Training and Rehab

Sports Medicine

The Punahou Athletic Training staff provide first aid and health care to all Punahou students, specifically those participating in interscholastic athletics. Athletes who are competing for Punahou, but have sustained an injury in a situation unrelated to their Punahou team activities, will be responsible for their own medical care. The staff will assist with emergency care and treatment of non-athletes who sustain an injury at school. However, responsibility for rehabilitation will be that of the individual student and his/her family.

List of 3 items.

  • Services

    Injury Prevention
    • Monitor injury trends via collection and analysis of Punahou athletic injury data and recommend appropriate changes in team training to reduce injury risk
    • Select, apply and modify prophylactic and protective equipment and other custom devices for patients/clients to minimize the risk of injury or re-injury.
    Management of Athletic Injuries
    • Emergency Care
    • First Aid
    • Injury Evaluation
    • Referral
    • Practice and Competition Coverage
    Rehabilitation of Athletic Injuries
    • Design and implement therapeutic exercise program
    • Utilize therapeutic modalities in treatment plan
  • Standard of Care

    The health and welfare of student athletes is Punahou’s first concern. The Punahou Athletic Training Staff adheres to the NATA Code of Ethics and the Athletic Training Educational Competencies as established by the NATA. 
  • Objectives

    Athletic Training Room Staff are committed to:

    • Providing efficient and timely care of athletic injuries that are incurred by Punahou athletes during their competitive season
    • Enabling injured athletes to return safely to competition
    • Reducing the risk of athletic injury for our student-athletes
    • Educating student-athletes about athletic injuries so they are empowered to lead healthier, injury-free lives
    • Coordinating with the strength and conditioning program, the coaches, the athletic support staff, school administration, physicians and other healthcare providers to provide the best possible healing environment for our student athletes
    • Facilitating a safe return to school and sport for student athletes after a concussion by coordinating care between teachers, school administration, counselors, the health center, parents, coaches, and the student athlete

Knowledge Base

List of 17 items.

  • Anterior Cruciate Ligament

    Anterior Cruciate Ligament (ACL) Sprain

    The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments in the knee. Approximately 150,000 ACL injuries occur in the United States each year. ACL knee injuries can cause many problems for kids who play sports. Besides the likelihood of having to sit out an entire season, they have a higher chance of developing osteoarthritis (a painful joint condition) later in life. Female athletes participating in basketball and soccer are two to eight times more likely to suffer an ACL injury compared to their male counterparts.

    Why do ACL injuries occur in kids?

    Most ACL tears do not occur from player-to-player contact.The most common causes of noncontact ACL injury include: change of direction or cutting maneuvers combined with sudden stopping, landing awkwardly from a jump, or pivoting with the knee nearly fully extended when the foot is planted on the ground. More information

    How can ACL injury be prevented?

    Several prevention programs have been developed in an attempt to decrease the incidence of noncontact ACL injuries. The focus of current prevention programs is on proper nerve/muscle control of the knee. These programs focus on plyometrics, balance, and strengthening/stability exercises.
  • Balanced Diet

    • Focus on refueling with fluids, carbohydrates and protein.
    • Meet energy needs by getting the right fuel on board from foods and fluids. The best balance: 55-60% of calories from carbohydrates, 10-15% from protein and 20-30% from fat.
    • Watch fat intake and a high-fat diet is not healthy- but neither is a zero-fat diet. Go for low-fat foods.
  • Carbohydrate (CHO) Recommendations

    • Carbohydrates are the main energy source for exercise and major fuel for the brain.
    • Carbohydrate stores in the body are limited.  Athletes must replenish muscle glycogen every day.
    • Carbohydrates should consist of about half of your total daily intake of calories. i.e. 2000 total calories /2= 1000 cal of CHO/4 grams in each CHO= 250 grams of  CHO
    • Top food sources: fruits, vegetables, whole wheat pasta, brown rice, breads, skim or low-fat milk, low-fat yogurt, whole wheat or grain cereals such as Cheerios, pretzels, whole wheat or grain bagels, honey, sweet potatoes, vanilla wafers or granola bars
  • Cervical Spinal Cord Injury

    Spinal Injuries

    Each year, approximately 12,500 new cases of spinal cord injury (SCI) are reported in the United States. Nine percent of these SCI are a result of sports and recreation. Among all US sports, the greatest number of catastrophic SCI occurs in football.

    Catastrophic SCI occurs when there is structural distortion of the cervical spinal column associated with damage to the spinal cord. The SCI that carries the greatest risk of sudden death for the athlete happens when the damage is at the C4 level or above and severe enough to affect the spinal cord's ability to transmit respiratory or circulatory control from the brain.

    In football, axial loading is the primary mechanism for catastrophic SCI. Axial loading occurs as a result of head-down contact and spearing. The incidence of quadriplegia in organized football has remained relatively low since rule changes by the National Collegiate Athletic Association (NCAA) and the National Federation of State High School Associations (NFHS) against helmet to helmet contact and spearing have been enforced. However, dangerous head-down contact remains a common occurrence on the football field.

    An athlete risks paralysis anytime he or she initiates contact with their head down. When the head is up, the cervical spine is in a position where it has maximum flexibility to endure impact without injury. When the head is down, the natural curve of the cervical spine is reduced, the vertebrae of the neck align in a straight column, which increases the potential for an impact resulting in a serious spinal injury.

    During a head-down hit, the head is stopped at contact, the trunk continues to move and the spine is crushed between the two.

    Whether intentional or unintentional, head down contact results in axial loading and is the primary cause of cervical spine fractures and dislocations in football. Football equipment, such as helmet and shoulder pads, do not prevent axial loading injuries of the cervical spine.


    Football hitting technique is the critical factor in preventing axial loading. When contact is made with the shoulder and chest while keeping the head up, the risk of serious head and neck injury is greatly reduced. When the head and eyes are up, the athlete can see the impact before it happens. Whether they are the ball carrier or the tackler, they can prepare their neck musculature accordingly for protection where the force of the hit can be absorbed by the neck muscles, intervertebral discs, and the cervical facet joints.

    In an effort to prevent SCI many organizations promoting child safety in sports have created instructional videos on safe tackling and safe blocking, including the National Athletic Trainers' Association (NATA) and USA Football.

    Proper football hitting technique

    How to tackle
    How to block
  • Concussion

  • Energy Drinks

    • Beverages such as Red Bull, Monster, Rockstar, etc. contain B vitamins, herbs, sugar and caffeine. Energy drinks are not tested or regulated by the FDA.
    • The differences between sports and energy drinks are: Sports drinks replenish electrolytes, sugar, water, and other nutrients; whereas, a large portion of energy drinks contain mostly sugar and high doses of caffeine.
    • Drinking an energy drink before activity may dehydrate the athlete since it contains caffeine, which is a diuretic.
    • Children and young adults under the age of 18 should not consume these drinks due to possible adverse reactions such as stroke, seizures, and sudden death.
  • Heat-related Illness

    Playing in high temperatures can be dangerous. Sweating is the process our body uses to cool itself, but with high humidity and hot temperatures, athletes' bodies can have trouble maintaining a safe body temperature. This may lead to heat-related illnesses. Athletes who are unconditioned or getting over illnesses are more likely to experience heat-related illnesses. Athletes and coaches should learn the warning signs and symptoms of heat illnesses in order to act quickly and give the appropriate care.

    The following are heat-related illnesses and websites to help distinguish the warning signs and aid in the proper course of treatment:
    The Hawaii High School Athletic Association recommends athletes take the following precautions to lower the incidence of heat-related illnesses:
    • Monitor their body weight before and after activity to ensure they are replacing fluids, especially during hot and humid events.
    • Monitor their urine color to ensure proper hydration levels. Replace fluids with water and/or sports drinks to replace fluids and electrolytes.
    • Sleep 6-8 hours a night and eat a well-balanced diet.
    For further information on how to prevent dehydration, please refer to the Korey Stringer Institute's website.
  • Hydration

    • Before, during and after training and games, drink water or sports drinks to prevent mental and physical fatigue.
    • Use a personal water bottle to hydrate throughout the day.
    • Drink 16-24 oz. of fluid one to two hours before practice/game.
    • Drink 5-10 oz. every 15 to 20 minutes during practice/game.
    • Consume a sports drink such as Gatorade when your activity goes longer than one hour.
    • Drink at least 24 oz. for every pound lost through sweat after practice/game.
  • Muscle Recovery Post Exercise

    • Help muscles recover faster by consuming 1-2 cups of low-fat chocolate milk within 30 minutes after intense exercise.
    • Eat a high carbohydrate, moderate protein meal one to two hours later to continue with muscle recovery.
    • Rehydrate immediately following
  • Patellofemoral Pain Syndrome

    What is it?

    Patellofemoral pain syndrome (PFPS) is a broad term describing general pain at the front of the knee and around the patella or kneecap. PFPS is the most common injury in athletes whose sport requires a high frequency of running and jumping. Pain is typically at worst with actions such as climbing or descending stairs, running, jumping, and squatting.

    The most common cause for patellofemoral pain is a malalignment of the patellofemoral joint as a result of a sudden increase in training level or overuse during intense athletic activity.


    The most common complaint for PFPS is a dull ache in the front of the knee. Oftentimes crepitus may be present, a popping or cracking sound or sensation in the knee, especially while climbing stairs or standing after sitting for a long time.

    The level of pain will be directly related to activity – type of activity as well as intensity and duration.
    • Pain increases with:
      • Exercise, particularly activities with repeated knee bends such as using stairs, running, jumping or squatting
      • Sitting for long periods of time with knees bent (ie. in a classroom, theater or airplane)
      • Increase in activity level
  • Pre-Event Meals

    • A pre-event meal is important to prevent hunger and to supply energy to muscles.
    • Three to four hours before the game, focus on carbohydrates, moderate protein, low-fat foods and fluids (pasta with a light marinara, a chicken or turkey wrap, vegetables, peanut butter sandwiches, a baked potato, cereal with low fat or fat free milk, crackers, rice, fruit, water, milk, juice, sports drink).
  • Protein Recommendations

    • Protein is important for building muscle, fighting infection and making enzymes and hormones.
    • Recommended intake: 1.4-1.7 grams of protein per kg body weight.
    • Protein sources: poultry, meat, cheese, fish, yogurt, milk, nuts i.e. almonds and peanuts, seeds i.e. sunflower or pumpkin, peanut butter, almond butter, eggs, tofu, and edamame.
    • Leaner protein: chicken and turkey breast meat, egg whites, fish, and cuts of beef.
  • Shin Splints

    Shin Splints – Medial Tibial Stress Syndrome (MTSS)

    Commonly known as shin splints, Medial Tibial Stress Syndrome (MTSS) is an exercise-induced overuse injury and the most frequent lower leg injury in sports. It is defined as pain along the inner border of the shinbone (tibia) that is associated with exertion such as running and jumping.

    Although MTSS is often not a serious injury, it can be disabling acutely and has the potential to progress into a more serious condition if not treated properly.


    The most common cause for MTSS is a sudden change in physical activity, where one tries to do too much too soon. Runners are at the highest risk of developing MTSS. Pain is caused by inflammation of the muscles, tendons and bone tissue around the tibia.

    Risk Factors

    The following are risk factors that may increase an athlete's likelihood of developing MTSS:
    • Pronation – Navicular Drop
    • Orthotic use
    • Body Mass Index
    • Running experience
    • Weakness of the lower leg muscles
    For more information on what causes shin splints, how to treat it and how to prevent it go to the following links:
  • Shoulder Impingement/Rotator Cuff Tendonitis

    One of the most common physical complaints for overhead athletes is shoulder pain. The shoulder is made up of several joints combined with tendons and muscles that allow a great range of motion in your arm. However, high range of motion makes the shoulder vulnerable to many different problems. One of the most common is shoulder impingement/rotator cuff tendonitis.

  • Tendonitis (due to growth)

    Sever's Disease:

    Also called Calcaneal apophysitis. It is an irritation to the calcaneal growth plate due to tightness of the Achilles tendon while the body is in the growth phase.

    1. Pain, swelling, in one or both heels
    2. Tenderness and tightness in the back of the heel that feels worse with compression
    3. Pain with walking, running or jumping and increases with activity.
    4. The pain may be especially bad at the beginning of a sports season.
    5. Pain increases with cleated shoes and shoes with limited heel padding.
    Sever's is more commonly seen in males during their growth spurt from ages 10-15. For girls, the growth spurt is generally from ages 8-13.

    1. Ice the heel for 20 minutes pre and post-activity.
    2. Add heel cushioning to shoes or change to shoes with more heel padding for the majority of the practices. Save cleated shoes for games.
    3. Limit running during practice regardless of shoes worn.
    4. Give periodic rest during activity to allow the heel to rest.
    5. Can use a compression pad taped to the calcaneus to provide some mild relief.
    6. Pain will not go away until the athlete can rest the heel for several weeks.
    7. Modify cardiovascular activity – bike or swim when possible to reduce repetitive trauma to the calcaneus.
    For additional information about Sever's Disease, please look at the following video:

    Osgood Schlatter's

    This is typically a sports-related complaint due to repetitive microtrauma resulting in traction to the apophysis at the tibial tuberosity and the distal patella tendon.

    1. Knee pain
    2. Tenderness
    3. Swelling at the anterior tibial tubercle
    Osgood Schlatter's is more commonly seen in males during their growth spurt from ages 12-15 and for girls in their growth spurt from ages 8-12.

    1. Ice the knee for 20 minutes pre and post-activity.
    2. Add heel cushioning to shoes or change to shoes with more heel padding for the majority of the practices. Save cleated shoes for games.
    3. Limit running during practice regardless of shoes worn.
    4. Give periodic rest during activity to allow knees to rest.
    5. A patella strap, placed between the patella and the tibial tuberosity may give some relief. The strap changes the primary tension and moves it from the tibial tuberosity to the strap sight.
    6. Pain will not go away until the athlete can rest the knee for several weeks.
    7. Modify cardiovascular activity – bike or swim when possible to reduce repetitive trauma to the knees.
    Knee pain is located at the origin of the patella tendon at the inferior patella pole.

    Symptoms and Treatment
    Identical to Osgood Schlatter's, except that knee pain is on the distal patella and proximal patella tendon.

    For additional information about Osgood Schlatter's Disease, please look at the following video:

    Hip Apophysitis

    Generally caused by high-intensity twisting activity associated with repetitive traction on an apophysis. Not an acute traumatic event such as kicking which may result in an avulsion.


    The most common sites include the Anterior Superior Iliac Spine (I) and the Ishial Tuberosity (V). These can occur as a result of kicking, rapid acceleration and deceleration, or jumping.

    1. Ice the apophysis for 20 minutes pre and post activity.
    2. Add heel cushioning to shoes or change to shoes with more heel padding for the majority of the practices.Save cleated shoes for games.
    3. Limit running during practice regardless of shoes worn.
    4. Give periodic rest during activity to allow hips to rest.
    5. Pain will not go away until the athlete can rest the knee for several weeks.
    6. Modify cardiovascular activity – bike or swim when possible to reduce repetitive trauma to the knees.
    For additional information about Hip Apophysitis injuries, please look at the following video:

  • Tendonitis (due to injury)

    Overuse injuries may be defined as a mechanism of injury as well as a specific injury. For the purpose of this discussion overuse injuries will be defined as a category of injury with specific injury etiology due to repetitive microtrauma with a gradual onset of pain. Overuse injuries are generally chronic in nature without a single onset episode.

    Tendinitis Injuries account for 19.69% of all injuries reported by Punahou athletes in grades 7 through 12, for the 25-year period from 1988 to 2013. This includes time-loss and no-time-loss injuries. As noted in Table 1, there is a decrease in tendinitis injuries, as the student/athlete gets older. Seventh-grade athletes, male and female, recorded 792 tendinitis injuries, 28.96% of the 2735 injuries reported. Tendinitis injuries accounted for only 12.36% of injuries for 12th grade athletes.

    Points of Interest Table 1:
    1. The 7th grade athletes reported the highest percentage of tendinitis injuries although actual overuse injuries were the lowest reported by any grade.
    2. The percentage of tendinitis injuries decreased annually for both genders.
    3. Females reported a higher percentage of tendinitis injuries at all grade levels than males.
    4. The number of female tendinitis injuries decreased after grade 9 as did the total injuries.
    5. Males reported more tendinitis injuries during the 11th and 12th grades, but the percentage of all injuries is lower.
    Observations from Table 1:
    1. Overuse tendinitis injury percentages decrease with age regardless of sport/activity for each sex.
    2. Females report a higher percentage of overuse/tendinitis injuries than do males for each grade.
    3. The total number of injuries decreases in 11th and 12th grades as do total gender specific injuries and gender specific tendinitis injuries
    4. Males report more total injuries than females with a lower percentage of tendinitis injuries.

    Points of Interest Table 2:
    1. Of the 6002 female varsity sport injuries reported, 2974 (49.5%) were time loss injuries.
    2. If No-time-loss injuries are ignored, 51% of all female injuries would go unreported.
    3. Overuse injuries (1620) accounted for 27% of all varsity female injuries.
    4. The overuse exposure rate is 1.81/1000 AE.
    5. There were 584 time–loss overuse injuries (9.7% of all injuries), which is 36% of all overuse injuries.
    6. A total of 1036 no-time-loss were reported (17.2% of all injuries) which is 64% of all overuse injuries.
    Specific Sports – Females
    Track and Field
    1. Track and Field (TF) had the highest annual participation rate with an average of 124 athletes competing at the Varsity/JV level per year.
    2. Female athletes reported 1674 injuries of which 731 (43.7%) were classified as overuse injuries.
    3. The overuse Exposure Rate was the highest at 3.19/1000 AE.
    4. Time-loss overuse injuries (232) accounted for 39.9% of all TF injuries with an exposure rate of 1.274/1000 AE.
    5. No-time-loss overuse injuries (439) accounted for 60.1% of all varsity TF injuries.
    Cross Country
    1. Cross Country (CC) had the second highest participation level for female athletes with an average of 68.5 athletes per year.
    2. Overuse injuries accounted for 377 (49.9%) of all reported injuries with 136 time-loss injuries (17.9% of all injuries).
    3. The Exposure Rate for all overuse injuries was 2.65/1000 AE with a time-loss exposure rate of .959/1000 AE.
    4. The No-Time-Loss exposure rate s 1.694/1000 AE.
    1. Varsity volleyball reported only 55 overuse injuries which is only 19.5% of all injuries.
    2. The Overuse Exposure Rate is 1.79/1000 AE. (Low participation rate)
    3. Only 8 of the overuse injuries were time-loss injuries for an exposure rate of 0.260/1000 AE.
    4. The No-Time-Loss injuries (47) accounted for 85.5% of all overuse injuries.
    5. Fourty-one of the 55 volleyball overuse injuries (74.5%) occurred to the lower extremities with only 10 shoulder injuries reported.
    1. Data for female wrestling is for 15 years, rather than the 25 years for male wrestlers.
    2. Female wrestling had the lowest participation rate with 10.9 participants per year.
    3. Wrestling reported on average 1 overuse injury per year (16) which is 4.4% of all injuries.
    4. Four time-loss injuries were reported during the 15-year cycle.
    5. The variety of cardiovascular and physical conditioning exercises did not result in repetitive microtrauma.
    1. Only 8.5% of all injuries (74) were classified as overuse injuries for varsity girl's soccer
    2. The no-time-loss injury (55) exposure rate was 1.202/1000 AE as athletes continued to participate with minor irritations.
    Canoe Paddling/Kayaking
    1. These sports reported 49% and 42% of all injuries as overuse.
    2. As the exposure rates are similar, it should be noted that 71% (63) of the overuse injuries involved lower extremities. These were the result of dry-land conditioning programs.

    Points of Interest Table 3:
    1. There were 1510 overuse injuries reported by varsity male athletes. This is 13.4% of all injuries reported, which is half of those reported by varsity females.
    2. The 541 time-loss injuries were 9.5% of all time-loss injuries reported.
    Track and Field
    1. Track and Field had the highest number of participants (average of 115/year) and the highest number of overuse injuries (495) which is 35.5% of all injuries.
    2. The Overuse Exposure rate was 2.43/1000 AE, second highest.
    3. The time-loss overuse injuries accounted for 25.7% of all time-loss injuries and 39% of all overuse injuries.
    4. No-time-loss injuries accounted for 61% of overuse injuries and had the second highest no-time-loss exposure rate of 1.483/1000 AE.
    Comparisons between Table 2 and Table 3.
    1. Males reported 5240 more injuries than did females. While the majority of this difference was due to football injuries, with football injuries removed males still reported >600 injuries more than females.
    2. Females reported more overuse injuries (1620 to 1510) than males and without football the number is 1620 to 1400.
    3. Males have more contact/collision type injuries than due females.
    4. Females report that 27% of all injuries are overuse, compared to male reported injuries at 13.4%.
    5. The exposure rate is 1.81/1000 AE for females and 1.39/1000 AE for males. The rate ratio is 1.30 reconfirming that females have a higher overuse injury rate.
    Contributing Factors for Possible overuse injuries.
    1. High School Physical Education (PE) credit is available for all students while participating in athletics. This credit is generally attained while in grades 9 and 10, but can stretch to grade 11.
    2. Students trying to earn this PE credit generally choose the non-cut sports.
    3. Lack of pre-participation conditioning, both muscular and cardiovascular, is the primary cause of overuse injuries in middle school and secondary school sports.
    4. Proper footwear is essential for all sports. Cleated shoes may place excessive stress on the calcaneus as the foot lands on the ground. A shoe with bars on the sole disperses the stress over the foot reducing the force on the contact points from the cleats.
    5. Establishing standards for cardiovascular conditioning, as well as technical and athletic skills, should be the basis for athletic participation.
    6. Athletic participation should be a goal for students, not just a means for easy PE credit.
  • Tournament Play

    • Get into a routine of using water and sports drinks for hydration and energy.
    • Drink water or sports drink in the dugout between breaks.
    • If your event is lasting longer than 1 hour, eat small amount of carbohydrates such as non-caffeinated exercise energy bar or granola bars, exercise energy gels, exercise energy chews, exercise energy shot, a small banana, slices of an apple, pretzels or a whole grain fig bar.
    • Have snacks available throughout the day: energy bars, bananas, oranges, fluids.
    • Replenish fluids and carbohydrates with nutritious meals within a half hour of post exercise.