Athletic Trainers’ Actions and Words May Contribute to Stress and Pain in Patients

By Mike McKenney, MS, ATC, NASM-CES

April is National Stress Awareness Month.  Typically, we look inward and focus on the stress associated with being an Athletic Trainer, interacting with difficult coaches, managing emergent situations and other aspects of our profession which merit discussion.  However, it is not often we stop and think about how our actions and words contribute to the stress level of those we are supposed to be treating.

A common dialogue in healthcare revolves around barriers to effective treatment, and what we can do to overcome those barriers for the benefit of the patient.  Stress is a barrier which becomes more prominent the moment a patient walks through the door.   As healthcare providers, we immediately ask the patient something along the lines of, “Do you have pain?”  However, is there really a need to ask this question or have an immediate answer?  If the patient is injured and seeking help, don’t we already know the answer before we’ve asked the question?   Patients will normally tell you two things: What is wrong, and how to fix it.  The important part of that interaction is how well we listen as clinicians and use the information provided to improve the overall quality of care.

Pain and stress walk hand in hand and managing both of them is often difficult, especially with a patient-oriented treatment approach.  Throughout our education, we are taught to gauge and track pain by using metrics such as the Likert scale, outcome measures or functional tests that may reproduce symptoms.  These approaches prove to be very useful for Athletic Trainers, but are they useful for patients?  After speaking with Dr. Adam Naylor, sports psychology consultant to Northeastern University Athletics, he suggests, “Constantly applying these measures, and asking these questions, can sidetrack positive progressions during rehabilitation.”  As a result, our altruistic approach to treating pain can actually make our job more difficult.

The reason these approaches can be harmful is that patients are constantly being reminded they are either in pain or cannot do something specific to their sport.  This results in an increased level of stress, which has been correlated with increased muscle tension, illness, narrowing of attention and loss of focus.  Combine all these together and we have created an environment that contributes to a slower rehabilitation process, with a patient now prone to re-injury.  Athletic Trainers skilled in listening and observation are often able to notice when their treatments inhibit pain.  This spares the patient repetitive stress-inducing rehabilitation sessions where they have to constantly describe their discomfort.

So … now what?  If you look hard enough, you will find something wrong with every patient who walks through the door, but I am not advocating we completely ignore pain and abandon objective testing.  We need to be more selective about how often and when we include these metrics as part of our treatment approach.  Additionally, it is important that Athletic Trainers be able to identify patients who cannot cope with stress and refer them to professional resources who can be allies in the treatment process.

Don’t ask patients if they have pain; ask them how you can help.

Athletic Trainers Handle Stress and Burnout

By Erin Chapman, MS, LAT, ATC

As Athletic Trainers (ATs), we spend 95% of our time worrying about the health and well-being of family members, friends and patients.  Little time is focused on our own mental and physical health.  I believe the characteristic of selflessness is what makes an AT intuitive and compassionate during a difficult time in a patient’s life, but it can also wear on the clinician’s emotional state.  Emotions do not only affect our mental health but also numerous functions of the body including the digestive, immune, respiratory and/or cardiovascular systems.  While many different stressors or factors can disrupt emotional health, the unique responsibilities – both professional and personal – of an Athletic Trainer are multifaceted, making it difficult to identify the source of one’s emotional change.

The National Athletic Trainers’ Association (NATA) and other outlets have established research to identify the causes of stress and burnout within the athletic training profession.

So, how are clinicians handling or managing stress and burnout?

Athletic Trainers often state that time, money and energy are limitations; therefore, it is imperative we find ways to deal with these noted shortcomings.  I was previously one of those ATs who did not take care of my mental well-being and felt as though I did not have the tools to tackle it myself.

During my first semester in a doctorate program, I was introduced to the Emotional Freedom Technique (EFT).  Through the implementation of the EFT, I learned about the stressors and emotions affecting both my professional and personal life.  The EFT is a treatment paradigm based upon psychological acupressure.  The technique uses tapping of the fingers to input kinetic energy onto specific energy meridians while thinking about the specific stressor or problem during the restating of positive affirmations.

While this is just one treatment paradigm for mental well-being and may not be your choice of intervention, there are similar paradigms that might be just as effective.  Identifying stressors or problems that are consuming your thoughts and emotions can help guide treatment interventions.  Listed here are other treatment paradigms: Sensory Flow, Traumatic Release Exercises (TRE), Qi-gong, yoga, Reflexercise and Reiki. Determining which technique is appropriate for you is the first step that allows you, as an AT practitioner, to help yourself prior to helping others.


Church, D. The treatment of combat trauma in veterans using EFT (Emotional Freedom Techniques): A pilot protocol. Traumatology [serial online]. March 2010;16(1):55-65. Available from: PsycARTICLES, Ipswich, MA. Accessed April 1, 2015

To Specialize or Not to Specialize

By Tim Koba, ATC

Undoubtedly, everyone has heard of the 10,000 rule that stipulates in order to reach expert status, 10 years or 10,000 hours of deliberate practice are required.  This study was initially looking at elite musicians and their non-elite counterparts. It was then transferred to other fields, including athletics.  This has, in part, contributed to the growth of single sport athletes and the clubs, coaches, centers and equipment suppliers that support the sport.  Unfortunately, early specialization does not guarantee long term athletic success, and may potentially limit it.

Whenever a new level of sport is undertaken, fewer athletes participate.  The large number of youth athletes fizzle out in high school, college and beyond.  For those who do move on, they tend to play more than one sport in high school with extra work put into their main sport.  They still require the deliberate practice required to excel, but not at the large commitment that has been suggested.  There is also concern that early sport specialization can lead to injury, burnout and other negative consequences, although sufficient data is still required to fully understand the relationship.

The information that we do have can help us to have honest conversations with athletes, coaches and parents when they ask our opinion on playing one sport or multiple sports.  One study looked at athletes who were in a single sport versus multiple sports and the injuries in the two groups.  The athletes who played a single sport, spending more hours per week in that sport, had greater risks for overuse injury.  This total volume of repetitive activity is related to injury risk across many sports.

Female athletes who play a single sport have increased incidence of anterior knee pain than those who play multiple sports.  A lot of research has gone into youth baseball players and elbow injuries. We know that the risk factors for developing elbow pain are throwing too many pitches in a day, throwing curve balls at a young age and throwing more months out of the year.  This understanding has helped lead to recommendations regarding pitch counts in youth baseball, although they may not be strictly adhered to.  Gymnasts are more likely to have wrist and lumbar overuse injuries, while specialized hockey and soccer players suffer from hip pain and the development of impingement.

These injuries are predictable based on the sport.  The understanding of when those injuries occur in relation to how often an athlete plays the sport is unknown.  Theoretically, participating in many sports or a neuromuscular training program can limit the repetitive motion of an individual sport and improve movement quality that can lead to fewer injuries.  The constant stress, physical and psychological, of intense sport training can lead some athletes to over-train or even burn out from their sport.  In order to adapt physiologically, the body needs time to adjust to a new stimulus.  Without adequate recovery periods built in, athletes may experience these, and other, negative outcomes of participation.

Right now, the best we can do is to discuss the risk of injury based on the sport and the importance of adaptation and volume control.  Sports are meant to be fun and youth athletes should be exposed to many sports for enjoyment.  Waiting longer to specialize may help delay an overuse injury, but nothing is guaranteed for playing at the next level.  The longer sports are fun, the more likely young athletes are to remain active throughout their life. That is the real victory.

Dental Injuries and Emergencies

By Beth Wolfe, CAGS, ATC

Dental injuries and emergencies are not new to the profession of athletic training.  Trauma to the maxillofacial area can be painful and unaesthetic for many, and Athletic Trainers provide a crucial role in preventing and treating these dental injuries.  It is important to recognize when a dental injury is a dental emergency, and it is imperative to always be prepared in the event a dental emergency occurs.

About Dental Injuries

Teeth and facial bones can be easily damaged with and without protective dental/facial equipment.  Wearing a mouth guard and helmet with a cage will significantly reduce the risk of sustaining a dental injury.  However, depending on the type and amount of force exerted on the facial region, injuries may still occur despite the use of protective equipment.  Emergency Action Plan (EAP) activations do apply to some types of dental injuries, and Athletic Trainers need to be prepared to activate their EAP in the event a dental emergency occurs.  Furthermore, Athletic Trainers need to have the proper supplies to effectively treat and care for a dental injury/emergency as the viability of a tooth will depend on the resources and immediate care of the healthcare provider.

Types of Dental Injuries

Some of the most common injuries to the facial region include (Knowlton, et al., 2014):

•   Fractures to the maxilla and mandible

•   Fractures to the tooth/teeth

•   Lacerations to the lips, gums, cheeks or other soft tissues

•   Tooth intrusion/extrusion

•  Tooth avulsion

Many dental injuries may cause the patient to bleed; however, not all bloody injuries are emergencies.  If a patient is bleeding it is best to control the bleeding with direct pressure by gauze, and the patient may assist by holding pressure with their hands or biting down.  Once the bleeding has subsided, it will be easier to assess the injury to determine if it is a dental emergency.  Tooth intrusions and extrusions, as well as facial lacerations, are uncomfortable and will need advanced medical care within 2-3 hours of the injury.  However, unless there is suspicion of a fracture to either the bony structures of the face or to the pulp/root of the tooth, these dental injuries do not need activation of the EAP.

Figure 1. – Types of Tooth Fractures. (Levkiv, M.)

There are 4 types of tooth fractures: enamel (most superficial), dentin (middle layer), complicated crown (inner layer that can bleed and is pink/red in color) and root (deepest portion, imbedded in gum) (Knowlton, et al., 2014).  A picture of these types of can be found in Figure 1. – Types of Tooth Fractures.  Enamel and dentin fractures can be painful and unaesthetic, but these are not emergencies.  These 2 types of tooth fractures do need advanced dental care; however, emergency room physicians will not be able to provide much care besides splinting, pain medication, antibiotics and a referral to a local dentist (A. Colangelo, personal communication, March 19, 2015).  Fractured pieces of the tooth may be kept in a cup of the patient’s saliva, cold milk or tooth storage solution (i.e., Save-A-Tooth or Hank’s Balanced Solution). Do NOTstore fractured tooth pieces in tap water or saline as this can cause damage to the remaining live cells in the tooth (A. Colangelo, personal communication, March 19, 2015).

Dental Emergencies and Care

A dental injury can become a dental emergency very quickly, and some of the most common dental emergencies are:

•   Complicated fractures of the tooth/teeth (pulp or roots exposed)

•   Avulsion of the tooth (tooth comes out of socket)

•   Suspicion of facial bone fracture or TMJ injury

These injuries DO need immediate medical attention, and activating the EAP is recommended.  For tooth avulsions and complicated fractures hold the tooth by the crown ONLY and refrain from touching the roots.  Rinse dirt and blood off the fractured or avulsed tooth using saline, tap water, milk or the patient’s saliva. Refrain from scrubbing or rubbing the tooth as this may remove the remaining periodontal ligament and/or other live tooth cells (A. Colangelo, personal communication, March 19, 2015).  In order to increase the likelihood of survival of a fractured or avulsed tooth, it is recommended that the tooth is relocated and placed back into the socket as soon as possible and preferably within 15 minutes (A. Colangelo, personal communication, March 19, 2015). If the tooth is relocated, have the patient bite down on gauze or wear their mouth guard (if they have one already molded to their mouth) in order to keep the tooth/teeth in place until they arrive at the hospital.


Information provided for this post was retrieved from the Crest Oral B Sport-Related Dental Injuries guidelines and Dr. Augustus Colangelo, Assistant Professor of Emergency Medicine and Attending Physician at Tufts Medical Center.


Knowlton, R, Kratcher, CM, & Smith, WS. (2014). Sports-Related Dental Injuries and Sports Dentistry. Crest Oral B Continuing Education Course. Retrieved from:

Levkiv, MO. (n.d.). Non-carious lesions of teeth that appears before teeth eruption. Classification, pathomorphology, clinic, diagnosis, differential diagnosis and treatment of un-carious lesions. Retrieved from:

Concussion Return to Learn Protocol

By Mackenzie Simmons, ATC

Over the past decade, concussion awareness and management have been on the rise after many heartbreaking stories about traumatic brain injuries have been brought to the surface.  Athlete Trainers are usually the frontline managers for concussions, and they know the importance of the gradual return-to-play for athletes.  If an athlete is to get another concussion while recovering from the previous one, it could ultimately be detrimental to their health and cause life-long injuries.  Research over the past few years has brought up another essential point about concussion management: return to learn protocol.

The Rocky Mountain Institute in Denver, Colorado has developed the REAP program (Remove/Reduce, Educate, Adjust/Accommodate, Pace), which not only emphasizes safely returning an athlete to sport but to school.  Thanks to Dr. Karen McAvoy, these guidelines have been adopted in many schools in the state of Colorado to promote concussion awareness and safety.  The REAP program breaks down the different roles for the concussion management team.  While an Athletic Trainer may be one of the primary caretakers during recovery, there are other essential members who need to understand their role.  The family, school academic team, team physician and the medical team all play pivotal roles when safely returning an athlete to participation and education.  The REAP program includes a very detailed protocol for the different responsibilities each role possesses during the recovery time.

A few states have introduced a state bill to implement a return to learn protocol within all school districts, but there needs to be more action by Athletic Trainers to fight for this important change.  All healthcare professionals know the negative affects that can occur when a concussion is not treated properly.  We, as Athletic Trainers, need to work on developing a return to learn protocol that can be adopted by the educational side of a student athlete’s career.  If your institution does not have a set protocol for returning a concussed athlete to school properly, what are you waiting for? For more information on the REAP program:

Education and Awareness of Athletic Training as a Profession

By Joni L. Cramer Roh, EdD, LAT, ATC

For decades Athletic Trainers (ATs) have been providing the public with an understanding of our profession.  Over the more recent years, with the changes in legislation, local and state laws, the athletic training profession has been better understood, yet the profession is not clearly understood by all.  Our profession is doing a great job, but there is still room to help promote awareness of the athletic training profession.

Recently, some of my undergraduate students in an accredited AT program and I went to a middle school (grades 6-8) to talk to the students about athletic training as a career. We provided the students with a little background of our education, clinical responsibilities, salaries and places of employment.  Prior to the presentation, a simple question was asked whether anyone knew what an AT did.  As most would guess, we were stereotyped as a fitness or personal trainer.  This was really not too surprising as that is what the students knew from their daily lives.  Many of their parents would go to a gym, workout and talk about having a trainer.

One may ask why we went to a middle school instead of a high school to educate the students about careers.  The answer is fourfold.  First, the teachers asked for parents to come to the schools, do a presentation and discuss their careers so students could be exposed to a variety of professions.  Second, by the time students enter high school, it is necessary to already have an idea of their possible profession. This is so they can  take classes at the high school level to prepare for that particular path (with so many Advanced Placement courses in the high school that are available, it is necessary to start with prerequisite courses, etc., as early as 9th grade). Third, my students are in the Kappa Omicron Nu (KON) honor society for the Human Sciences.  One of the national initiatives is called Kids and Careers, and this presentation supported such an initiative.  Furthermore, this supports the Athletic Trainer awareness initiative.

Some of you may be aware that athletic training has recently adopted a program that promotes healthcare professions to high school students around the country.  There are currently 450,000 kids involved, according to Michael Goldberg, District 2 Director.  However, as I previously mentioned, it is important to consider educating individuals prior to high school so that students can have the proper sequencing of courses.  Consider how you can reach the middle school youth and promote athletic training awareness.

Heads Up Football

By Tim Koba, ATC

There is some good news regarding the safety of youth football. Coaches who have completed the Heads Up Football training program, developed by USA Football, have decreased concussions on their teams compared to untrained coaches.

Since concussions, and especially concussions in football, are such a big concern right now, it is great to see that there is some training being done to address the issue. The program emphasizes proper heads up tackling technique using the shoulder to make contact and wrapping up the opponent. This has led to a decrease in head to head collisions and fewer head contacts during the season.

By learning the proper technique at a young age and being coached consistently in that technique, athletes will develop fewer injuries and continue to play over time. If more youth leagues adopted this or similar training programs for their coaches, it could be a step toward decreasing concussions in football.

The researchers also discovered a direct link between coaching behavior and player safety. The coaches who had received additional training and incorporated those techniques into their practices had decreased rates of injury. If the correlation exists across sports, then developing educational program for coaches can have far reaching effects on reducing player injuries in many sports.

Hopefully, more research is performed evaluating the effectiveness of this type of training on decreasing concussions and injuries in general. Based on the current information, it should be incorporated into the educational curriculum for football coaches at any level.

Managing Hamstring Strains

By Tim Koba, ATC

Hamstring injuries are one of the most common injuries in sports. Time lost from competition can be substantial, and there is a high risk for re-injury.

One of the reasons that the hamstring is so susceptible to injury is that it crosses both the hip and knee joints. During running, the hamstring works to decelerate the knee at ground contact and then assist the glutes to accelerate the hip into extension. This change in function is believed to be one of the reasons that the hamstring is injured.

Risk factors for injury include a previous hamstring injury and weakness in the hamstrings.

Currently, there is a lack of systematic research on effective hamstring prevention, treatment and rehabilitation programs. Stretching has not been shown to decrease injury risk, and our current knowledge on prevention has been primarily performed on soccer athletes utilizing Russian/Nordic hamstring exercise as an eccentric training technique. This exercise has been effective in reducing the rates of hamstring strains in soccer athletes. However, due to the eccentric action of the exercises, it does cause DOMS, so starting a program should be progressed accordingly. While not studied for prevention, Romanian deadlifts activate the hamstrings eccentrically, and they can be an adjunct to a prevention program.

If a hamstring is strained, the location can affect the time lost from competition. Proximal hamstring injuries, avulsions and larger lesions all increase the time to heal. If you have access to a physician doing corticosteroid injections, this can assist in decreasing the healing time without an increased risk for re-injury.

Rehabilitation of hamstring injuries follows the same guidelines as other rehab programs including decreasing pain and inflammation; restoring range of motion and neuromuscular control; and strengthening and progressing to higher speed and higher functioning sport specific drills. A more holistic rehab program focusing on core stability, hip strengthening and neuromuscular control is more effective than an isolated strengthening and stretching program in return to sport and re-injury rates. Adding in eccentric exercises in the late strength phases can assist with injury prevention as well as incorporating agility and running drills to improve proprioception and stride mechanics.

While the evidence for the most effective treatment of hamstring injuries continues to be developed, we know that eccentric training is beneficial at preventing initial strains and recurrent strains. The added benefit of eccentric hamstring strengthening is that they can also help decrease ACL injuries in certain populations.

What have you found to be effective in preventing and rehabbing hamstrings?

Planting the Seeds for Athletic Training Awareness

“What do you want to be when you grow up?” This is the question posed to children by adults from a very early age into young adulthood.

Often children will respond with professions they hear about, see on TV or interact with on a daily basis including police officer, teacher, firefighter or doctor to name a few.  But how do you give a name and face to the athletic training profession?

In the new children’s book, “Do you want to be an Athletic Trainer?” author Marsha L Grant-Ford and contributor Jonathan Ford help to plant the seeds of athletic training awareness in children by offering a glimpse into the exciting world of the certified Athletic Trainer (AT).  This non-fiction book includes descriptions of ATs who work with doctors to keep active people healthy.  ATs are featured in businesses, hospitals, physician offices, sports teams and the rodeo.  The book also mentions ATs working in the military, law enforcement, NASCAR and NASA.

With its colorful pictures and detailed descriptions, children are given a face and name to the ATs they see in their daily lives.  Professional tasks are introduced and explained in captions including patient education; taping and bracing; orthopedic and general medical examination; therapeutic interventions; emergency skills and concussion management.  This book is just one way for children to see a realistic view of the importance of ATs in keeping active children and adults healthy at work and at play.

For more information or to purchase a copy, please visit the following link.

Rehabilitation for Patellofemoral Syndrome

By Tim Koba, ATC

There was a new article published in the Journal of Athletic Training that compared the outcomes of two separate treatment protocols on patellofemoral syndrome (PFS).

The potential patients were screened and then enrolled in either a hip strengthening protocol or knee strengthening protocol. Patients met with the Athletic Trainer three times a week for six weeks and were instructed to do their home exercises six times a week.

At the end of the six weeks, both groups showed improvement in pain and dysfunction associated with PFS. The hip strengthening group had resolution in symptoms prior to the knee group, but the overall improvement was not statistically significant.

Adopting a hip or knee strengthening program, or a combination of both, is an effective way to treat PFS. For a link to the article click here.

What protocols do you currently employ?