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Orthopedic surgeon leads one-of-a-kind institute in sports
injury prevention research and advocacy efforts
by Robert Trace
ORTHOPEDICS TODAY associate editor
ANN
ARBOR, Mich.
 David H. Janda, MD, has
a mission. He and his staff at the Institute for Preventative Sports
Medicine, located on the campus of St. Joseph Mercy Hospital in Ann Arbor,
Mich., are waging an all-out effort to help coaches, parents, league officials
and players prevent sports injuries.
It also doesn't hurt that Janda
and his colleagues are helping take a bite out of national health care expenses
through their injury prevention efforts.
The institute conducts
seminars for the lay and medical communities on injury prevention, and is
currently the only health cost containment organization of its kind in North
America. Just one of the research team's findings provided keys to preventing a
proposed 1.7 million injuries annually in the United States, with a savings of
$2 billion in health care costs per year.
Injuries caused by sports,
falls, motor vehicle accidents and the unintentional discharge of firearms
remain the leading cause of death for individuals between the ages of one and
44, and these accidents cost the U.S. more than $133 billion each year in health
care costs, according to Janda, who is director of the institute. He is also an
orthopedic surgeon specializing in sports medicine at Orthopaedic Surgery
Associates, a nine-physician orthopedic practice in Ann Arbor, Mich.
"Injury remains the most under-recognized major public health problem in this
country," he said, "and still we don't hear much about it in the media. The
public needs to understand that there are many potential solutions to this
problem."
He continues to field occasional inquiries from persons
wondering whether a proactive preventive approach would cut into an
orthopedist's business. "As an orthopedic surgeon, my job is to do what's best
for my patients, period," he responded. "There will always be patients who need
our specialized care. But I think one of the problems we've run into in this
country is not focusing enough on the prevention issue. Health care needs to be
made more affordable, and the way to help do that is by preventing need."
A labor of love
Janda volunteers 10-20 hours a week conducting research in
his lab at the institute, or touting the cost and health benefits of proper
sports injury prevention techniques to various groups.
Organized
recreational softball-which attracts over 40 million participants nationally
each year-is a particular area of interest for Janda, who claims 710/o of all
injuries from recreational softball and baseball result from sliding. While some
of these injuries are attributed to poor musculoskeletal conditioning, shoddy
sliding technique, and occasional alcohol consumption, the primary cause for
these foot and ankle injuries is a late decision to slide, he said.
A
baserunner's risk for injury is also determined in part by the type of base he
or she slides into, Janda acknowledged. Standard stationary bases are bolted to
a metal post that is sunk into concrete in the ground. "Breakaway" bases
utilizing a rubber mat fixed to the playing field by several low-profile rubber
grommets can be displaced at a fraction of the more than 3500 foot-pounds
required to dislodge a traditional stationary base. The breakaway bases, he
added, differ from bases which are secured to the mat via a magnetic or Velcro
strip, which can become ineffective when exposed to dirt or water.
Benefits of 'breakaways'
In their observations of more than 8500 players in a
softball league at the University of Michigan where half the games were played
on fields using stationary bases and the other half were played using breakaway
bases, Janda and his colleagues identified 45 sliding injuries involving
stationary bases. Only two sliding injuries occurred on the fields equipped with
breakaway bases. The total treatment costs to these 45 injured players came to
over $55,000, an average of more than $1220 per injury, excluding lost work time
and related costs, Janda said.
In the two injuries occurring on the fields using breakaway
bases, including a non-displaced medial malleolar ankle fracture and an ankle
sprain, the total medical costs for both injuries was only $700, or $350 per
injury. The ratio of injuries occurring on the stationary bases was 22.7 times
higher than that for the modified breakaway bases, Janda pointed out.
These findings were replicated in another phase of the
study, in which all fields were equipped with breakaway bases. Again, just two
injuries occurred in the more than 1000 games monitored, with the median costs
totaling only $400. This represents a reduction in injury occurrences (compared
with games played on stationary bases) of 98.70/o, Janda said. The
corresponding reduction in related medical treatment costs exceeded
990/o.
A congressional matter
Following Janda’s testimony before the House Appropriations
Committee on Labor, Health and Human Services, House officials developed federal
recommendations for the use of breakaway bases on recreational baseball and
softball fields in all federally operated facilities. These include all U.S.
military facilities worldwide, as well as federal correctional institutions.
Although Janda is advocating for mandatory use of breakaway
bases at both the amateur and professional baseball levels, he is pleased, for
now, that federal institutions are taking a proactive approach to prevention.
"According to the Pentagon, the No.1 reason for missed days in the military is
sports injuries," said Janda. "Hopefully, efforts like these will help eliminate
lost work time and the added costs of treatment and rehabilitation."
Still, a majority of Little League baseball fields and
office recreational softball leagues use the traditional stationary bases.
"It's a shame because we spent less than $1000 on this
series of studies, and according to the government, we found a way to save $2
billion in health care costs," Janda said. "when it comes to prevention, this is
not the exception; it is truly the rule. A very small outlaying of expenditures
can have a huge ramification on the prevention of injuries, as well as a huge
ramification in the prevention of health care costs."
 Financial support
As a policy, the institute does not accept financial
contributions from the government or from sports product manufacturers in order
to best serve the public without a conflict of interest.
"Funding continues to be an ongoing area of contention for
us," he added. "Unfortunately, the insurance companies haven't shown much
interest in funding our projects, even though we have demonstrated, through
scientific research, the steps coaches and players can take to prevent injuries
and save medical costs."
Instead, the institute must rely on tax-deductible
contributions from individuals, foundations, corporations, and by grants from
public and private agencies to support its research and operations. The
institute's annual budget is approximately $200,000.
The institute's pursuit of better safety measures has not
been limited to breakaway bases, either Janda and his group recently studied the
fatalities of 34 children over the past 17 years who died after being struck in
the chest with a baseball during an organized baseball league game, causing
fatal arrhythmia.
The researchers compared the different chest protectors and
softer, heavier baseballs currently on the market. "what we found was that even
through many of the manufacturers made claims about how well their product
worked, they had no scientific data to back up them up," Janda said.
 Working with auto
industry
Janda teamed with David Viano of General Motors, whose
company contributed crash test dummies and the Hybrid III Crash System-a
sophisticated computerized modeling structure used by the Justice Department for
ballistics testing and auto manufacturers for crash testing-to measure the force
of a fatal chest impact. The researchers then measured the potential for injury
resulting from the impact, even when the child was wearing a protective
device.
The researchers also measured the intensity of the impact
using traditional baseballs compared with softer, heavier baseballs claimed by
manufacturers to be safer for children. "We found the softer baseballs and the
chest protectors afforded no statistically significant benefit to the players,
and in some cases made the injuries worse," observed Janda, whose findings
appeared in the Clinical Journal of Sport Medicine.
He said the soft baseballs were too heavy to be effective.
"When we did our high-speed photographic work, we found the softer balls
actually stuck to the chest longer, posing a greater risk to damaging the
internal organs," Janda pointed out. "It enabled more energy and force to be
driven into the heart. The softer but larger-mass balls also pushed off with
greater force on the rebound, and we found the force of that 'double-hit' to be
additive."
Janda also reported the special chest protector for batters
and pitchers acted like a conductor, funneling the energy into the heart over a
shorter time period.
One important byproduct of the institute's research was the
introduction of softer, lighter baseballs. In a study to be published this
spring in the Journal of Trauma, Janda and colleagues detail their
findings on the effectiveness of these new lighter, softer baseballs.
Teach the fundamentals
The simplest, and often most efficacious preventive
measure, Janda believes, is teaching young athletes the fundamentals of their
sport. "We can't overemphasize the importance of instructing players on the
proper techniques of their sport, such as sliding in baseball or heading the
ball in soccer, so they can play safely."
For example, some children playing in leagues using the
softer, heavier baseballs are not instructed on how to get out of the way of a
pitch coming right at them. Many of these children are also assured by their
coaches that because the baseball is softer, the risk for injury is much less.
"Many of these children panic and step right into the pitch, and the ball hits
them in the chest," he said.
Janda became particularly disgruntled when Ann Brown,
director of the federal Consumer Product Safety Commission, recently
recommended widespread use of the softer, heavier baseballs, based on
information provided to her by the product manufacturers. "That kind of 'blind'
recommendation gives folks a false sense of security," Janda said. "It's like
claiming that, because a Cadillac and a Yugo are both cars, they are comparable
in terms of performance and safety."
 Soccer
safety
The institute is also researching the incidence of fatalities
among young soccer players who hit their head on the goal post, or had the goal
post topple over and fall on them.
After identifying the deaths of 18 children over a 13-year
period, Janda and his colleagues began work on a softer, lighter goal post. "It
took us about two years to design a goal post that was thinner and which didn't
alter the goal dimensions or the rebound of the ball, yet still protected the
athlete if he or she ran into it," he said. "We tested the goal post material
and it reduces the force incurred by a player's head or neck by over 600/o. We
also conducted a two-year field study on the effectiveness of the goal posts,
and of 14 player impacts with the post, there were no injuries."
In a related effort, Janda and colleagues observed soccer
coaches as they led their young players in heading drills. He recommends
children use a special helmet when first learning to head the ball.
"We would watch the coaches line the kids up; one child
would go first and head the ball a couple of times, and the coaches would
commend him as he staggered away," Janda said. "The next thing we knew, we were
seeing all these little children staggering around the field like little
Muhammed Alis. When we asked the children afterward what they liked most and
least about soccer practice, they would always say they disliked the heading
drill the most. They said after the drill they felt dizzy, or heard ringing in
their ears, or saw two of everything, or they felt like they would throw up.
Actually, these are all signs of a mild concussion."
At risk for brain damage?
Janda and his crew are conducting a longitudinal study of
soccer players ages 11 - 13 in Ann Arbor to determine if several years' worth of
heading a soccer ball in practice and competition has an effect on their
information processing abilities. Janda's project is inspired by a Norwegian
study conducted a few years ago of soccer players ages 19 and older who played
soccer throughout their school-age and adolescent years. The researchers there
reported that 85Wo of those studied demonstrated permanent information
processing and memory deficits.
"Most coaches we've approached about this lean toward
tradition, and are not enthusiastic about having their players wear helmets,
especially during the games," he said. "Many of them feel their players will be
'wimps,' or they won't learn how to head the ball properly. But by wearing the
helmets at least during practice, or using soccer balls with less air during the
heading exercises, the players might not leave practice with the kinds of
concussive symptoms we've been seeing."
A busy agenda
The institute is also busy pursuing safety product evaluations
and research in a number of other areas, including:
· alternative coaching techniques in
football;
· the development and testing of a
different type of cleated structure to reduce foot, ankle and knee injuries in
football;
· a study of non-lethal projectiles
used at sporting events for crowd control;
· a surveillance study assessing the
prevalence and severity of recreational basketball injuries;
· the prevention of cervical spine
injuries in hockey; and
· studies of shin guards and their
protective capabilities in soccer
Proposed projects include the development of future
protective head gear for football and biking, improved surfaces for running, and
a shoulder injury prevention program.
As part of the institute's advocacy efforts, the Advisory
Council will continue to extend the research findings of the institute to the
public. Advisory Council members include leaders from amateur and professional
sports-including notables like John Unitas, Oscar Robertson, Walter Payton and
Bonnie Blair-as well as community and business leaders who lend their expertise
on sports and health care cost-related issues.
Gaining recognition
Janda said the institute's efforts are slowly gaining
recognition throughout the world, and the institute has already assisted the
House Subcommittee on Commerce, Consumer Protections and Competitiveness in its
investigations of the ethical practices of manufacturers marketing sporting
goods alleged to be safer Likewise, the American Academy of Orthopaedic Surgeons
developed a position statement advocating the widespread use of breakaway bases,
predicated on Janda's research findings.
Janda has presented his research to the American
Orthopaedic Foot and Ankle Society, the American College of Sports Medicine, the
Canadian Academy of Sports Medicine, and the National Athletic Trainers
Association. He also presented his findings to the French government, and he
will be the keynote speaker on sports injury prevention at a meeting this
November hosted by the Australian government and the Sydney Olympic Organizing
Committee.
"We all tend to think of sports injuries as being little
bumps and bruises, and not having significant ramifications," he said. "But the
medical and job-related costs that add up when someone misses work for several
weeks and has to have surgery and rehabilitation can be very significant. Some
of these athletes may never be the same after their injury, and that's what we
want to avoid."
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