Archive for June, 2016

Implications of Joint Hypermobility

Wednesday, June 29th, 2016

Posted June 29, 2016

Tim Koba, MS, ATC
Twitter: @timkoba

By Tim Koba, MS, ATC

If you’ve ever heard someone say they are double jointed, they may have generalized joint hypermobility. Generalized joint hypermobility is a connective tissue phenomenon characterized as having loose connective tissue including joints and skin. This is more common in adolescents and females. As we age, the collagen tends to stiffen up, but for some people, this extra joint motion can lead to various aches and pains.

The common screening tool for assessing general joint hypermobility is the Beighton score, which is a series of movements. The 4 movements are performed bilaterally. A scale of 4 or more out of 9 is indicative of having generalized hypermobility, but a score of 6 or higher is more indicative of having associated symptoms. The tests are pinky hyperextension done bilaterally, the ability to touch your thumb to your forearm bilaterally, hyperextension at the elbows and knees bilaterally and the ability to palm the floor from a standing position.

The reason we are concerned for joint hypermobility is the implication for injury and pain. Because the joints have some additional laxity or movement, symptomatic individuals have excessive joint motion. This additional motion can lead to a pain response as the joint moves beyond a normal range.

When I looked at the research to determine if the presence of general joint hypermobility can lead to injury risk, I was surprised the answer was generally no. For most injuries, the risk of sustaining an injury increases if there has been a previous injury. For those with joint dislocations, the presence of generalized hypermobility was not as important as local hypermobility of that joint. There is a connection between generalized joint hypermobility and ACL risk in soccer players. However, this is probably related to the knee joint being loose and the fact that the individuals are not able to adequately stabilize during intense activity.

While the ability to predict injury based on generalized joint hypermobility does not seem evident, there are some interesting correlations when looking at different injury subsets. For people who suffer from musculoskeletal pain, back pain during adolescence and fibromyalgia, there is a higher number of symptomatic individuals who have generalized joint hypermobility. Once again, the thought is joints have additional movement, which causes a pain response.

For many people who suffer from musculoskeletal pain, they have a hard time getting their pain receptors to calm down. The 2 main treatments for hypermobility-related pain are exercise and massage or soft tissue work. The goal of exercise is to improve body awareness, positioning, control and strength. When the muscles are working properly, they have the ability to aid in joint stiffness, and normal joint motion may decrease the pain response. Massage therapy and soft tissue work can help to ease pain through touch and by addressing specific problem areas. While the research is not definitive on the effectiveness of either exercise or massage, there are some observational studies that suggest it can help.

The key take-home point is generalized joint hypermobility is usually benign, although there are other symptomatic forms; however, it can be involved with excessive motion that causes musculoskeletal pain. The main treatment and preventative technique is to exercise in order to better stabilize joints, learn and reinforce proper movement and body control. In a flared up state, massage can help decrease the associated pain.


Folci, M and Capsoni, F. (2016). Arthralgias, fatigue, paresthesias and visceral pain: can joint hypermobility solve the puzzle? A case report. BMC Musculoskeletal Disorders; 17 (58).

Pacey, V. et. al. (2010). Generalized joint hypermobility and risk of lower limb joint injury during sport: A systematic review with meta-analysis. American Journal of Sports Medicine; 38.

Palmer, S. et. al. (2014). The effectiveness of therapeutic exercise for joint hypermobility syndrome: a systematic review. Physiotherapy; 9 (002).

Scheper, M. et. al. (2015). Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome (hypermobility type); it is a challenge. Journal of Pain Research; 8.

Tobias, et. al. (2013). Joint hypermobility is a risk factor for musculoskeletal pain during adolescence. Arthritis and Rheumatism; 65 (4).

About the Author

Tim Koba is an Athletic Trainer, strength coach and sport business professional based in Ithaca, New York. He is passionate about helping others reach their personal and professional potential by researching topics of interest and sharing it with others. He contributes articles on injury prevention, management, rehabilitation, athletic development and leadership.

You can connect with him on twitter @timkoba or check out his blog


My dad was the coach; I was the Athletic Trainer

Friday, June 17th, 2016

Posted June 17, 2016

By Mike Hopper, MS, ATC

Many people love spending time with their families, and my family was no different. But what made my family unique was that life always revolved around sports. Growing up with 3 older sisters and a younger brother, with mom being a teacher and dad being a teacher/coach, to say that I grew up around athletics would be an understatement. In fact, that childhood experience clearly drew me into my career as an Athletic Trainer (AT).

All of my siblings were active in one sport or another, and I played 3 myself. In fact, I played for my dad in all 3 sports. So working together in the sports atmosphere was nothing new. When I graduated from college, I spent a little over a year at one school before I was transferred to my alma mater. At the time, my dad was an assistant boys’ basketball coach at Waterloo.

At Waterloo, I worked alongside my dad for 2 years.  My dad was the coach; I was the Athletic Trainer. During those 2 years, we spent a lot of time together. Some would see it as a negative thing to say that work often went home with us. However, we also had many great conversations because we shared so much in common.

My dad and I did have slightly different perspectives resulting from our different roles, but I did learn something from the experience. I know that I have been able to adapt and work alongside different coaches due to my relationship with my dad. He taught me how to work with coaches who have different personalities and to be loyal.

As a veteran of 40+ years in high school coaching, my dad is that “old school coach” who may not always understand our role as ATs. But I know he is terrified thinking about how quickly we can be put into life-threatening situations, and as the AT it’s my job to manage the situation. After all, I am still his son, and it’s scary to him that I have to take on that responsibility.

When it was time for me to move on, and into bigger and better things, I too became Coach Hopper. In Texas, many ATs go by “Coach” or by “Doc.” It was such a weird feeling for a long time because Coach Hopper was always my dad, and now it’s me. For many, my dad will always be Coach Hopper, but to me he’ll always be Dad.

So on this Father’s Day weekend, I want to wish Coach Hopper a Happy Father’s Day! I have learned so much and being the son of a coach has helped make me into the AT I am today.




Guidelines on Listing and Abbreviating Degrees, Licenses and Credentials

Tuesday, June 14th, 2016

Posted June 14, 2016

By Melissa Breazile, Content Coordinator

Proper treatment of degrees, licenses and credentials has been a source of confusion and misuse for years. Many Athletic Trainers are unsure how to list or abbreviate the qualifications that follow their names.

Consistency in how Athletic Trainers identify themselves alleviates confusion and lends credibility to the profession. The following is intended to provide clarity as you identify yourself in signatures, business cards, letterhead or any other written format.

A 2003 article by Ken Knight, Chad Starkey and Chris Ingersoll established guidelines for displaying degrees, licenses and credentials, and this information is still valid today.

The article says it is proper to list academic degrees first, licenses second and credentials last. Here, credentials include BOC certification. For instance, a BOC Certified Athletic Trainer holding a master’s degree and working in a state where licensure is not required should write, “Sally Snow, MS, ATC” – not “ATC, MS.”  The same BOC Certified Athletic Trainer working in a state with licensure would correctly write, “Sally Snow, MS, LAT, ATC.” See the illustration for an example.

What do these qualifications mean? Licensure provides a legal right to practice, while certification, which is voluntary, states that a professional body – in this case, the BOC – has determined that your knowledge and skills have met a pre-determined standard. If you use more than one credential, list them in order of difficulty of obtaining them. With credentials of similar difficulty, such as ATC and PT, list them in chronological order.

Common Errors and Exceptions
Because confusion has persisted over the years, we know of several common errors. One such error involves listing licensure and certification as a single abbreviation; such incorrect examples include ATC/L, LATC and ATC/R. The first example implies that certification is more important than licensure, which is not the case. The second and third examples improperly append the ATC® credential, which is a registered trademark and cannot be modified.

- In Texas, everyone is an LAT because not all Texas ATs have to be certified. Texas has its own set of requirements to earn a license, BOC certification and/or the Texas licensing exam.

So as far as BOC and our protection of the credential, we do not regulate against the improper treatment of licensure and regulation. However, we do regulate against those who use the ATC® credential and are not currently certified.

Finally, we offer one more note on usage. Despite the common misconception, ATC is not a noun. An AT is the person who holds the credential, while ATC is the credential. For this reason, it would be inappropriate to say, “Bob Jones is the ATC for the Cardinals.” Instead, it is correct to say, “Bob Jones is the AT for the Cardinals.”

Access the article by Knight, Starkey and Ingersoll at, and click on the “Public Relations” tab.

Correction January 2017:

This guideline is no longer true: Wisconsin, by state law, does not allow you to use ATC®; the law specifies the use of LAT.




Practicing Responsibly: Understanding Athletic Training Regulation and State Practice Acts

Tuesday, June 7th, 2016

Posted June 7, 2016

Nicole T. Wasylyk

Nicole T. Wasylyk, MSEd, LAT, ATC

Athletic training regulation varies across the United States from no regulation to registration, certification and licensure. Understanding the laws that regulate athletic training services within your area is key to responsible practice.

So what’s the difference between certification, registration and licensure?

The least restrictive form of government regulation is registration; these states require individuals to submit information prior to practicing as an Athletic Trainer (AT). Registration usually requires name and qualifications, but this can vary based on the state. Next is certification; certification protects the titled use of the term Athletic Trainer and is granted to those who meet predetermined standards. In a state where certification is the only requirement, an uncertified individual may perform the duties of an AT but they may not use the title Athletic Trainer. Finally there is licensure, which is the most restrictive form of government regulation. In a state that requires licensure it is illegal to practice athletic training without first obtaining a license.

With ATs employed in clinics, hospitals, collegiate and interscholastic roles, it’s important to understand the language of laws and practice acts. Some states contain restrictive wording that may, unfortunately, limit an AT’s ability to perform services for certain populations. Alaska, for example, states ATs may provide services to athletes; their definition of an athlete “means an individual who participates in an athletic or sport-related exercise or activity, including interscholastic, intercollegiate, intramural, semiprofessional, and professional sports activities.”1 Although not completely restrictive, the act does reveal concerns about use of language and how it can limit an AT’s ability to practice in certain settings.

An example of non-restrictive language includes that from the state of Wisconsin. ATs in this state may evaluate and treat individuals who participate in physical activity with the definition of physical activity being “vigorous participation in exercise, sports, games, and recreation, wellness, fitness, or employment activities.”2  This definition is inclusive of a myriad of patient populations, allowing ATs to practice in any number of settings.

ATs are growing into more dynamic and diverse roles; we provide services to individuals indiscriminate of athletic ability. Rethinking the way our practice acts are written may be critical in the coming years as we progress as a profession so as not to restrict our services to athletes and athletic populations. Some practice acts may not yet be reflective of our new roles or may contain legislation that is over a decade old with minimal amendments since inception.

If you’ve ever seen the Schoolhouse Rock “How a Bill Becomes a Law,” you’ll understand how it takes time and significant effort and support to pass legislation. Similar effort is needed when amending these laws. The National Athletic Trainers’ Association (NATA) and Board of Certification (BOC) have made strong efforts to improve the practice of athletic training, both through support of state licensure and bills related to athletic training practice. Current legislative efforts include the Sports Medicine Licensure Clarity Act (H.R.921 / S. 689), which seeks to provide legal protection for ATs or sports medicine professionals who travel to another state with an athletic team solely to provide care for their team. Currently, medical liability insurance does not cover an AT when they travel with their respective team to states where they are not licensed to practice.3

Be sure to access your state practice act and read through it in its entirety. Even though licensure is required for the vast majority of states, not all practice acts are created equal. Scope of practice is not entirely determined by a practice act, but it is crucial to know exclusions to practicing that may be described within the document. Access your state practice act through the NATA or BOC websites.

References and Resources:




State Regulation

NATA Scope of Practice Webinar

Sports Medicine Licensure Clarity Act

About the Author

Nicole Wasylyk works as an Athletic Trainer in a physician practice at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire. Prior to DHMC she resided in Madison, Wisconsin and was an Athletic Trainer in a physician practice at Meriter-Unity Point Health. Wasylyk obtained her Bachelor of Science in Athletic Training from Boston University and Masters of Science in Education from Old Dominion University. She has completed a residency program for healthcare providers who extend the services of a physician at UW Health. Wasylyk also obtained her orthopedic technician certification. Her professional interests include injury surveillance and prevention, standardization of best practices and patient reported outcomes collection. 


Best Practices for Young Athletes

Thursday, June 2nd, 2016

Desi Rotenberg,

Posted June 2, 2016

By Desi Rotenberg, MS, LAT, ATC

Athletics and sport play a significant role both in the lives of the child and in the lives of the parent. A positive experience can yield retention and adherence to a sport, whereas a negative experience can lead to non-compliance and an unwillingness to grow within the sport. The goal for youth sports is two-fold: to create a fun, engaging environment that is learning and team-centered, and to teach young athletes how to begin priming their body and improving their performance through fitness training.

The first aspect is ensuring the children are with teams, coaches and programs that are truly vested in the development of their self-esteem and their true potentials. Development of talent and skill is important; however, as we often see, when the focal point is solely on winning, the development can be hindered.

Dr. JoAnn Dahlkoetter, a leading sport performance psychologist, came up with the “Top 5 Mistakes Parents and Coaches Make in Motivating Young Athletes”1:

1. Parent or coach overreacts when the athlete does not perform up to expectations

2. Demanding too much time or commitment from the athlete, resulting in chronic injuries or being burnt out

3. Giving an inordinate amount of attention to the star player and ignoring the value of other team members

4. Increasing the pressure and expectations as the season goes beyond the appropriate expectation for that age group

5. Not encouraging the young athlete to have a balance within their life (i.e. school, family, social circle, rest)

Over time, these negative stigmas and reactions can have a deep, long-lasting impact, especially on athletes who are emotionally fragile and sensitive. We must ensure that before an athlete can begin a productive and successful fitness training regiment, their mindset must be pointed in a positive direction and healthy priorities must be established. It will be the responsibility of the parent and the coaching staff to create an environment that brings out the greatest potential of each child in a safe, controlled manner.

Furthermore, sport specialization can also be harmful to a young athlete’s growth and development. Myer et al. validate that focusing young athletes on one specific sport and quitting all other sports can lead to increased likelihood of chronic injury and burnout.2

Avoiding burnout can be a product of diversifying sport and exercise at a young age and encouraging young athletes to engage in healthy training habits. In order to ensure the optimal growth and development of young athletes, allowing unstructured play should be encouraged. In addition, sports should allow young athletes to continue to develop motor skills and to participate in an alternative, fun atmosphere. This can alleviate some of the pressures placed on young athletes by the demands of the sport.

A follow-up study by Myer et al. indicated that a “periodized strength training model” should be utilized to prepare young athletes for the demands that will be placed on them later in their athletic lives.3 Every athlete should have opportunities for mental and physical rest and recovery, and parents and coaches must be sensitive to the needs of each individual.



2. Myer, Gregory D., et al. "Sport Specialization, Part I Does Early Sports Specialization Increase Negative Outcomes and Reduce the Opportunity for Success in Young Athletes?" Sports Health: A Multidisciplinary Approach (2015): 1941738115598747.

3. Myer, Gregory D., et al. "Sports Specialization, Part II Alternative Solutions to Early Sport Specialization in Youth Athletes." Sports Health: A Multidisciplinary Approach 8.1 (2016): 65-73.

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. 



Decreasing Injury Risk

Wednesday, June 1st, 2016

Tim Koba, MS, ATC
Twitter: @timkoba

Posted June 1, 2016

By Tim Koba, MS, ATC

If you are involved with youth sports and have seen injuries suffered by the participants, you should know it doesn't have to be that way. There have been several studies examining the effectiveness of implementing an alternative warm up specifically geared to decrease injuries. So far, the findings have been successful. Now, a study out of Canada also points out decreasing injury risk in sport saves money for the healthcare system, too.

Depending on the injury an athlete suffers, the financial, physical and mental cost can add up quickly. In the event an injury requires a surgical repair, the costs can skyrocket and the athlete may not return to participation. This lack of participation can have profound health effects if they suffer early joint pain, arthritis and inactivity leading to chronic illness or obesity. Obviously, this is a worst case scenario and the majority of injuries are relatively minor and easily treatable. Still, the possibility does exist for long term impairment. This is especially true for ACL injuries, medial elbow injuries in baseball players and shoulder labral tears.

So, if there is a chance some of these injuries can be decreased, we should take it. The good news is that while preventing all injuries is not possible, there are steps that can be taken to decrease certain ones. We know some of the global and more specific risk factors for suffering an injury. When athletes increase the intensity of their activity too quickly, they are more likely to get injured. Having already sustained an injury makes you more likely to suffer a recurrent injury.

Prior to puberty, boys and girls demonstrate similar movement patterns that change after puberty. Part of this divergence may be contributing to the increase in injuries suffered by female athletes after this time. We also know females are more likely to suffer ACL injuries and following a specific exercise program can decrease that risk.

Many studies have been conducted with soccer teams to determine the effectiveness of these programs. But, there is nothing specific about the exercises that make it special for soccer. The exercises are more global neuromuscular movements that if performed properly can improve movement quality, strength and performance metrics while decreasing the risk of injury.

Many programs are readily available for implementation, or there are community resources that are able to help. Finding and working with a qualified Athletic Trainer, physical therapist, strength coach, personal trainer or coach who understands the sport, common injuries and conditioning is a great place to start. They are able to find the research studies and programs available, demonstrate and instruct teams in how to perform the drills and be available to assess ongoing progress.

Taking the time to learn a few specific movement based exercises and drills can improve movement quality and strength. It can also lead to better, more conditioned athletes who are able to stay healthy throughout the year. With the ever increasing cost of healthcare and percentage of people with obesity, we need to do everything we can to keep people healthy and active from an early age. Incorporating injury prevention programs into a practice is a simple way to have a large impact.


About the Author

Tim Koba is an Athletic Trainer, strength coach and sport business professional based in Ithaca, New York. He is passionate about helping others reach their personal and professional potential by researching topics of interest and sharing it with others. He contributes articles on injury prevention, management, rehabilitation, athletic development and leadership.

You can connect with him on twitter @timkoba or check out his blog,