8 Best Practices for Treating High-Level Athletes

Orthopedic Sports Medicine

While orthopedic surgeons strive to treat all patients the same, professional athletes' goals are often different from the average patient or weekend warrior. Here, orthopedic and sports medicine physicians from around the country discuss eight best practices for treating high-level and professional athletes.

1. Give them a clear timetable for return after an injury.
After an injury, high-level and professional athletes can deal with learning that they'll have to sit out for three weeks or two months depending on the injury, but they can't deal with a physician who says "we'll wait and see." With many patients who have minor injuries, the physician can recommend physical therapy or other healing methods that may or may not produce results, but this same method doesn't work with professional athletes. "Time is always of the essence and there is a very high premium in being able to successfully predict how long an injury is going to take before the athlete recovers," says Daniel Lamar, MD, an orthopedic surgeon at Coastal Orthopedics in Bradenton, Fla., and team physician to the Tampa Bay Buccaneers, Pittsburgh Pirates and U.S. Soccer. "The athletes need to know down to the day or week when they will be able to return."

The athletes, coaches and team owners need a timetable set for their recovery and return as quick as possible. "The faster you give them this information, the better they can deal with it," says Craig Westin, MD, orthopedic surgeon at the Chicago Center for Orthopedics at Weiss Memorial Hospital and medical director of Chicago's Joffrey Ballet. Even a rough estimate that may change in the future is better than no estimate at all. Err on the side of caution with return dates and make sure you don't keep any secrets from the athletes about the severity of their condition, Dr. Westin says.

2. Let them play through mild injuries.
When high-level and professional athletes have mild or chronic injuries, they may be able to play despite the injury, though recreational athletes in the same position would be advised against activity. Depending on where the athlete is in the season and the severity of the injury, playing through the injury is a possibility. "If we know the chances of the athlete getting worse are minimal and if they want to play, we often let them play," says Jon Divine, MD, an associate professor in the department of orthopedic surgery at the University of Cincinnati College of Medicine and head team physician for the UC Bearcats. Divine is also an orthopedic sports medicine physician with University Orthopaedics & Sports Medicine and the team physician for the Cincinnati Commandos, a professional indoor arena football team. "At the same time, we need to make sure we are not being cavalier about the approach either. We really need to balance what the athlete wants and needs to do."

For example, if players have mild stress fractures, the team physician may put them on crutches during the day so they can unload the pressure. Then, during practice or games, the athletes are allowed to participate without the crutches. As sports medicine physicians further expand evidence-based medicine practice, team physicians will have better guidelines for negotiating treatment for the athletes' injuries with their desire to return to play. "As team physicians, we need to have a high level of medical evidence to support our decisions," says Dr. Divine. "Right now, we often call upon our experience and knowledge of physiology and biomechanics when treating athletes and returning them to play."

Whenever possible, it is important to allow athletes to play because it impacts their livelihood. "What might be indications for surgery are more or less appropriate for professional athletes than they are for recreational athletes," says Dr. Lamar. "You have to respect the athlete's livelihood as part of the process."

3. Do surgery in an ASC.
Having access to an ambulatory surgery center is key for team physicians treating high-level and professional athletes because the surgery center schedule is often more flexible than a hospital's. "We do a vast majority of our cases in the outpatient setting," says Arthur Valadie, MD, an orthopedic surgeon with Coastal Orthopedics in Bradenton, and team consultant to the Pittsburgh Pirates and the US Soccer Team. "Having the surgery center available is a nice thing for us to offer these athletes." When athletes are injured, they expect immediate diagnosis and surgery, if surgery is the appropriate treatment method. They can't wait three months for their procedure, as patients undergoing elective surgery might be able to do.

There is often less flexibility in hospital operating rooms than surgery centers, and the ASC's flexibility makes them a prime location for treating these athletes. "My OR bookings in hospitals are often three months out while in the ASC they are three weeks out," says Joseph Burkhardt, DO, an orthopedic surgeon in Battle Creek, Mich., and team physician for the Battle Creek Revolution professional junior hockey team. "If I have an overflow and I need to perform a surgery on an athlete, the patients only have to wait another day."

4. Perform minimally invasive procedures when possible. When surgery is necessary, less invasive procedures, such as arthroscopic surgery, are best for the athlete. Arthroscopic surgery damages less tissue and is associated with less pain, which speeds up the recovery process. "If we can limit the pain and weakness, we can shorten the recovery," says Dr. Westin. "If there is less damage from the repair, the rehabilitation process is easier and faster."

5. Utilize strong fixation techniques for ligament reconstruction.
Athletes often suffer ligament injuries, such as ACL tears or rotator cuff tears, and it's important to have a strong fixation point in those repairs. "The fixation techniques you would utilize in athletes as opposed to non-athletes are different because athletes are going to put your repair to the test," says Dr. Burkhardt. For ACL reconstruction, the surgeon may want to use the individual's own tissue to ensure graft acceptance. Tissue grafting takes longer with an allograft, so using an autograft may allow athletes to begin rehabilitation quicker.

Additionally, the surgeon has the choice of using soft fixation techniques with interference screws or solid fixation points with a washer lock fixation and closed loop end of buttons technique. For athletes, you often want to use a washer lock fixation to ensure stability. "The interference fixation point might slip, and you want to make sure the fixation point is solid before going into rehabilitation," says Dr. Burkhardt. "If the fixation slips, you might have a delay."

6. Keep the player's best interest in mind for returning them to play. High-level athletes experience pressure from several sources to return to play after an injury. This is especially true for professional athletes who have multi-million dollar contracts from teams and coaches expecting them to help win games. Sometimes you might feel pressure from the coaches to return the athletes, but keep the player's safety in mind. "Coaches might not like your decision, but in the long term, they'll agree they want their players better and healthy for as long as possible," says David Wallis, MD, team physician for the Los Angeles Galaxy and Chivas USA professional soccer teams. "You certainly want to keep the implications of your decision in mind. When you release someone to go back to play, that impacts the player, the team and the season. You need to keep the players' health and safety paramount."

Players also feel this pressure to return quickly and you may have to sideline them longer than they'd like. Beyond the financial pressures of returning to the game, the athlete also experiences personal pressures to heal as quickly as possible. "Players don't want to be known as fragile or injury prone," says Karl Kaluza, DO, a sports medicine physician with Sports Medicine at Legacy Medical Group — Lake Oswego (Ore.) and team physician for the Portland Timbers professional soccer team. "But if the injury is so severe that they can't return to play right away, I usually put my foot down and say 'that's not their decision, it's my decision and I don't think returning is appropriate.'"

7. Be educated about each position athletes play in the sport. Team physicians should be familiar with each different position played by the athletes on their team to effectively treat them and return them to play at the appropriate time. "You have to understand the different positions and whether the athletes will be able to handle what is required of them," says Robert Watkins, Jr., MD, an orthopedic spine surgeon and co-director of Marina Spine Center at Marina Del Rey (Calif.) Hospital, and spinal consultant for the Los Angeles Dodgers and other Los Angeles teams. "If the athlete has a spinal injury, you need to understand what type of torque and forces will go through the spine when they are in play." For a further example, a knee injury might impact a catcher's ability to return to play more than it would for an outfielder or designated hitter. Keep these things in mind when recommending treatment and following the athlete through physical therapy so they are able to perform at their highest level when returning to play.

8. Have a good relationship with other subspecialized physicians.
In the past, one physician could provide most of the medical attention athletes needed. Now, however, the lead team physicians subspecialize in one area and recommend their colleagues to athletes with other types of injuries. "You have to be comfortable handling the problems these athletes encounter," says Dr. Valadie. "Otherwise, you risk having a bad outcome and professional athletes could file lawsuits." For example, if you are a knee specialist and the athlete has a rotator cuff tear, you may want to recommend another physician in the area who focuses on treating rotator cuff tears because they will have a better outcome.

"You have to have access to others who are able to come out of their practice and treat the athletes," says Ralph Gambardella, MD, orthopedic sports medicine surgeon and president at Kerlan-Jobe Orthopaedic Clinic in Los Angeles and orthopedic consultant to the Los Angeles Dodgers. "I don't think you can successfully be a jack of all trades anymore."

Also network with other healthcare professionals who work with the athlete, such as physical therapists, sports psychologists and nutritionists, says Robert Dimeff, MD, director of sports medicine at UT Southwestern Medical Center in Dallas. "You have access to a lot of helpers to make sure the athlete is ready to return to play," he says. These people help to ensure the athlete is undergoing an appropriate exercise regimen and consuming the right number of calories so they don't fall out of shape as a result of the injury. "During the off season, the injured athlete might also want to stay close to home and you can find them good professionals to stay in touch with," he says.

Read other coverage on team physicians:

- 8 Biggest Challenges Facing Team Physicians for Professional Athletes

- 10 Stories for Team Physicians About Concussion Awareness

- How Physicians Can Help Decrease Injuries in Young Athletes: Q&A with Rothman Institute's Michael Ciccotti

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