Archive for February, 2016

ETHICS IN ACTION: BOC Facility Principles: It’s all well and good until …

Thursday, February 25th, 2016

Posted February 25, 2016

By Kimberly S. Peer, EdD, ATC, FNATA

The Board of Certification (BOC) created the BOC Facility Principles document and the accompanying online resource as tools for secondary and post-secondary programs to self-assess their compliance with best practices for facility management. Both resources provide a checklist designed to assist Athletic Trainers (ATs) and other relevant personnel including but not limited to human resources management, principals and athletic directors to provide a safe, effective and legally sound healthcare environment.

As an AT, it is your professional obligation to review the document and utilize the checklist to ensure an optimal environment. However, what happens when you find your facility is not compliant with these guidelines and your administration or superiors choose not to act to remedy the problem? What is your legal and moral obligation to ensure these principles are enacted in your facility? What is your responsibility if you continue to practice in this environment when you discover you are not compliant and nothing is being done to bring the facility in alignment with these best practices?

A major ethical dilemma occurs when you know there is a problem and your administration ignores the problem. If you stand up for what you know is right, you risk losing your job or facing other alienation tactics. If you continue to offer services despite the lack of compliance, are you doing what is right and good? Are you responsible if something bad happens even if it was your superior or administrator who chose not to remedy the problem? How far are you willing to go to demonstrate moral courage and do what is right? What are the potential ethical and legal consequences if you ignore your findings? How would you handle this situation if your administrator chose not to remedy the problems you found?

Moral courage requires that we stand up even when we could potentially face exposure or significant loss. Moral courage is reflected when we stand up for what is right despite potentially harmful consequences, personally and professionally. But this is easy in theory, hard in practice. Where do you draw the line and decide it is worth the fight for what is right? How do you decide when values such as loyalty to the employer and your patients conflict with honesty regarding potentially harmful environmental issues in the facility?

Although guidelines and principles provide a strong foundation upon which to guide your practice, they are not all-inclusive nor do they always carry consequences if not followed. But ethical behavior should not be regulated by policy or guidelines; it should be inherent in all we do as professionals. A wise man once said, “In matters of principle, stand like a rock. In matters of preference, go with the flow.”


Life as an Athletic Trainer: A Balancing Act

Tuesday, February 23rd, 2016

Posted February 23, 2016

Desi Rotenberg

Desi Rotenberg, MS, LAT, ATC

Life has many ways of challenging us. In our personal lives, our professional lives and really in any aspect we can imagine. A question I often find myself asking is, “How can I stop the chaos of life for just a few minutes?”

At first, I didn’t believe it was possible. Especially as a young, entry level Athletic Trainer (AT), it seemed every other night I was working an enormous number of hours, like a record playing around and around with no end in sight. Now don’t get me wrong; I love what I do. But always having to focus on the needs of others can be extremely taxing, both on the body and on the mind.

After being in the profession for a few more years and gaining significant insight in both my professional life and in my emotional maturity, I was able to establish a pattern in my day to day functioning that has helped me exponentially. It is almost as if it is night and day. The solution that personally made a world of difference, was finding a balance.

In biology, we talk about the concept of homeostasis, or the constant process of biological tissue creating an ideal equilibrium for optimal functioning. If my body can subconsciously and automatically create balance within itself, why couldn’t I do the same in my own life? It wasn’t until I started applying various principles to my own life that I began to realize just how much control I really did have.

I believe there is an algorithm that can be incorporated into daily life, which can make all the difference when achieving balance, both internally (mind, body, soul) as well as externally (personal and professional life).

First, in order to maintain balance between home and work life, you must identify the priorities. Are your priorities your immediate family or your professional family, including players, coaches and employers? Secondly, are you doing the job for yourself or for someone else? You cannot help others, and subsequently achieve equilibrium, until your needs are first met.

I could tell you yoga, diet and exercise are the cure-all, but I believe that those are only half of the solution. In order to achieve balance within yourself, there are 4 things you should try in order to find the equilibrium that can open the door for optimal functioning on a regular basis:

1. Focus your energy on areas where you can give your best effort

We often spend a lot of our time and energy wasting it. Find something in your professional and your personal life you can attach yourself to and enjoy doing. Ensure that it gives you a healthy challenge and frequently removes you from your comfort zone.

2. Stay loyal and trustworthy

I like to call this one professional integrity. The reason this one is listed, is because it is extremely difficult. Think about how easy it is to gossip about a co-worker or supervisor when they are not around. Think about how often negative thoughts of others cloud our judgement. If we maintain a positive mindset, and maintain our ability to think logically and rationally, others will trust us with more responsibility. They will see you don’t get caught up in office drama, and you are there to do your job to the best of your abilities. It will also help you establish honest, true professional relationships. At the end of the day, be the person that if someone were to gossip about, others would say, “That just can’t be true.”

3. Stay faithful in your personal and professional relationships

I call this one personal integrity. Who are you when no one is around? Often we search for affirmation and feedback from external sources, and it can erode our sense of self-empowerment and self-esteem. It is usually the ones who are closest to us who believe in us the most. Always remember people are around you because they love you. It can be a difficult thing to remember but can prevent you from seeking temporary affirmation in the wrong places.

4. Allow your mind an opportunity to relax

Whether it’s yoga, running, swimming, jazzercise, meditation or underwater basket weaving, find a hobby outside of your professional realm. As an AT, you have so much knowledge in your head and you have to constantly be putting that knowledge and those skills to use. Allow your brain to focus attention elsewhere, on tasks that are challenging, yet fun. Set time on a daily basis to decompress. Focus on all of the good things you have in your life and reflect on how far you have come, both in your personal and professional lives.

The key to success is having a balanced mindset. Athletic training is an extremely difficult profession and is not meant for everyone. For everyone who struggles, and believe me when I say that everyone struggles at one point or another, it is important to remember you are never really alone. At the very least you have yourself. In order for athletic training to continue to be an upstanding profession, we must challenge ourselves every day to create balance within our lives.

About the Author

Desi Rotenberg, originally from Denver, Colorado, graduated with his bachelor's degree in 2012 from the University of Northern Colorado. He has been a BOC Certified Athletic Trainer since 2012 and earned his master's degree in Exercise Physiology from the University of Central Florida in 2014. He currently is a high school teacher, teaching anatomy/physiology and leadership development. Along with being a teacher, he wears many hats, such as basketball coach, curriculum developer and mentor. He has been a contributor to the BOC Blog since the summer of 2015. 


Top 5 Hockey Injuries

Thursday, February 18th, 2016

Posted February 18, 2016

Mike McKenney

By Mike McKenney, MS, ATC

Ice hockey is a sport often defined not only by its fast-paced action, but also by the injuries that result from contact between players or being hit into the boards. Specific injuries and their occurrence vary between men’s and women’s hockey, youth hockey compared to adult and professional compared to amateur levels of play. However, there are common injuries that routinely occur at all levels of play.

Groin Strains

One of the most frequently encountered injuries in ice hockey is groin strains. Numerous pre-disposing factors for this condition have been suggested in the literature.   However, there seems to be more widespread agreement that they are a result of imbalances between abduction and adduction muscle strength at the hip, in addition to having a prior history of adductor injury.1 Skating in hockey is unique and unlike any other athletic movement in sports. As a result, the demands placed on the pelvis and hip are often difficult to manage once injury has occurred. Adductor strength and control are needed in order to help support the pelvis through the transition of one leg to the other while skating. During a stride, players will briefly load both hips simultaneously as they are transitioning from one leg to the other for their next stride. Loss of pelvic control through the adductor will result in injury during this transitional movement.

Structural knee injuries

In a contact sport such as ice hockey, knee injuries are bound to happen. However, it is rare that these injuries result from non-contact activity as seen in other sports like basketball or soccer. If a ligament is involved, it is typically the result of someone falling on an opponent’s leg, sustaining knee-on-knee contact or a player’s skate being caught on the ice as they are hit in their upper-body. The exception to these occurrences are goaltenders who can experience medical collateral ligament (MCL) and meniscus injuries due to the unique nature of their position and the commonly used butterfly style of goaltending, which puts additional stress on those structures.

Acromioclavicular Joint Injury

Similar to other contact sports, injury to the Acromioclavicular joint or AC joint is a common occurrence in ice hockey, and tends to happen more when players are old enough to begin body-checking.2 What is deemed a legal body-check at most levels of play subsequently places the AC joint in a position to absorb a significant amount of force with shoulder to shoulder contact. This is especially true when a player is hit into the boards with their arm positioned across the body. For hits that are more straight-on, the clavicle is placed at a higher risk with the possibility of disrupting its role in the AC joint should a fracture occur.


Even though leagues at all levels are taking steps to remove intentional head-contact from the game, the risk of concussion is still present. Interestingly, according to NCAA injury surveillance data for women’s ice hockey, concussions account for up to 22% of injury in games and 13% of injuries sustained in practice.3 This is much higher than what is reported for men at the same level.4 However, the inverse is true at the youth levels where the occurrence of concussion in boys’ high school hockey is only second to high school football.5 This widespread occurrence supports the continued need for Athletic Trainers to be vigilant in their recognition and appropriate treatment of athletes who sustain a concussion.


In a sport where a frozen rubber disk routinely travels at high rates of speed, it is not surprising that contusions are a common injury, particularly to the lower extremity, foot and ankle when the puck is shot into a crowd of people. Additionally, upper extremity contusions are often the result of players getting cross-checked or slashed by another player’s stick. For those who don’t watch hockey regularly, this behavior is supposed to be penalized, but far too often is not.


1. Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128.

2. Hagel BE et al. Effect of bodychecking on injury rates among minor ice hockey players. Can Med Assoc J. 2006;175(2):155-160.

3. Agel J, Dick R, Nelson B, Marshall SW, Dompier TP. Descriptive epidemiology of collegiate women’s ice hockey injuries: national collegiate athletic association injury surveillance system, 2000-2001 through 2003-2004. J Athl Train. 2007;42(2):249-254.

4. Agel J, Dompier TP, Dick R, Marshall SW. Descriptive epidemiology of collegiate men’s ice hockey injuries: national collegiate athletic association injury surveillance system, 1988-1989 through 2003-2004. J Athl Train. 2007;42(2):241-248.

5. Marar M, Mcllvain N. Fields SK, Comstock RD. Epidemiology of concussions among united states high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747-755.

ETHICS IN ACTION: Return to Play - Insights through the Lens of the Prima Facie Healthcare Principles

Wednesday, February 17th, 2016

Posted February 17, 2016

By Kimberly S. Peer, EdD, ATC, FNATA

Return to play decisions are complex and multi-faceted in most cases. The environment in which Athletic Trainers (ATs) work often complicates the situation. Coaches, parents and other personnel put the AT in difficult situations with their own demands and rationale for the return to play decision.

Several recent cases involving the St. Louis Rams quarterback Case Kennum and the Ravens quarterback Joe Flacco have brought these issues to the forefront again. Although not the only cases in contemporary sport and certainly not only evident at the professional level, they bring to point several considerations from an ethical perspective.

Using the prima facie healthcare principles as a framework for reflection, these cases present several interesting dilemmas. When considering the principle of beneficence or doing good, the regulations are in place to protect the athlete by allowing the AT to make the decision on the return to play.  Athletic Trainers are professionals who are trained to use evidence-based medicine to determine if an athlete is ready to play or not.

Similarly, if you look at the principle of non-maleficence or do no further harm, we can again see how the AT should be the medical professional to make the decision without compromise from other interested parties. Protecting the athlete from further harm is a fundamental role in healthcare, and although predictive in nature, it is relatively easy to predict the potential outcomes based upon a physical examination and the nature of the sport.

The third principle – respect for autonomy – provides a bit of a challenge, especially when considering professional athletes. If informed of the potential risks, should the athlete be able to make their own decisions? In the professional ranks, should an athlete be able to say they are willing to take the risk of more serious injury because, if they do not, it could impact their future earning potential or career? If we believe this is the case, how do we manage the fact that the athlete may be subtly or even explicitly influenced by fellow teammates or coaches? Is this coercive autonomy the same as a truly independent, autonomous choice?

Lastly, we have justice. As a principle, it is designed to allow all persons to be treated equally no matter what other influences are present. Many legislative and best-practice policies and guidelines are devised to protect all persons in the same manner. However, what happens when these guidelines are overlooked or blatantly ignored? Are the consequences strong enough to change behavior or are the professionals, specifically, willing to pay the fines to win the game?

The nature of sport at all levels has changed dramatically over time. It has become high stakes even at the most fundamental levels of participation. As we continue to hear more and more about return to play for specific injury situations, we will be faced with an increasing number of ethical issues as they unfold. To keep your moral footing on this slippery slope, you must be anchored in policy, evidence-based medicine and moral courage.



How much water is enough for athletes in training and competition?

Monday, February 15th, 2016

Posted February 15, 2016

Mike McKenney

By Mike McKenney, MS, ATC

A question Athletic Trainers answer on daily basis is how much water athletes should ingest during training or competition. Fluid replacement guidelines intended for the general population are typically insufficient for an athletic population. Care must be taken to deliver advice that is not only evidence-based, but realistically implemented. No standardized recommendation or volume of water will be accurate since fluid replacement demands will vary between individuals based on sweat rate, amount of fluid lost during sport and many other physiological variables to include factors that influence drinking behavior. This means metrics that suggest drinking 1 ounce for every pound or kilogram of body weight are largely inaccurate, and depending on activity level, could potentially be harmful.

During exercise, athletes should only drink when they are thirsty, and not attempt to ingest as much fluid as they can tolerate.1 The primary reason behind this is safety and an effort to prevent exercise-associated hyponatremia (EAH).

Many beverages available to athletes are largely hypotonic in composition, which if ingested in large amounts, can dilute plasma sodium concentrations to dangerously low levels causing EAH or potentially death.1 This includes sports drinks, which are often chosen over water with the intended goal of replacing electrolytes lost through sweat. However, the electrolyte content found in many commercially-available sports drinks is inadequate for electrolyte supplementation. The volume an athlete would need to ingest in order to replace their average electrolyte losses would far exceed their fluid losses, resulting in overdrinking and EAH.1,2,3 Sadly, in 2014 a high school athlete in Georgia died as a result of overdrinking hypotonic fluids that included sports drinks: .

Athletic Trainers can play a pivotal role in preventing EAH. In addition to recommending that athletes drink-to-thirst during activity, a red flag for EAH is maintaining or gaining weight during exercise as a result of excessive fluid intake.1 Even though changes in body weight are not always a reliable measure of overall fluid balance4,it offers a practical approach for ATs to monitor athletes on a day-to-day basis, especially in situations where fluid ingestion may exceed an athlete’s total fluid losses. Athletes should not fear weight loss during exercise as it is normal, and mild to moderate dehydration while drinking-to-thirst does not pose a threat to healthy individuals.1  However, following activity, slightly different strategies need to be employed for fluid replacement.

Thirst is a poor indicator of hydration status in humans. Research5 has demonstrated that humans only replace up to 70% of fluid losses if we drink until the cessation of thirst. While this is acceptable behavior during exercise, it can pose problems with maintenance of plasma volume and overall recovery following activity. Athletes should continue to monitor their body weight and continue to drink following activity. However, athletes should drink in amounts that do not cause them to gain weight beyond what they have lost, as the risk to develop EAH is still present.1 Additionally, athletes should aim to return to their normal weight first thing in the morning, or prior to their next training session or game. In addition to fluids, replacing sodium post-exercise can also aid in the rehydration process, which will be covered in future blog posts. Please see the below sources for additional material on this topic.


1. Hew-Butler T, et al. Statement of the third international exercise-associated hyponatremia consensus development conference, Carlsbad, California, 2015. Clin J Sport Med. 2015;25(4):303-320.

2. Twerenbold R, Knechtle B, Kakabeeke TH, Eser P, Muller G, von Arx P, Knecht H. Effects of different sodium concentrations in replacement fluids during prolonged exercise in women. Br J Sports Med. 2003;37:300-303

3. Weschler LB. Exercise-associated hyponatremia: a mathematical review. Sports Med. 2005;35:899–922.

4. Tam N, Noakes TD. The quantification of body fluid allostasis during exercise. Sports Med. 2013;43:1289-1299.

5. Nose H, Mack GW, Shi X, Nadel ER. Role of osmolality and plasma volume during rehydration in humans. J Appl Physiol. 1988;65(1):325-331.

Additional Article on Zyrees Oliver:

About the Author

Mike McKenney is an Athletic Trainer (AT) at Northeastern University in Boston, Massachusetts, where he is the Medical Coordinator for their Division I men’s ice hockey program.  Prior to Northeastern University, he served as an AT in multiple settings including secondary schools, Division I athletics and professional cycling; additionally, he worked as an AT who extends the services of a physician for a large orthopedic group.  He has also provided services for many organizations to include the Boston Marathon, USA Cycling and USA Volleyball.

McKenney is a hydration and electrolyte replacement consultant for the Atlanta Hawks of the NBA.  His professional interests include hydration, electrolyte replacement, thermoregulation in sport and postural restoration.  McKenney completed his athletic training education at Gustavus Adolphus College in Saint Peter, Minnesota and master’s degree at North Dakota State University in Fargo, North Dakota.  His graduate research was published in the February 2015 edition of the Journal of Athletic Training.


“Concussion” – A Movie Review from an Athletic Trainer’s Perspective

Friday, February 12th, 2016

Posted February 12, 2016

By Claudia Curtis, MS, LAT, ATC

As a moviegoer, I found “Concussion” to be very well done. The plot flowed well, did not feel too drawn out and the acting was superb. Will Smith did an excellent job portraying the main character, Dr. Bennet Omalu, taking you on his journey and making you feel what he felt.  It gave insight into what was happening behind the scenes for years regarding chronic traumatic encephalopathy (CTE) before the American public was aware of the situation. The movie was produced in a way to keep all kinds of viewers engaged, science for the healthcare professionals, game footage for the sports enthusiasts. The footage shows a lot of big hits, frequently without proper technique. In terms of a cinematic experience, I was pleased with my movie choice.

However, as an Athletic Trainer (AT), how did I feel watching “Concussion?” First and foremost, I was horrified at the way  ATs were portrayed in the movie. This movie focused mainly on the neuroanatomy and the discovery of CTE, not necessarily something  Athletic Trainers have a role in. However, there is one scene where “trainers” are mentioned, and it is done in a rather ignorant way. The scene discusses the fact that the NFL did research prior to Dr. Omalu regarding the presence of CTE.  However, the “researchers” named on the study were a rheumatologist, an equipment manager and a “trainer.” The response to that comment was, “Don’t they just tape knees?” This is a pretty large stage for our profession to be improperly represented, leaving a bitter taste in my mouth that lingers even now.

The impressions I took from this movie span far beyond that one scene though. This movie made me feel a variety of emotions: sympathy, anger, fear and confusion to name a few, alternating throughout the scenes. The person I saw the movie with, a non-healthcare professional, after the movie said, “I wish they had given us more information about what’s been learned since this all started.”

What I realized is that there aren’t a lot more answers right now, but rather that more questions have developed with time and research. How many years of impacts might cause CTE? Does it matter the level of sport played (high school vs. college or professional sports)? Does it matter if consciousness was lost? Are we doing the right thing to prevent this in our concussion recovery programs? Will these concussion return protocols prevent CTE?

I could probably fill an entire page with questions. There is one I’m still asking myself: Is this movie enough to convince high school kids of the real danger that concealing concussions could have long term?

In-Depth Look: Meet an Athletic Trainer for Disneyland Park

Thursday, February 11th, 2016

Posted February 11, 2016

Jena Hansen-Honeycutt, MS, ATC, PES is an Athletic Trainer at Disneyland Park in California.  Her role includes working with the entertainment staff to improve performance and prevent injuries.

Describe your setting:

I work with the entertainment staff at Disneyland by providing injury prevention services for a diverse work force, including but not limited to, character performers, equity stunt performers, actors, gymnasts, puppeteers, dancers, musicians, photographers, show support technicians, and cosmetology technicians.

How long have you worked in this setting?

I have been working in this setting for 2 years.

Describe your typical day:

A typical day depends largely on the shift that you are working and staff that you will encounter. I mostly work in a location that works with Parades and entertainment support staff. On a typical day I would initially check my email and schedule to see if there are any scheduled appointments for the location I am at. About 2 hours prior to the parade step-off time we see the performers as needed and provide services to aid them in preparing for their day (i.e., warm-up, exercise progression, first aid, taping, etc.), improving performance, and preventing injuries. At the time of Parade step-off there is a drop in patient load and we take a lunch break.

Upon returning from lunch the performers are taking a break and checking in with AT staff as needed, preparing for the next performance, and creating a plan for progression. Following this second wave of parade preparation we complete any documentation that could not be completed earlier and clean our facilities. In other shifts, I would work with smaller shows and spends the day going to the areas of performances/ where performers are taking breaks and check-in with them to provide them with injury prevention services and education regarding health and wellness.

What do you like about your position?

I enjoy working with the performers and all other support staff, the patients are uniquely aware of their body and work diligently to improve performance and prevent injuries through participating in movement and performance screens. This patient population enjoys learning how to make their body function more efficiently.

What do you dislike about your position?

In this location there is a large patient population making it difficult to have continuity between athletic trainers providing services to the individuals.

What advice do you have about your practice setting for a young AT looking at this setting?

I would encourage other ATs to seek opportunities in their area where they can contribute to providing AT services to groups of performing artists as this population is in need of quality health care services.

In-Depth Look: Athletic Trainer in an Orthopaedic Clinic

Wednesday, February 3rd, 2016

Posted February 3, 2016

Joe Cygan, MS, ATC, OTC, RMSK is a Clinic Coordinator for an orthopaedic clinic.  In this role, he works as an Athletic Trainer (AT) and extends the services of the physician in an orthopaedic clinic.

Describe your setting:

I am a Clinic Coordinator and work as an AT for Dr. Peter Millett at The Steadman Clinic in Vail, Colorado.  The Steadman Clinic delivers orthopaedic care whether the patient is an injured professional athlete or just wants to be able to walk again without pain.  The clinic specializes in knee, hip, shoulder, elbow, hand, spine, foot and ankle injuries.

How long have you worked in this setting?

I have worked in this setting for 3 years.

Describe your typical day:

I usually arrive around 7:00am or7:30am and begin preparing for clinic or surgery.  This typically involves reviewing the patients for the day and making sure we have all notes and images we need for their visit.  If we are having a clinical day, we usually start by seeing the patients who had surgery the prior day either in physical therapy or in the hospital to make sure they are ready to go home.  We then start clinic around 8:30am.

My main responsibilities include seeing the patients initially, formulating a differential diagnosis for new patients and determining how surgical patients are recovering from their surgery.  I then go in with Dr. Millett and see the patient and coordinate any follow-up care the patient may need, including MRI, labs or surgery.  We also have another AT and 2 Physician Assistants (PAs) who do the same thing.  We typically see 30 to 40 patients per day.  At the end of the day, I make sure there are no outstanding issues such as MRI authorizations, patient phone questions and missing notes.   After that, I dictate about all of the patients I saw that day.

On surgical days, I get in about the same time and help make sure we are ready for all of our cases for the day.  We typically do 7 to 10 cases a day.  We make sure the patients know what procedure we are performing and that they are comfortable with the procedure.  We also go over post-operative pain management medications to make sure there are no contraindications to the medications.  I then either scrub in and act as a first assistant in surgery or I stay in clinic and catch up on paperwork.  That way I’m available for patients who call in with questions or concerns.

What do you like about your position?

I like being on a team of healthcare professionals who include orthopedic surgeons, PAs and ATs.  I also enjoy that we have a fellowship program for both ATs and physicians, with whom we can exchange knowledge.

What do you dislike about your position?

The insurance industry is getting harder and harder to get approval from in a timely manner.  As a clinic, we try to get patients everything they need within 24 hours. Unfortunately, insurance companies do not always see it that way.

What advice do you have about your practice setting for a young AT looking at this setting?

I would advise young ATs to get some experience prior to coming to this setting.  This is still a relatively new setting and role for our profession.  We need to be very knowledgeable of injuries and be able to diagnose independently and confidently.