one hand. The quicker the exchange of the ball, the more effective the exercise. Perform 10 times on the right leg, then 10 times on the left leg. Do more reps as fitness improves.
Important: Always keep knee slightly bent. Do not let knee buckle inwards.

#6- Forward-Bend In Single-Leg Stance
Purpose: Improve coordination and balance; strengthening of the leg muscles.
Starting position: Just like exercise 5.
Action: Like exercise 5, but before throwing back, touch the ball to the ground without putting weight on it. Perform 10 times on the right leg, then 10 times on the left leg. Do more reps as fitness improves.
Important: When viewed from the front, hip, knee and foot of the supporting leg should be in a straight line. Keep weight only on the ball of the foot, or lift heel from the ground.

#7- Figure-Eight’s In Single-Leg Stance
Purpose: Improve coordination and balance; strengthening of the leg muscles.
Starting position: Just like exercise 5.
Action: Like exercise 5. Before throwing back, swing the ball in a figure-8 through and around both legs: first around the supporting leg with the upper body leaning forward, and then around the other leg while standing as upright as possible. Perform 10 times on the right leg, then 10 times on the left leg. Do more reps as fitness improves.
Important: When viewed from the front, hip, knee and foot of the supporting leg should be in a straight line. Always keep knee slightly bent and do not let it buckle inwards.

#8- Jumps Over A Line
Purpose: Improve jumping power and technique.
Starting position: Stand on both feet hip width apart, about a 1 foot to the side of a field line. Bend the knees and hips slightly so the upper body leans a little forward. When viewed from the front, hip, knee and foot should be in a straight line. Arms are slightly bent and close to the body.
Action: Jump with both feet, sideways back and forth over the line and back as quickly as possible. Land softly on the balls of both feet with slightly bent knees. Jump 10 times side to side, then 10 times forwards and backwards over the line. Do more reps as fitness improves.
Important: A soft landing and quick take-off are more important than the height of the jump. Spend as little time on the ground as possible. Do not let knees buckle inwards.

#9- Zigzag Shuffle
Purpose: Improve coordination and jumping technique.
Starting position: Stand at the start of the zigzag course (6 marks set 10 x 20 yds), legs shoulder width apart. Bend the knees and hips so the upper body leans substantially forward. The lead shoulder points in the direction of movement.
Action: Shuffle sideways to the first mark, turn so that the other shoulder points to the next mark and complete the zigzag course as fast as possible. Always take-off and land on the balls of the feet. Complete the course twice. Do more reps as fitness improves.
Important: Always keep upper body leaned forward with the back straight. Run quietly by absorbing ground contact with the knees, do not let them buckle inwards.

#10- Bounding
Purpose: Improve jumping power and technique.
Starting position: Stand on the take-off leg with the upper body upright. The arm of the same side is in front of the body. When viewed from the front, hip, knee and foot of the take-off leg should be in a straight line.
Action: Spring as high and far as possible off the supporting leg. Bring the knee of the trailing leg up as high as possible and the opposite arm bent in front of the body when bounding. Land softly and quietly on the ball of the foot with a slightly bent knee. Cover 30 metres twice. Bound further as fitness improves.
Important: Do not let knee buckle inwards during take-off and landing.

#11- Fair Play
Purpose: Know that a substantial amount of football injuries are caused by foul play. Observance of the laws of the game and especially Fair Play are essential for the prevention of football injuries.
Important: Play Fair!

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FIFA Fair Play
By Dr. Don Kirkendall

Before every international match under the auspices of FIFA, you see the teams enter the field, sometimes escorted by children and led to the center of the field before kickoff. Behind the players there will be a large yellow flag with the insignia of the FIFA Fair Play for all to see.

Ever wonder what that means? I mean, it’s just some slogan on a flag.
I had occasion to visit FIFA House in Zurich recently and learned that the Fair Play motto extends to virtually every aspect of the game and serves as the foundation of commitment to the game at all levels. “It is FIFA’s mission to ensure that the good image of football is always maintained throughout the world. Special attention is paid to promoting the concept of Fair Play, with a world-wide campaign aimed at education and ethical values, including the fight against racism and attempted corruption in football.”

In order to strive toward these lofty goals, FIFA has 10 statements of fair play that, on the surface, might seem obvious, but look closer and one can see that almost every week, some aspect of fair play is tempted. And these tenants are not mutually exclusive; there are interconnected in every aspect of the game. You can’t pick and chose. For the good of the game, all connected to soccer are to abide by them all.

1. Play to win. This might seem obvious, but there are circumstances that might have 1 or more players on a team that might not be trying to win. There are circumstances where a team may play for a tie. But FIFA implores to play always to win. Anything less shows disrespect to the game.

2. Play fair. Again, an obvious consideration. But haven’t you seen a player’s jersey pulled? The professional foul? A player writhing on the ground?

3. Observe the Laws of the Game. Play within the laws as they are set down and don’t try to stretch an interpretation. I saw a U10 game once. After this one team took a shot, 5 players stood, fingertip-to-fingertip, across the top of the penalty box forming a gauntlet for the coming goal kick. Now for this age, a goal kick is quite a challenge. Yes, this team observed the Laws, but ignored the statement against unsportsmanlike conduct.

4. Respect opponents, teammates, referees, officials and spectators. Ever see one player spit at another? Gesture at the ref once the back is turned? Curse at the opposition? Make obscene gestures to the crowd? Of course you have.

5. Accept defeat with dignity. This was very visible at the World Cup this year. Practically every team left the field with their heads held up. The image of the US team after their loss to Germany was a great statement of this.

6. Promote the interests of football. If it is good for the game, within these 10 guidelines, then promote.

7. Reject corruption, drugs, racism, violence and other dangers to our sport. For the most part, soccer has been resistant to drug use when compared to other major sports like cycling, cross country skiing, American football, baseball, ice hockey and others, but racism and violence are still problems, particularly in the stands. Thankfully, the issue of corruption is rare.

8. Help others to resist corrupting pressures. The financial state of the game is somewhat precarious is some countries and there might be outside pressures that could damage the game. It is everyone’s responsibility to keep corruption out of the game.

9. Denounce those who attempt to discredit our sport. Luckily in the US, the people who denounce our sport are usually uninformed media out to make some waves. I liked the survey prior to the 94 World Cup here in the US that said two-thirds of the country didn’t even know it was being held. So? That meant there were 80-90 million who did! Did you realize that in 2002, the US was the second largest country participating (to China) with the 2nd most participants (to Brazil). Speak your mind and defend our sport without taking the defensive stance that the anti-soccer media loves.

10. Honor those who defend football’s good reputation. This begins with your teammates, and extends to parents, coaches, refs, local, state, national and international administrators. It’s the only game the world plays and it is our duty to protect it.

Copyright © 2003 Donald T. Kirkendall

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You Need Water
By Dr. Don Kirkendall

The national news shows are reporting the drought across the desert southwest is the worst on record. Lake Powell water levels are down an astonishing 115 feet. Hollywood is remaking the classic football movie The Longest Yard (why I wonder, but I digress) …at a New Mexico detention center, the producers want natural grass and the locals are having a fit about the amount of water needed to keep the grass green. Water really can be an item of importance and debate, regardless of the setting.

I have just returned from my annual trek to the American College of Sports Medicine meeting where all things science and activity are on the agenda. You would think that the issue of water and sports would be well hammered out, but it really hasn’t. About the only thing known for sure is this: withholding fluids (whatever the fluids are) is flat wrong, bordering on negligence. Just because Denzel Washington, in Remember the Titans, told his football team that ‘water makes you weak’ is hardly an endorsement or justification to restrict water intake. It’s the recipe and guidelines that is the root of confusion. For example:

• When we work out, we sweat. When we sweat, we lose weight. Therefore, we should try to drink fluids to prevent weight loss. Not so fast. Anyone training who is trying to match fluid intake with sweat loss will feel bloated and likely get nauseous and could very well vomit. So how closely should intake and losses be matched? Most athletes will sweat more than they drink, and about the maximum difference that can be comfortably tolerated is 2%. Thus, a 150lb player who adequately drinks during training might weigh 147 after practice…if they can keep up with sweat losses. Not as easy as it sounds. The more practical guideline is to try to regain the weight over 24 hours (I was in a study once where we were to replenish 4% sweat losses in 4 hours-typical time from weigh-in to wrestling. No one could do it and the one who did got sick).
  
• All you have to do is drink water. Nothing is better than water. Not so fast on this one. Water is only good if it stays in you and pure water doesn’t stay in the body very long. Go work out and look at the color of the urine…pretty yellow and concentrated. Drink lots of water and the next couple urinations will lighten up. This is good. But a little later, the urine will darken up again. However, if the fluids have some salts in it, more water stays in the body…the urine will lighten up and stay lighter for longer periods.
  
• Everybody sweats, so everybody drinks the same because everybody sweats the same. Yeah, right. Look at your teammates or other people working out. Some sweat big time, others hardly seem to sweat and do you really think your sweat tastes as salty as your teammates?. Obviously, there is more fluid being lost by one than the other. However, the salt concentration of sweat varies a great deal between people. The big time…Man U, Ajax, Juventus, AC Milan, Real Madrid, etc. all test the sweat concentrations of their stars and prescribe drink make-ups specific to the player…Hey, these guys are worth millions and the owners are going to do anything to keep their stars healthy and on the field. You can’t get this done (well, yes you could…it isn’t all that hard, just need access to a good university exercise science program and a few bucks to pay for the service-write me, I’ll give you the name of the closest people to you). Anyway, it is kind of scary just how good the sense of taste is. The heavy salt sweaters, given the choice, will chose the more salty drinks while the lighter salt sweaters will favor less salty drinks. Thus, have water and a sport drink available and let the players satisfy their thirst however they want….they will probably do a pretty good job of mixing the salt and water needs.
  
• A final bit of logic to consider. In long term events (triathalons, ultramarathons) have had people drink too much water and develop some pretty severe symptoms indicating that their system is too diluted. I only bring this up because of the number of summer tournaments being contested with players playing multiple games in a short period of time. The fluid balance of salt and water is pretty closely balanced by the kidneys – get too much or little of either and the kidneys will adjust whether water or salts get dumped or kept to ensure proper balance. One problem with the kidney blood supply is that during exercise, the blood flow slows down to divert blood to the working muscles meaning less blood flow and subsequent urine volume. Now we all know that sweat is a combination of salt and water meaning we are losing both when we sweat. Now if you only drink water, you are only replacing the water lost, not the salts. Water is absorbed by the GI system pretty quickly….far more quickly than the kidneys filter the blood. Thus, the delicate salt and water balance of the body is being diluted by drinking just water. Thus, it is also a good idea to have both water and a sports drink available and let the kids choose. Keep it close, available, and cold (important).

A couple other items from ACSM.

1. This one hit the papers recently. I can’t remember the country, but the water bottles made available to the opponents had been tainted with a powerful tranquilizer in an attempt to gain an advantage.
2. The potential for tainting of supplements (and the possible positive drug test) is pretty high. After a manufacturer prepares and bottles a supplement, the machinery must be cleaned (the most expensive part of the entire process for the supplement manufacturers) before working on the next item. If the prior item has a banned item, it can show up in the next batch and you are stuck. Willing to take that risk?
3. Most supplement suppliers procure their raw ingredients from the cheapest source possible. One Chinese supplement company routinely found positive tests for testosterone. Their plant shows no presence or contamination, but it turns out that one of their suppliers supplied tainted material.
4. OK, so go after the suppliers. How? You test positive and blame a company for that positive test. Can you conclusively say that once the bottle was opened that the product wasn’t contaminated after the fact? That is the defense the producers would take…
5. The chance of testing positive may be small, but when a positive test pops up, just try getting out of it. There were 2 positive drug tests at the Euro 2004…the first for the Euro. One was for a performance enhancing drug, the other for a corticosteroid-a medically prescribed drug that the doping control officers were aware of….so far.

By the way, as a lover of the beautiful game, I am always looking for the opportunity to watch great games, and I find too many Americans will pass on such a chance. If you missed the Netherlands v Czech Republic game at the Euro on Saturday June 19, you missed what I think was probably one of the greatest modern era games (Czech Rep won 3-2 after being down 0-2). Brilliant individual and team offense, world class saves, idiotic moves by coaches, 30m shots off the crossbar…worth the price if it comes out on DVD. Much to be admired, learned and appreciated no matter what the interest level of the spectator.

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Research You Can Use –
Further refinements in sport drinks
By Dr. Don Kirkendall

When new sports science information is published that might be pertinent to the game, I like to alert the coaches because new data typically is published in a place that is advantageous to the author (promotion and tenure considerations), but not in a place where the information will impact the athletes and coaches. A recent study adds further data in the ongoing study of nutrition and physical performance. In the July issue of Medicine & Science in Sports & Exercise, the research team at James Madison University headed by Dr. Mike Saunders reported evidence that consuming a modest amount of protein in a sport drink during exercise increases endurance, reduce muscle damage, and enhances recovery. I have reported on similar findings for Soccer Journal, but this project had better experimental controls that make it more applicable to the practicing athlete.

Fifteen male cyclists completed a stationary ride to exhaustion while drinking either a conventional carbohydrate sports drink (Gatorade®) or a drink containing carbohydrate and protein in a 4:1 ratio (Accelerade®). The following day, the cyclists completed a second ride to exhaustion at a higher intensity, this time without drinking anything. Muscle damage (from serum CPK levels) was measured before the second ride and performance on both rides was determined (how long it took them to reach exhaustion). When reviewing articles that compare two products, ethical disclosure requires that the researchers declare whether they or this project has received money from one of the manufacturers to sponsor research. Dr Saunders and colleagues received no money from either product to conduct this study. You may have noticed that Soccer Journal has had advertisements for Accelerade® in the past.

On average, the subjects were able to cycle 29% longer in the first ride and 40% longer in the second ride when given the carb:protein drink. In addition, muscle damage (CPK levels) were 83% less when using the carb:protein drink.

According to Dr. Saunders, director of the Human Performance Laboratory at James Madison University, “This study provides further confirmation of the value of adding protein to a conventional carbohydrate-electrolyte sports drink. Our results suggest that athletes in all sports where endurance and recovery are critical would benefit from a protein-containing sports drink.”

Just how the addition of protein to a drink aids subsequent performance is not well understood. It is known that simply adding more carbohydrate to a conventional sport drink does not make it more effective. There seems to be a special interaction between carbohydrate and protein, but determining the specific nature of this mechanism will require further study. An increasing body of work suggests that carb:protein drinks work; the question is how they work.

There are two thoughts about how the addition of protein to a sports drink might reduce exercise-related muscle damage. The protein may raise amino acid levels in the blood. Elevated levels of blood amino acids have been shown to reduce muscle protein breakdown. The protein in the sports drink might also be used for energy during extended exercise, resulting in less breakdown of muscle protein as a source of energy that can occur when muscle glycogen levels are severely depleted.

Now, some might say that the carb:protein drink was successful because it had more calories than the carb alone drink, but I seriously doubt that the few extra calories as protein would lead to a 40% improvement in performance the next day. The math could be done…the extra calories needed for the next ride is far more than the extra calories added by the protein in the drink.

One of the problems faced in soccer is the short recovery periods between matches. Soccer is not scheduled as rigidly as is football. In scholastic or collegiate seasons, games could be played with 1-2 days rest. Club tournaments can have multiple games in the same day, so preparation for the next match really does begin right after the one just finished. You can’t rely on the players to make the best decisions regarding preparation during a short recovery window. One of my main mantras on recovery between matches or practices involves food choices and when the right choices are to be eaten after exercise. And if you aren’t paying attention to this 2nd most critical factor in performance (after physical training) and your opponent is, then your team is going into matches at a competitive disadvantage. I know of teams who, through booster clubs, have an ‘assistant coach for nutrition’ whose responsibility it is to make sure the players make proper food choices…these folks aren’t low carb types either! Parents and boosters may choose a low carb diet, but that would not be helpful for competitive athletes.

The interesting part of this project was that the diet after the first ride was standardized so the added work the next day was not due to eating lots more carbohydrate. The authors suggest that reduced muscle damage could at least partly explain why the cyclists given the carb:protein sports drink on day one were able to perform so much better than their counterparts on day two. This particular result has important implications for athletes who train hard every day, like your players do.

At this time, Accelerade is the only sports drink on the market containing the 4:1 ratio of carbohydrate and protein that has proven so effective in the new study and in previous studies. It should be used in the same way as a conventional sports drink. Players should consume 4-6 ounces every 12-15 minutes throughout each practice and game and an additional 8-12 ounces immediately after practices and games to further boost recovery

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Speed Development For Soccer
By Dr. Don Kirkendall
(Part 1 of 6)

Regular readers of this column will attest to my bias that the fitness component that is most important to success is soccer-specific endurance - a good aerobic capacity to speed recovery from fast running. What I haven’t addressed is the faster running part of that statement - speed. This is a topic that UNC coach Elmar Bolowich suggested that I address. In his travels, he sees many teams that make little attempt to develop speed and thinks players and coaches want ideas of how to improve speed.

In the mid 1950’s the nature of the game changed forever when the great Hungarian national team destroyed, dismantled and wholly embarrassed England 6-3, in Wembley. It was a game that was not as close as the score indicated. Observers of that game commented on the remarkable speed and work rate of the Hungarians. Why, the Hungarians had 4 or 5 players who could run the 100 meters in 11.5 seconds or less!

I first started paying really serious attention to the World Cup in 1974 and read that all the field players from the former East Germany could run under 11s for the 100m - from 4-5 players under 11.5s to the entire team under 11. Nowadays, 11.5s speed might not be fast enough for a good high school team.

The game I see today is played so much faster than the game I played. Is that a result of a better athlete, better coaching, or something else? I would like to think it is the first two, but I also see coaches using the free substitution rule to encourage players to run as fast as they can - get tired and then be pulled for a rest.

So players have the mindset to sprint whenever they are on the field. If you have watched recent NCAA men’s finals you have seen teams that try to play at a high pace all game vs. teams that play a more controlled pace and use speed selectively like past winners Wisconsin, St. John’s and UNC.

Speed is an elusive creature. Is it innate or can it be developed? What goes into the concept of speed? The first player to the ball may not be faster than the opponent. Some people just consistently get there first.

The great Larry Bird of the Boston Celtics was never to be confused with a sprinter, but he always seemed to be in the right place. Was it speed afoot or speed of thought or both? Ajax uses their TIPS plan to evaluate 16-year olds: technique, intelligence, personality and speed and they consider speed as the trait with the least potential for improvement.

The University of Pittsburgh’s coach, Joe Luxbacher, describes speed as having seven components: perceptual speed (using the senses to decipher various elements of game), anticipation speed (predict what will happen before it happens), decision-making speed (making decisions in the shortest amount of time), reaction speed (ability to react to some action by teammate or opponent), speed without the ball (maximum movement speed), speed with the ball (movement with the ball at highest possible speed), and game action speed (make effective tactical decisions to changing conditions).

If you look closely at this list, you will see that much of the different aspects of speed are related to speed of thought and decision-making. These are things that can only be developed by playing the game.

Yes, “the game is the best teacher”, but you can help it a bit. It is fairly easy to modify small-sided games to require players to recognize, anticipate, decide, react and act more quickly. Just reduce the size of the field putting more players in a smaller space, so defenders are on the attacker quicker. This will force both offense and defense to speed up the thought process. 6v6 in half a field can be speeded up dramatically by just playing in the penalty area.

Obviously, skills need to be very good to be successful (the T of the Ajax TIPS program). In games like this, the opponent grabs a missed trap very easily. If you don’t have good skills, you can’t play in a game like this. And most defensive tactics today are geared toward reducing the size of the field and putting more players in a small space.

Physically, development of speed is largely based on improvement in running form. And from experience I can say that the running form of soccer players will never be confused with that of a sprinter in track. Speed specialists like Vern Gambetta think running speed can be thought of as combinations of starting speed, acceleration, top end speed, deceleration and matching speed with teammates (think of the running back that out runs his blocking).

In addition, remember that agility and speed are two different animals. The fastest players are not necessarily the most agile and the most agile may not be the fastest. Elements of agility and lateral speed involve recognition, reaction, decisions, balance, footwork, change of direction, and avoiding obstacles.

Over the next three columns, I will address the concept of speed and how it can be improved. Realize that what you will see are suggestions to improve specific aspects of speed by improving the mechanics of running.

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Improving Straight Ahead Speed
By Dr. Don Kirkendall
(Part 2 of 6)

Last time, I introduced the concept of speed being part mental (e.g. decisions and anticipation) and part mechanical (running form). Straight ahead speed has been broken down by conditioning specialists like Vern Gambetta as starting speed, acceleration, top speed, deceleration and cooperative speed.

Starting speed is largely a response to some stimulus that involves a series of cognitive processes. For example, you are covering a striker. Their midfielder sees your striker, looks down, and strikes the ball. Who gets to the ball first? In order to intercept this pass, you have to make a number of decisions quickly - what space is the striker moving to? Is the ball played to feet or space? How fast are they moving? What is your speed? When do you have to start running to beat them to the ball? How about the pace and spin on the pass? How do you time your response to the pass in relation to the striker’s speed? Is the ball on the ground or in the air? If in the air, you have to plot out the flight of the ball and determine where on the field and your body (head, chest, foot, etc) you plan to first contact the ball, then add in the opponent’s skills and speed. Then factor in what you will do with the ball. Control? Head the ball? One-touch? Two-touch? Shot? Clear? To whom/where? All this and more are done in fractions of a second, every time something with the ball changes. These are all part of those mental features that end up being speed of thought and reactions. These aren’t reflexes; these are reactions - not the same thing. A reflex, like the knee-jerk reflex, doesn’t involve the brain. A reaction does because there is input from many places to process and interpret and then decide on a coordinated response.

How does one get better at this? Deliberate practice and repetition. Some say the real difference between the elite and the not-so elite is that the elite has practiced skills so much that the execution of the skills is 2nd nature, performed on a subconscious level so-to-speak, that lets the conscious part of the brain focus on tactics, not skill.

But the running part can be improved. This too is mental because improvement in running speed is largely changing how you run, the skill. In soccer, improvement in top end sprint speed is not all that important. Why? Look at 100m sprinters. These runners don’t reach top speed until the middle third of the race; it takes 30m to reach top speed. In soccer, full, all-out sprints (i.e. over 30m) are pretty rare. Most runs are of 30m or less.

What that means is that the time spent teaching one to increase top-end sprint speed might be time better spent on other lessons - like the first 30m where the player is reacting and accelerating, but never quite reaching top speed. Thus, the initial first steps are important.

Break the form for the first steps down and 3 factors are critical: posture, arm action, leg action; the acronym is PAL.

Posture-Most people bend at the waist when running, especially when taking off. While it is correct to lean forward when accelerating, the lean actually comes from the ankle, not the waist.

Arm Action-We all know the arms and legs work together diagonally; right leg and left arm forward. An exaggerated arm action in height and rate of arm swing helps the leg action when running fast.

Leg Action-The first 4 to 6 steps should focus on pushing against the ground in such a way as to propel the body forward. This is where many young players err. They mistakenly think that by taking big first steps they will cover a lot of ground fast. If that first step is long, then they are actually slowing themselves down by applying a braking force until their body gets over and beyond this lead foot and they can start pushing against the ground to go forward. If these first few steps are short, all their effort goes into pushing against the ground and propelling themselves forward. After 4 or 5 steps, they can then stand more erect and bring their hips under their trunk.

Warming up for speed training

It is very important to prepare the muscles for speed work. This kind of high intensity work can cause an unprepared muscle to pull (strain). Warm-up seems to protect muscles from strains. Popular activities include pendulum swings of the legs both sideways and front-back, carioca with long strides, short strides, in a partial squat and standing tall, high stepping, high and long reaching, ‘volley traps’, and passive stretches of the hams, quads and groin. Some people like using hurdles and elastic bands.

A progression for teaching acceleration

POSTURE: Start in the time-honored ‘ready position’ with the legs bent, feet shoulder width or more apart and arms loose at the sides. Girls really need to learn this position. For some reason, they don’t get into this position properly. Now, lean and take 5 short (and quiet) steps forward walking, turn and repeat jogging. Stress short steps. Next, with a partner facing in front, have the player lean straightforward and the partner uses their hands to catch the player by the shoulders. Keep the body straight and hold the position for about 5 seconds to get used to the position. Get used to the lean at the ankles, not the hips. Now, repeat and run out 8-10 steps emphasizing the first 4-5 should be short strides. Finally, repeat without the partner - lean forward at the ankle into short strides for 8-10 running steps.

Arm action can be practiced stationary and some players might think it looks odd to spectators. Standing, perform a very exaggerated arm swing, all the way up, down and way back. Then sit straight legged and repeat, only now the arms are bent to not hit the ground. Do a lot of these. With vigorous arm swing while seated, the player can almost raise their seat off the ground. Now stand, feet staggered, and exchange arms back once, as fast as possible. Right hand up in front of the face, left back at the hip. On command, switch as fast as possible. Repeat lots of times, but only one switch then stop.

Leg action is trained with a partner, too. First do some knee hugs by bringing the bent leg and knee as close to the chest as possible - hug it in. Next, repeat that partner drill where the player leaned into the partner and the partner caught the shoulders. Only this time, the partner resists while the player pushes for 4-6 strides. Then vary this with the partner resisting strong for 3-4 steps, loosen up for 3-4 steps, then quickly let go, turn and run off so that the player must chase. Now lean into the partner and the player hugs a knee. The partner releases and the player now has to get the foot down and take off to run out.

Other activities for acceleration can be used to get them used to feeling the speed. For example, if there is a slight slope, have them do these drills going downhill, or do the take-offs downhill. Or have them walk, then on command, execute their new skills to accelerate into a run. Or have them do 2-legged hops forward or to the side, then on command sprint out as fast a possible. Or do a carioca then sprint out in any direction. Perhaps have them jump back and forth over a ball 3-5 times, then sprint out. Or scramble up from a push-up position. Or have them take the first step in one direction and move off in another direction. Maybe do a 2-footed jump, then on landing do a 180 and take off. All the time using the proper form of posture, arm action and leg action.

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Recovery Within A Game....
The Importance Of Endurance
By Dr. Don Kirkendall
(Part 3 of 6)

Coaches are forever trying to design their training to improve the performance of their athletes by trying to join fitness-technique-tactics together.

If you can’t control the ball, you won’t execute the tactics. You may be well skilled, but can’t run the full 90 minutes or you can be fit, and skilled, but don’t know how to attack a defense or . . . you get the picture.

Most coaches are pretty good at teaching skill and tactics - that’s fun. It is the fitness aspect that perplexes many coaches. This game requires most aspects of fitness: endurance, speed, power, strength, etc.

You have read my comments in earlier articles suggesting that the teams with the most endurance are the most successful. But just because you can run 3-4 miles at a good clip doesn’t mean you have soccer-specific endurance.

The game has many aerobic periods (walking and jogging) as well as periods where aerobic energy isn’t coming fast enough so you add energy produced anaerobically and that makes you tired.

So, we tend to neglect an important aerobic period, recovery from higher intensity exercise. In my opinion, the key to physical performance in soccer is your ability to recover quickly from one run so you can run again, sooner or at a faster pace than your opponent the next time you have to run.

Plus, games may be scheduled less than 48 hours apart, so you have to recover from the first game to be ready to play the next game. This article is the first of a 3-part series on recovery.

The game is comprised of repeated short bursts of hard activity broken up by periods of lower intensity running and standing. When you walk or jog, you get energy from the use of oxygen metabolizing fats and carbohydrates (glucose and glycogen) into waste products of carbon dioxide and water that are easily handled by the body.

When you increase the speed of running to a cruise, sprint, or when dribbling (the most intense part of the game), you add energy from the anaerobic metabolism of glucose/glycogen. Only now you get a waste product that is not handled well by the body - lactic acid.

Once produced, the body has to get rid of the lactic acid and this is done during recovery while running slower, walking or while standing. During this reduced intensity work, you still inhale lots of oxygen - the more oxygen your lactic acid-filled muscles can use (a function of training), the faster the lactic acid is eliminated.

Therefore, to teach the body to learn to recover fast, you must train to recover. This is done by playing games that have restrictions to force intensity and limit recovery, usually small sided games with lots of dribbling and minimal rest.

Practice 11 v 11 games are not intense enough and have too many long rest periods to be effective. The body must learn that it has to eliminate lactic acid quickly, so you force high intensity play with minimal rest during these small-sided games. This will promote a good aerobic system - the key to fast recovery.

The fuel for the game is part fat (for low intensity work) and glucose or glycogen (for low and high intensity work). Even the leanest player has plenty of fat to fuel a game, but the problem is that the body really has to work at metabolizing fat and as such, you can’t run real fast if fat is your main fuel.

Carbohydrates on the other hand can fuel the production of energy very quickly, thus you have the energy quickly to run faster. The problem is that the carbohydrate tank is limited and if you run out, you slow down because fat is the primary fuel if you run out of glycogen.

Most players start to run low on carbohydrates in the last 15-30 minutes of a 90-minute game. If this happens, you can’t run as fast or run fast very often because you are low on fuel (carbohydrates).

So, you may have a good aerobic system, but if you have no fuel to power yourself for high intensity work, you won’t be able to run fast. Ever wonder why so many goals are scored late in a game?

There are ways to boost energy while playing. We know that most players don’t eat real well (too little carbohydrate at the wrong times of the day) and go into the game with a less than optimal tank of carbohydrate fuel.

If a player consumes some carbohydrate right before the game and at halftime, he/she can keep their blood glucose levels up and give the muscles some fuel they wouldn’t have had. You can increase your power output (running volume and intensity) late in the game this way. This has been shown in soccer, running, cycling, triathalon, and other sports where low carbohydrate is a factor in fatigue.

While some players can eat candy of some sort, most people don’t like the solid food in their stomach while playing. New drinks have been formulated to deliver lots of carbohydrate that can be absorbed by the small intestine that is then delivered by the blood to the muscles in need of the fuel.

The carbohydrate is formulated is such a way that it shows up in the blood within a few minutes. Carbonated sodas are never the correct choice. Instead try products like EnduroxR4 or GatorPro, PowerAde, or others you might find in a nutritional or grocery store.

But training to recover fast, and drinking the right source of carbohydrates for that game is only one part of the recovery process. Now you have to recover from the game to play the next game. That involves repairing the damage to muscles that occurs as a result of exercise and refilling your fuel tank so you have more fuel for exercise in your tank than your opponent - the topics of parts #2 and #3.

You will see that research has led to advances in post-exercise recovery that have been incorporated into new products that can help prepare for, and recover from, competition.

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Recovery Between Games...
Repairing Muscle Damage
By Dr. Don Kirkendall
(Part 4 of 6)

Recovery is a fact of life in the exercise business. You run hard, you continue to breathe hard when you stop - recovering from that run. You exercise a lot on any particular day (especially exercise you are not accustomed to) and you feel sore the next day or so.

In addition, for long hard practices you run down the fuel used by your muscles. While recovery between runs during a game is critical to your teams performance, recovery in the hours after a game is critical to your performance in the next game(s). Recovery from the soreness you feel the next day is today’s topic.

Let’s say you have been playing pick-up soccer during the off-season. Your coach calls and says a tournament has been scheduled the next weekend. Your current level of play has prepared you for one thing: pick-up games. Real competition is at a much higher level of running volume and intensity that you are not prepared for and you know how you are going to feel the next day - sore.

Your joints have less range of motion, muscles may be tender to the touch, may take longer to get loosened up, maybe even some swelling. And it all goes away with time. You may have even had a coach who said the best thing for sore muscles is to do whatever it was that made you sore in the first place (old adages have some truth in them).

Ever wonder what it was that made your muscles sore and what you might do to minimize future soreness?

The soreness you feel is actual physical damage to the muscle cells in predictable locations. For those of you who know some muscle anatomy, the damage is found where the actin and z-lines unite, mostly near the muscle-tendon junction. Muscle cell walls are also at risk for damage.

The cause of damage is less well understood. One thought involves lengthening contractions of muscles during high-tension activities. For example, you get sore from lowering the weight during a forearm curl (lengthening contraction), not from raising the weight (shortening contraction). You don’t use as many cells when lowering the same weight so each cell is doing more work. In soccer, soreness comes from landing from jumps, stopping, slowing, changing directions and other activities.

There is growing evidence that oxygen, that most important element in life, can actually trigger reactions within your body to create toxic compounds called free radicals. These highly reactive and unstable compounds have the potential to cause damage to muscles and other cells.

If you exercise in smoggy conditions, you increase your intake of ozone and nitrogen oxide leading to even more free radicals. These free radicals can strike the walls of your muscle cells, mitochondria, heart and blood vessels and are partially to blame for muscle damage, soreness and reduced endurance.

So how do we repair the damage of exercise? One way is to exercise. One of the fastest adaptations to training we have is attacking soreness. Do something new on Monday and you are sore Tuesday and maybe Wednesday. Do that same exercise again the next Monday and you have little or no soreness the next days - that is rapid adaptation. But just because you don’t “feel” soreness doesn’t mean there is an absence of tissue damage. There still is some damage.

What about those free radicals? Our bodies are smart and know how to deal with these compounds. We have enzymes referred to as “anti-oxidants” (superoxide dimutase or SOD for you chemists out there). In addition, there are classes of vitamins that possess antioxidant properties to help repair tissues and inactivate free radicals. The primary vitamins with antioxidant properties are vitamins C and E.

After exercise, the damage to the muscle cell walls allows some proteins to leak into the blood. The main indicator of cell damage is an enzyme called CPK (creatine phosphokinase). When this is in the blood, there is muscle damage somewhere.

Multiple studies have shown that athletes who supplement their diet with vitamins C and E have less overall muscle damage (less CPK) and faster recovery from exercise (CPK in the blood disappears faster). This is the case no matter if the antioxidants were ingested separately (pills or from food) or as part of a nutritional supplement (a drink).

There is ample evidence that athletes should supplement their diet with vitamins C and E. The RDA for vitamin C is 60 mg/day (in 1996, NIH recommended 200 mg/day), but doses of 500-1000mg/day raise the antioxidant pool sufficiently (don’t overdo it, excess vitamin C can lead to diarrhea).

The RDA for vitamin E is 30 IU/day, but years of high doses (800 IU/day) have shown no untoward effects. Research has shown 200-400 IU/day is sufficient to improve recovery from exercise.

Getting this amount of vitamins can be a problem. Vitamin C is found in most fruits and vegetables while vitamin E is most commonly ingested in fats/oils, meats, nuts, and legumes, but can be found in many sources.

The training athlete may need to ingest extra vitamins as a supplement. You can get these as pills or in some of the current sports drinks. Current drinks that contain vitamin C and E are Endurox R4, IsoStar and Hydrafuel, however, Isostar has no carbohydrate (see October Southern Soccer Scene article on the importance of carbohydrate during exercise), so your choices are limited.

Coming next month: Getting a leg up on your opponent - replacing spent fuel.

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Recovery After Games
By Dr. Don Kirkendall
(Part 5 of 6)

Some sports are rigidly scheduled like football - one game/week with seven days to prepare for the next game. The schedule of other sports, like soccer, basketball, and ice hockey can have variable days between contests and tournaments may have only hours between games. The problem is how to best use the time between contests. The focus here is on food choices and timing to ensure that your ‘gas tank’ is as full as possible for the next game.

Regular readers will remember that lack of fuel (muscle glycogen) is one of the primary reasons for fatigue in soccer. When muscle glycogen is low, the distance run and running speed both decline, especially during the second half.

With three or more days between games, there is enough time to refill the muscle glycogen tank. If there is less than two days between games, and the player doesn’t follow some simple guidelines, they will likely enter the next game with less glycogen. This means they will tire earlier in the game because they run out of fuel sooner.

There are three main factors that go into rapid recovery of muscle glycogen: food choices, timing of food intake, and the interaction of food choice and timing with insulin.

Food Choices: Glycogen is a carbohydrate, so it is best to eat carbohydrates (but don’t forget the protein). Nutritionists group carbs according to their glycemic index - a statement on how intensely the food stimulates pancreatic release of insulin. Foods with a high glycemic index bring about the greatest release of insulin while low glycemic index foods don’t lead to a large release of insulin. Melissa Mullinix addresses this index and offers food examples in her column this month.

Timing of food intake: Just choosing the right foods is not enough. When the food is eaten is equally important. The problem is that the best time to eat and fill the muscles is when you aren’t too interested in eating - the first two hours after exercise.

During this two-hour period, choose foods with a high glycemic index for the fastest replenishment of muscle glycogen. In addition, a little protein is helpful. Research shows that the largest insulin response is from a 4:1 mixture of carbs to protein. Take in one gram of carbohydrate/pound of weight.

For the 150-pound player, that would be 150 grams of carbohydrate and about 40 grams of protein (you have to read those labels!). Keep fat intake at an absolute minimum. The body doesn’t care if the nutrients are as a liquid or as solid food. Most players might not want to eat anything solid or a meal in this two-hour time period and would prefer a liquid “meal.”

In the next two hours, solid food for a meal is more palatable. Choose moderate to high glycemic index foods, with 60-65% of the calories as carbohydrate, 20-25% fat and the remainder protein. This will help keep the refueling process moving along at a fast pace.

Over the remainder of the 24 hours, choose low to moderate glycemic index foods trying to take in 3-5 grams of carbohydrate per pound of weight. That 150-pound player should take in, over 24 hours, a total of 450-750 grams of carbohydrate. Keep the calorie proportions the same: 60-65% carbs, 20-25% fat, remainder protein.

Interaction of food choice and timing with insulin: Insulin has been prominently mentioned in this summary. Some people have called insulin the “master recovery hormone” because it assists in transporting glucose (blood sugar) from the blood into (muscle) cells as well as stimulating the hormones that help make glycogen - just what you need during recovery.

After exercise, the muscle cells are especially sensitive to insulin meaning more sugar gets into the cells and more glycogen is made. After two or more hours, the insulin sensitivity of the cells declines. This is why getting some carbohydrate in soon after exercise is so critical.

If an insulin response is important after exercise, can this response be elevated even more to further enhance making muscle glycogen? Research has shown that the insulin response can be boosted if a little protein is ingested.

The optimal ratio of carbohydrate and protein seems to be 4:1 as mentioned earlier. This can double the insulin response and increase glycogen production by 30%. Protein can be as food or as an amino acid supplement. Arginine is an amino acid that has been studied extensively and seems to be quite good at stimulating the insulin response.

Another amino acid, glutamine, is helpful to help with tissue repair discussed last month as well as many aspects of the immune response. Don’t overdo the overall protein intake because eating too much protein can slow down this process.

Most players aren’t looking to sit down to a meal or eat any solid food in the critical two-hour period after training/competition. But, there are drinks that meet the criteria I have discussed.

From parts #1 and #3 of this series, the quickest way to get carbs into the blood is from a drink that is sweetened with a glucose polymer (e.g. high fructose corn syrup, maltodextrins) or high glycemic index carbohydrates. From part #2, you can minimize damage and speed repair of cells between exercise sessions if extra vitamin C and E and glutamine are ingested.

From this article, the mix of carb:protein is important in speeding along the replenishment of muscle glycogen. Current drinks on the market may satisfy some of these criteria, but products that can do all three are limited. See the table for a list of current drinks and choose the drink that best fits your needs. Most of these products can be found in specialty sports stores (e.g. cycling), nutrition stores (e.g. GNC) or grocery stores.

The goal is to choose the best foods to be eaten at the proper time so that muscle glycogen will be as high as possible for the next game. If your opponent hasn’t done this, then you will be at an advantage and be able to press the attack late in the game when they are tiring.

Based on a 12 oz serving;
* per bar
1Arg=arginine; glut=glutamine; leu=leucine, val-valine; isoleu=isoleucine

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Increasing Energy With New Sports Drinks
By Dr. Don Kirkendall
(Part 6 of 6)

“Older” coaches should remember that the landscape for fluid replenishment changed dramatically 35 years ago when Dr. Robert Cade at the University of Florida developed Gatorade, the first commercially successful sports drink. Some of Florida’s football success then was attributed to Cade’s drink because it helped maintain cardiovascular performance and provided an energy source to working muscles.

Since then, many studies have refined the formulas and have shown that athletes consuming a 6-8% carbohydrate drink that also includes some sodium and potassium, can exercise longer and with less fatigue than athletes who drink only water.

Today, there is a staggering selection of sport drink choices that are basically all the same. Read those labels and it seems the only feature that distinguishes one drink from the other is taste. Throw some different types of carbohydrate into water, toss in some salt and electrolytes, add some flavor and you have - a sports drink. While the marketing people for the various companies will tell you their drink contains some other ingredients in trace amounts, most of which have little, if any, effect on exercise performance.

Now, there is new research from the University of Texas that just may alter our view of what constitutes an ideal sports drink. The Texas group has focused on the benefits of some protein included in a drink. They have shown that, in the right proportions, protein provides a synergistic effect increasing the energy efficiency of every gram of carbohydrate consumed. This research just might have the same impact on current sports drinks as the original Gatorade research had on the use of water during exercise.

What we see is that protein plays a role in improving exercise performance by stimulating insulin release. Insulin may be a most important biological factor in controlling energy use during exercise. We know that insulin facilitates the transport of carbohydrate into the muscle cell.

Consume a sports drink containing carbohydrate and that carbohydrate is absorbed into the blood. But, to improve muscle performance, that carbohydrate must get into the muscle cell where it can be used for energy. That’s why insulin is so important.

It is true that consuming carbohydrate will stimulate insulin. The same Texas group has shown that carbohydrate consumed during variable intensity exercise could boost insulin levels. By increasing carbohydrate uptake, there is a sparing of stored muscle carbohydrate - muscle glycogen. Sparing muscle glycogen gives you a greater reserve of fuel that enables you to run further and faster, especially late in the game when a large fraction of goals are scored.

But carbohydrate can stimulate insulin only to a point. Adding more carbohydrate to the drink will not produce an additional increase in insulin release.

In this case, more carbohydrate is not better, so here is where the protein becomes important. When protein is added to a carbohydrate drink, an additional increase in insulin is the result. In addition, protein provides other benefits: branched chain amino acids also have been shown to delay fatigue.

Then why protein isn’t an essential component of every sports drink? In large amounts, protein delays gastric emptying. Slowing of gastric emptying delays water and carbohydrate absorption; the last thing you want to do during performance. This could be a major problem if a sports drink contains a high concentration of protein per serving.

The real problem was determining the ideal ratio of carbohydrate:protein for a sports drink. After many trial “recipes”, the preferred 4 grams of carbohydrate to every 1 gram of protein was developed. With this ratio, a sports drink can deliver the benefits of protein (greater stimulation of insulin) without negatively impacting fluid and carbohydrate replenishment (delayed gastric emptying). Such drinks should help the player re-hydrate and deliver more energy in the form of carbohydrate to muscles during exercise.

Sounds great in theory, but you don’t care what the drink does to insulin; you care about exercise performance.

The Texas group tested athletes on three different occasions. They were given either water, a standard 7.75% carbohydrate sports drink or a 7.75% carbohydrate and 1.9% protein sports drink (Accelerade, PacificHealth Labs) during exercise of varying intensities. The results were very obvious.

The athletes consuming the carbohydrate:protein drink in the 4:1 ratio had an amazing 24% improvement in endurance when compared to the standard 7.75% carbohydrate drink and an impressive 54% improvement when compared to water.

Their work suggested that the addition of protein increased insulin and glucose uptake by the muscle providing an immediate source of energy to the exercising muscle. The result - a sparing of muscle glycogen (a known cause of fatigue in soccer) and a significant improvement in endurance (the critical performance factor in soccer success).

Consider a couple important statistics from the knockout round of the France World Cup: 40% of all the goals were scored in the last 15-20 minutes of the game.

Injury surveys of youth soccer players also show that nearly 25% of all injuries occur in the last 10-15 minutes of a game.

Sounds like teams are running out of gas (glycogen) and getting scored on. Also sounds like players are out of glycogen and can’t react appropriately and are getting injured. So what kind of players do you want on your team? Tired players getting scored on late in the game? Players who get hurt late in the game? Or do you want players well fueled who can react to the changing dynamics of the entire game?

You can help your team. Select drinks that contain the correct carbohydrate:protein proportion, otherwise you are compromising the ability of their muscles to perform at their highest levels. The combination of carbohydrate and protein in the 4:1 ratio enables can help athletes perform in the later stages of training or competition.

The bottom line.....players can train and compete longer and harder and that will lead to improved performance. We are entering a new era in how sports drinks not only can reduce the risk of dehydration, but also can optimize athletic performance.

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Soccer Headgear And Returning To Play
By Dr. Don Kirkendall

The current wording of Law 4 regarding player equipment is pretty vague. I quote from the FIFA web site: "A player must not use equipment or wear anything which is dangerous to himself or another player (including any kind of jewellery [sic])."

From here, there is a description of the uniform (I thought it was interesting that "thermal undershorts" must be the same color as the shorts), shin pads, goalkeepers, infringements, and restarts (nothing about shoes, just that players must wear footwear).

The use of any protective equipment beyond the shin pads is up to the referee’s interpretation of this law. We have all seen players wearing such things as protective goggles, knee braces, ankle braces, and maybe even a soft, or protected, cast. The hot topic right now is about the use of protective headgear designed to reduce the force of ball impact on the head.

A league in Milwaukee has mandated protective headgear this spring. There are a variety of products on the market that vary from little more than a sweat band to some elaborate ‘caps’ that cover a large part of the front of the head.

I am not qualified to interpret the law as would a referee. But there are concerns about some of the claims of the designers of these devices with respect to reductions in forces transmitted to the brain.

On May 2, the Consumer Products Safety Commission held a meeting of people interested in the topic of heading and head injuries in soccer. The basic feeling at the meeting was that the risk of head injuries was related more to impact trauma (head-head, head-ground, head-foot, etc) and that there is insufficient data at this point to implicate purposeful heading of a soccer ball.

There are many underlying questions regarding head injuries (i.e. concussions or the newer term ‘mild traumatic brain injuries’ or MTBI) and protective headgear. For example, just how much does a player actually head during practices/games? How does this vary by age group, position, playing level, and sex? What is the impact force by the ball on the head? What are the changes in impact force according to ball velocity and spin? By age? By ball size? When wet? When very hot?

Just what is the necessary impact force for a concussion? Does this differ when the head is prepared for heading vs. when the head is not prepared? How about where the ball (or more importantly - other player body parts/ground) contacts the head? How much of a reduction in impact force is possible by the headgear? Does this change as it gets wet (rain or sweat)? As it gets hot or cold?

How many cycles of contact can the devices take before losing their absorption characteristics? How will the use of headgear change the nature of the game? Might the headgear actually increase the chance of injury? What is the long-term outcome of head injury in the very young and will headgear have any effect?

How about rule changes to eliminate heading in the very young? Space limitations prohibit listing all the potential questions about soccer, MTBI and protective headgear, but you get the idea.

For me, one of the most important discussions was not about headgear and concussions - it was the criteria for return to play. Real (potentially fatal) problems happen when a player returns to play too soon. Most guidelines are based on the grade (mild, moderate, severe) of the injury. Yet it was pointed out that there are over 15 different definitions of concussion and concussion grading criteria.

In addition, to use a series of questions on the sideline is inappropriate if you don’t know how they did on the series of questions in the absence of injury. That means, each team should undergo something like the Standardized Assessment of Concussion (SAC-see sidebar) at the start of the season and have the results available at each game. Then when injured, the player gets the SAC assessment again and these results are compared with their previous test. If they test the same and have no signs/symptoms (be careful, the player will lie to you to get back into the game), they can return to the game, if not, they are held out, period. Not sure? Then hold them out.

Medical clearance is a necessity after a head injury. Of course, this clearance can differ based on what definition for concussion grading the MD uses (gets complicated doesn’t it). But there are other signs and symptoms that don’t recover as quickly as the SAC for example, so when in doubt, hold them out.

One thing that everyone agreed on was that a person can be concussed and never lose consciousness. I have said it here before and will say it again - you don’t have to get ‘knocked out’ to have sustained an MTBI.

What can you take to your team from all this? First, there is no longitudinal data to implicate purposeful heading in reported cognitive deficits in soccer players. Any deficits can be explained by other factors such as prior concussions or other known factors associated with cognitive deficits (e.g. alcohol, drugs, learning disorders).

Second, a single test of function is not as strong an indicator of an MTBI as is an uninjured test compared with post injury tests (order that card mentioned in the sidebar - probably the only endorsement I will ever make in this column).

Third, there is no evidence to suggest that protective headgear will be effective in preventing MTBI. And fourth, appropriately, Law 4 is Law 4; the use of protective headgear is up to the referee’s interpretation.

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Heading Is Often Technique And Confidence
By Ray Alley

There have been a number of articles written about concussions recently. In our October issue Dr. Don Kirkendall addressed concussions related to soccer.

Much of the awareness has arisen from the number of concussions suffered by National Football League quarterbacks. Along with these NFL articles, there always seems to be concern about heading soccer balls and the "threat" of brain damage.

While there hasn’t been a single study that has shown brain damage from heading by young players, this is a good time to stress the importance of teaching young players the proper heading techniques.

Even with the best of technique, it is still possible for a player to smack a soccer ball with his/her nose or face. However, the more likely the result of poor heading technique will be hitting the ball on the top of the head.

It is important to get young players to understand that they must impact the ball, rather than letting the ball impact their head. Then the force of the impact will be directed to the ball.

Begin teaching technique through a progression. You can initially use a softer ball, perhaps a PE "dodge ball" or "kick ball." Start the players from a sitting position, teaching movement from the waist as they approach the ball. Move to the knees so that you can bring the neck and shoulders into play. Arch your back, thrust through the ball, and follow through a bit.

Teach your players to head the ball just above the eyebrows, and below the hairline. Initially stress keeping the eyes open - the natural reflex will be the close them on impact. However, they need to see what they are heading.

Remember that the position of the chin is important. If the player lifts the chin the ball will go up. Good technique for a clearing header by a defender, but not so good for a header on goal. Tuck the chin down to the chest to make the header go down. Good technique for scoring that important goal.

Once your players get a grasp of the technique put them on their feet, heading back to a teammate who is serving the ball underhanded. Slowly widen the space between the two players to lengthen the service.

Heading requires a lot of confidence. You can’t force anyone to head a soccer ball. You can give players good fundamental technique and create an environment in which they are willing to give it a try.

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Maintenance Of Fitness.....
Staying In Shape During The Offseason
By Dr. Don Kirkendall

A player/reader wondered about how to maintain the fitness achieved this past fall over the winter break. This is an excellent inquiry and the answer supports that old coaching adage "it’s easier to stay in shape than to get in shape."

It may come as a surprise, but detraining and maintenance of fitness has been studied a great deal. We know how fast a person loses conditioning and we know what might be the minimum training necessary to maintain the current level of conditioning.

Most of this work has focused on endurance and less on strength issues. But, as has been pointed out before, in terms of fitness, the great discriminator between teams is endurance, so this research has direct application to soccer.

The initial work on detraining used bed rest as the model and also used people recovering from heart attacks or surgery. Currently, there is a lot of work on detraining as directed toward zero gravity and space travel.

From a global perspective, training leads to two major adaptations. First is the ability of the cardiovascular system to deliver oxygen to the cells and second is the ability of the cells to use the oxygen delivered to them.

The details of each adaptation are too deep for this article. Nevertheless, the training research shows that the central cardiovascular adaptation to training takes time to improve its ability to deliver oxygen while the cells improve their ability to use the delivered oxygen pretty quickly.

When training is stopped, the cells lose what they have gained pretty quickly (10 days to two weeks is about right) and the cardiovascular system detrains much slower.

You may have experienced this when you work out after being off for a short break. That first workout doesn’t feel too bad. During that workout, the cardiovascular system, that has not lost too much, sort of takes up the slack from the cells that detrained so quickly. Lay off for a month or more and you are starting back at ground zero in terms of endurance fitness.

Now, the question arises as to what can be done to maintain fitness; what is the least one can do and still keep most of their fitness. Remember that training is a mixture of frequency of training (days/week), intensity of training and duration of training (minutes/day).

All three factors have been explored and all three have to be considered in answering this question. Studies like this are difficult.

First a group has to be trained, then they have to stop and change only one factor while keeping the other two constant. One week of no training does not significantly reduce endurance.

Reduction in frequency: If the training intensity and duration are maintained (work as hard and as long as before, but not as often), a reduction of training days by 1/3 or 2/3 (in the research, that is from six to four or two days per week) maintains endurance fitness measured as time to exhaustion on a cycle ergometer.

Reduction in duration: If the training frequency and training intensity are maintained (work as hard and as often, but not as long as before), a reduction in minutes per session by 1/3 or 2/3 (or from 40 minutes/session to 26 or 13 minutes per session) maintains endurance fitness.

Reduction in intensity: If training frequency and duration are maintained (work as frequently and as long, but not as hard), a reduction in training intensity by 1/3 or 2/3 results in significant losses of endurance fitness.

What these results show is that training frequency and duration can be reduced with little effect on overall endurance. However, when one trains, they need to train at a training intensity similar to what they trained at during the season. The quickest way to detrain is to reduce training intensity.

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Eating To Play
By Dr. Don Kirkendall

A letter was sent to the editors requesting information about eating around game times. With the new season nearly upon us, it is probably a good time to review some topics associated with nutrition and sports performance.

This has been one of the most intensely researched topics in the sports performance literature and there have been many advances from the "Saturday morning steaks" that dads might remember from their high school football days.

Research can be grouped into four categories regarding the timing of eating: training days prior to competition, day of competition, during competition and after competition. In brief, carbohydrates are the best choice so choose foods that give the most carbohydrate per serving.

Days Prior To Competition

This was the first real focus of study that lead to the "glycogen loading" concept. Without going into a lot of scientific history, the typical routine now is to gradually reduce training volume and intensity while increasing the fraction of the total diet that is carbohydrates. This will help the muscles load up extra glycogen (the main fuel for muscles) for the game.

In soccer, this is not a common practice unfortunately. Most research shows that the muscle glycogen levels of (male) soccer players are no better than the spectators in the stands - not good.

Studies on soccer players have shown that those with the most pre-game muscle glycogen run the farthest at the fastest speeds during a game. As such, it is surprising to see that glycogen loading schemes have not been as universally adopted in soccer as they have in traditional endurance sports like running, cycling, cross-country skiing and triathalons.

Five to six grams of carbohydrate per kilogram of body weight over a 24 hours period is the typical suggestion so read those labels on food packaging. Remember, 1 pound of body weight/2.2 = kilograms of body weight.

Day of Competition

There is probably no more area full of misleading information than eating the day of competition - the proverbial pre-game meal. Most pre-game meals are eaten in the 3-4 hours prior to competition. But realize that the food eaten will have little to do with the energy expended in the game. That comes from what was eaten in the 2-3 days prior to the game.

Most players eat what they like so they won’t still feel full come game time. Remember that the more calories (i.e. fat and protein) in a meal, the slower the food leaves the stomach. Carbohydrates are always the best choice as fruits, cereals, juices, pancakes/waffles etc. over sausage, eggs, steak, or many choices on the breakfast menu at a fast food restaurant.

Food in general, and carbohydrates in particular, should be avoided in the last hour before play. Carbohydrates stimulate an insulin response which lowers blood sugar and also stimulates the production of serotonin, a chemical in the brain that reduces arousal (makes you listless and sleepy).

Both are obviously counterproductive to competition. If something must be eaten, choose low glycemic index foods as they cause less of an insulin response.

Immediately prior to competition (in the minutes before kickoff), carbohydrates can be taken in. The excitement of the game will counteract the insulin response and the fresh carbohydrates give the muscles an extra source of fuel. The type of carbohydrates is important. Foods should be of a moderate or high glycemic index (see table).

Carbohydrate supplement drinks work great. "Clear" candies (jelly beans, "Gummy" candy, Skittles etc. you get the idea) are another choice. .

Eating During Competition

During the game, carbohydrate supplement drinks given before the game and at halftime have been shown to increase running volume and intensity in the second half in soccer players. This is important to consider because goals become more frequent later in the game as players get tired.

If you have more energy than your opponents, you are more likely to have an advantage over the opposition and hopefully, score more later in the game. As you can see from the table below, the ubiquitous orange slices at halftime are pretty low on the priority as a carbohydrate source.

Eating After The Game

The game uses muscle glycogen (carbohydrate) so it must be replaced. Research has shown that muscle is the most receptive for carbohydrate replacement in the first two hours after exhaustive exercise. Therefore, it is important to eat some moderate to high glycemic index foods in the first two hours after a game.

From the table, you see there are quite a variety of options for food, most of which require a little planning and typically do not come in a bag or a tray from a fast food restaurant. With games at 12 noon and 4 pm, it is necessary to get some carbohydrates back into the muscles quickly.

Remember, fast foods are high in fat and protein and can remain in the stomach at the start of the next game (depending on when it was eaten and how much was eaten) and doesn’t return much in the way of carbohydrates to the muscles, therefore should be avoided.

A nutritionist gave me a good suggestion: make up bags of Chex Mix with some pretzel sticks added (forget the oil and baking requirement) and let the players eat this after the game. Clear candy is also good as are raisins, cakes, pies, bagels.

Ideally, eat 50-75 grams of carbohydrate every two hours until you reach the total based on your weight (5-6 grams/kg body weight).

But don’t get the idea that all the carbohydrate can be replenished in a couple of hours. Under the best of conditions, it can take 20 hours to fully replenish muscle glycogen from muscles that have been completely depleted.

Eating for sports performance requires a bit of planning and clock watching, but can lead to improvements in performance. When done properly, the players will notice they have more energy late in games as well as when they have multiple games with minimal recovery between games.

For more information, try:

http://www.olympic-usa.org/inside/ - USOC website for nutrition information including some sample menus.

http://www.mendosa.com/gi.htm - a complete discussion of the glycemic index.

http://www.mendosa.com/gilists.htm - for a long list of foods with their glycemic index. These last two sites are written for diabetics, but contain much useful information.

Syrups (e.g. maple, corn, cane); Honey; Bagel, white bread, jams, jellies; Potato; Most cereals; Raisins, banana, watermelon, pineapple; Carrots, cooked; White rice; Maltodextrin; Jelly beans, Skittles, pretzels, most candy bars

Whole grain bread; Spaghetti; Corn; Oatmeal; Oranges, grapes

Yogurt; Peanuts; Beans, peas; Apple, peach, pear; Milk and milk products.

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Soccer's Most Common Injury!
By Dr. Don Kirkendall

In past columns, I have reported to you some basic details about the injury study that the Sports Medicine Section of the Department of Orthopedics at the Duke University Medical Center has been carrying out for the last year and a half.

Of interest is the mechanics of injury to players in the Classic soccer program in North Carolina. We do this with the financial aid of Nike, Inc. and the able assistance of the administrative staff at North Carolina Youth Soccer Association. And we can’t forget the coaches and team managers who keep us posted about the team’s injuries.

Having talked at some length about ankle injuries, you might assume that is the most frequent of injuries. But in reality, the most common injury is a contusion (no real surprise here). The bumps and bruises that go with the game make this the main "occupational hazard" of playing soccer. As this year’s data collection is still proceeding, the details I note are from the most recent full year: 1997-1998.

• For every girl who suffered a contusion, there were three boys with contusions. But remember, there were three times as many boys playing, so overall, the contusion rate was about the same for boys and girls.
• What position had the most contusions? In descending order it was defenders, forwards, midfielders, goalkeepers. This was for the group overall.
• However, for girls, the rank order was goalkeepers, defenders, then forwards and midfielders, goalkeepers. This was for the group overall. For boys, the rank order was goalkeepers, defenders, then forwards and midfielders.
• As usual, the injuries were most frequent in games. Typically 90% of injuries happen in competition and that is the case here also.
• Ice was the course of immediate first aid, but 20% said they did not seek any treatment.
• This is a minor injury 54% missed no games or practice and 80% missed one week or less.
• Fatigue did not appear to be a factor. Contusions were about equally split between the halves and fairly even for early, middle or late in each half. Other injuries happen as players get tired, but not this one.
• Care to guess what body part was injured the most? The knee led the way, thigh, shin, ankle and foot were relatively the same.
• Everyone was wearing their (required) shin pads. 77% of the shin pads were plastic or OSI. Don’t try to draw any conclusion about what shin pad type is the best at protecting against shin contusions from this data.
• The injuries occurred on the ball (82%), the player usually fell (63%), but few could stay on and continue (20%). They came off and were treated with ice.
• More details from this project will be discussed in future columns. Remember that these results are preliminary and should not be considered absolute.

To make sure we get to all injured players, the coach or team manager needs to be careful to include the injury cards with each game report. The support of Nike, Inc and the NCYSA state office will allow us to get the most complete data for this important project.

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A Report On Knee Injuries
By Dr. Don Kirkendall

I have started to report back to you about the injury study that the Sports Medicine Section of the Department of Orthopaedics at the Duke University Medical Center has been carrying out for the last year and a half.

This project looks at the mechanism of injury to players in the Classic program in North Carolina. We do this with the aid of Nike, Inc. and the able assistance of the administrative staff at North Carolina Youth Soccer Association. And we can’t forget you coaches and team managers who keep us posted about your team’s injuries.

There are lots of soccer injury statistics in sports medicine magazines. As mentioned in a prior article, the ankle is the most injured body part, but the knee follows.

To see if there are any suggestions that could be made in the way of preventive measures that might reduce the number and severity of knee injuries, we need to know how the injury happened.

After each game, the team manager or coach mails us an injury report card, then the player is called and interviewed.

Most doctors will say that the majority of knee injuries happen when the foot is planted. 76% of the players said that their foot was planted at the time of injury

Word of mouth comments frequently blame the condition of the field. The players we called (five out of every six) said the surface was flat and even.

Traction was excellent (4%), good (25%), average (44%), fair (24%) or poor (12%). When traction was fair or poor, it was due either to water or the field being very hard and dry.

Changing direction is a common mechanism of injury to the knee, especially in knee ligament sprains. Twenty-six percent (26%) of players with a knee injury were changing directions while 56% were not. The rest couldn’t recall.

If they were cutting, it was a routine cut (e.g. plant right foot, cut left).

We tried to get the player to estimate the knee flexion angle at the time of injury. Two thirds of all knee injuries occurred at or near full extension. About one third were about midway in the range of motion and only two injuries happened when the knee was very flexed.

At the time the knee collapsed, 54% of time it collapsed to the middle, 30% to the outside and 15% were hyperextended.

The player may or may not have heard a "pop" from their knee at the time of injury

Interestingly, 28% did not seek medical advice and thus did not receive a medical diagnosis. When a diagnosis was made it was: ligament sprain (60%), contusion (10%), cartilage damage (10%), tendinitis (5%). The rest of the players who received a diagnosis couldn’t recall what it was.

Being thrown off balance and trying regain balance has been implicated in knee injuries. Eighty-eight percent of the players felt they had been knocked off-balance. Fifty-eight percent of those thrown off balance tried to regain their balance leading to the injury.

Of those with a ligament sprain, it was about 50-50 whether they tried to regain their balance.

While only one in six players with a knee injury thought their shoe became "stuck" to the ground, all those who did think it stuck sustained a knee sprain. Of those who didn’t think their shoe was stuck, 43% of those injuries were knee sprains.

We will explore more details from this project in a later column. Remember these results are preliminary and should not be considered absolute.

To make sure we get to all injured players, the coach or team manager needs to be diligent in including the injury cards with the each game report. The support of Nike, Inc and the NCYSA state office will allow us to get the most complete data for this important project.

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Training For Endurance In Soccer
By Dr. Don Kirkendall

Over the last couple of years we have been collecting information on the fitness of youth soccer players and it tells us a great deal about the type of training being conducted at the club level. We test for speed, jumping power, anaerobic capacity, endurance and agility. What is most evident is that the endurance aspect of training for soccer needs more emphasis.

Why is endurance so important in soccer? This isn’t a distance running event; soccer is a bunch of 10-50 yard runs. But remember, all those runs add up.

And don’t forget that while endurance builds up the ability to run long and hard, it also improves the ability to recover between runs which is likely the most important benefit of having high levels of endurance. But players don’t have to hit the streets to improve endurance.

To understand the importance of endurance, consider work out of Norway, Eastern Europe and Milwaukee.

In Norway, the endurance of the first-place team was over 10% greater than that of the last-place team. In Eastern Europe, final placings could just about be predicted based on their endurance test results.

Over several years in Milwaukee, the final points (3 points for a win, 1 point for a draw) for a college team were correlated with endurance; the greater the endurance, the more points. Strength, power, speed and agility are not as predictive of final success.

The fitness tests were given to U12-U18 Classic players and the levels of endurance were not appreciably different between ages, especially in the girls.

Among the boys, there is a jump from U13 to U14, but not much change from there on. This indicates that the bulk of the training is focused on technique and tactics.

So, a few questions about training need to be asked.

1. How do we train for endurance in soccer?

Endurance can be increased using interval training, i.e. manipulate the work/rest interval. Therefore, increase the intensity of training (work) and decrease the recovery (rest) periods. Remember the demands of the game and direct training toward that. Lots of shorter, higher intensity runs, but limit the rest periods.

A drill that is two minutes of work and two minutes of rest is too much rest in soccer. Also, remember that the most intense aspect of soccer is dribbling. So to increase intensity and decrease rest, make the sides smaller (e.g. 3v3, 4v4) which keeps the players more involved in the play.

To increase the volume of running in training games, make the field of play larger. Instead of 4v4 in the penalty area, play the game in twice the size of the penalty area.

2. How often should intensity be a focus in training?

Three days per week is a good figure. You have to assume that the game itself is a training stimulus. So, 1-2 sessions with some emphasis on fitness would be appropriate. In many cases, games are on the weekend and training is Tuesday and Thursday. So, each practice should have some fitness component.

Don’t train for fitness on successive days. They need either a day of rest or low-intensity training.

3. How much each session?

No more than one third (1/3) of any training session needs to be devoted to high intensity work. So if training is 90 minutes, plan on about 20-30 minutes being directed to fitness. These need not be successive minutes. Two or three 10-minute segments of high intensity training are better than one long segment.

4. How can I modify practice to push fitness?

Economical training means to train two of the three factors of play (fitness, technique, or tactics) at the same time. So, let’s say you play a game that requires wing play (tactics). Do this for a while, then require a 10-yard sprint after each pass (fitness).

Or make the game faster by playing two-touch, or require a player to beat an opponent with the dribble prior to passing (technique), or combine two or more restrictions (5v5 wing play, beat a player dribbling, then sprint 10 yards after passing). Play this for 10-15 minutes and you have had a good hard segment.

5. What must I be concerned about?

First, after the hard segment, give the players a rest period. Second, in high intensity training, more is not better. Excessive high intensity training can lead to injury, over-reaching or over-training. Third, don’t start training with the hard segment, build up to it, break, then build up to it again.

Southern Soccer Scene continues its monthly column on sports science topics from the Sports Medicine Section at the Duke University Medical Center and UNC Hospitals. The authors are members of the US Soccer Sports Medicine Committee including from UNC--Dr. William E. Garrett, Jr. (U.S. National Teams Physician and Committee Chairman), John Lohnes and Dr. Don Kirkendall (exercise physiologist--and from Duke University Patty Marchak (athletic trainer for the 1996 US Women’s Olympic Team).

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