Here are seven big trends and concerns for sports medicine physicians treating elite athletes next year.
1. Concussion management. One of the most important concerns for elite athletes is concussions they sustain during play. Concussions can have longstanding implications for the athlete’s ability to continue performing on the field as well as their life after retiring from sports. As a result, much research is being done on the biochemistry of head injuries and high impact sports are developing protocols for concussion management and prevention.
“The new protocol the NFL has put in place has been geared in an unprecedented fashion to the utmost safety of the athletes, so now there are special protocols we need to follow for safeguarding the game as it’s being played,” says Spero Karas, MD, head team physician for the Atlanta Falcons and director of the orthopedic sports medicine fellowship program at Emory Sports Medicine in Atlanta. “There are now medical observers up top watching the game with the announcers to detect injuries on the field that we might not be able to see, especially if we are already attending to someone else on the sideline.”
The trained medical professional up in the booth provides an extra set of eyes on the field. If the observer sees something, he or she phones down to the medical personnel on the sideline and asks that the player be examined.
“That’s a really important safeguard and the NFL wants to maintain the integrity of the game and safety of the athletes,” says Dr. Karas. “However, there are also strict protocols in place for the in-game and post-game management of athletes who do incur concussions. There are a set of steps we have to follow to ensure their brain has recovered from the impact prior to being allowed to play again. A better understanding of the biochemistry of the brain and flux of chemicals released or inhibited during head impact can better allow us to institute measures in the future.”
Professional teams and leagues are now relying more on physicians and medical providers to make decisions about when athletes can return to play. The athletes can’t return until they are cleared by the team physician, and most physicians are conservative with their judgments.
“We have to make the decision whether the athlete can continue to play or whether he’ll have to come out of the game,” says Sam A. Labib, MD, knee and ankle surgeon at Emory Sports Medicine and consulting foot and ankle team physician for Georgia Tech and the Atlanta Falcons. “We make that decision based on medical facts. These decisions have to be made on the spot and it is part of the sports medicine that you don’t learn in the books, but if you do it for years you’ll develop that knowledge base.”
Baseline testing can help physicians decide when the athlete’s cognitive abilities have returned, but they don’t work for athletes who don’t speak English.
2. ACL injuries. Athletes in all sports are at risk for anterior cruciate ligament injuries, and there have been several advancements to traditional treatment over the past few years. Surgeons are now looking at more anatomic ways to reconstruct the ACL with less invasive procedures.
“Traditionally we have been limited by the techniques we employed to position the reconstructive graft in the proper place, but our understanding of the anatomy has allowed us to replicate — through the advancements in techniques and tools — a more anatomic knee,” says Dr. Karas. “There is a movement toward more anatomic techniques through nontraditional approaches.”
The new procedures use grafts that stretch from where the initial ligament starts to where it ends to more closely mimic natural anatomy. “My partners and I use these new techniques to perform over 400 ACL surgeries per year,” says John W. Xerogeanes, MD, chief of sports medicine at the Emory Orthopaedics & Spine Center and head orthopedist and team physician for Georgia Tech. “These advanced techniques provide better outcomes, which is crucial once athletes undergo surgery. We don’t want the injury to happen again after the athlete returns to play.”
3. Playing surface. The playing surface can have a big impact on injuries, especially in professional football. Some fields are indoor while others are outdoor, and some include synthetic turf while others are natural grass. Many teams have switched to synthetic turf because upkeep is low and it’s an even surface. However, there is some data that suggests these artificial turfs may increase the risk of injury.
“The grip and traction of artificial turf is so sure and true that it may predispose some athletes to knee and ankle injuries,” says Dr. Karas. “An athlete plants his or her foot for a cut and twisting maneuver, which might have some slippage in traditional grass, but in synthetic turf the grip is so true that there isn’t a slip. The force is translated to the ankle and knee, which can cause a sprain.”
Continued research into these surfaces could lead to a more controlled environment in the future. Another issue football players have is turf toe. Researchers and biomechanical specialists are developing footwear for the athlete to prevent these types of injuries.
“New developments in bracing and orthotics allow us to provide the athlete with dynamic support of the ankle with new braces that reinforce stability and further prevent future injuries. This is evident in athletes with ankle instability and turf toe injuries,” says Dr. Labib. The surgeons are marrying the clinical care of athletes with work in the lab.
“We are trying to meld science in the lab with the clinical care of athletes,” says Dr. Karas. “There is a growing body of work now to not only understand how the forces in the foot and ankle relate to the surface, but also how we can work with the shoe industry to provide the type of footwear with a specific athlete to prevent certain positions of the foot and avoid some of these injuries in the midfoot and the forefoot.”
4. Injury prevention. A newer field in sports medicine emerging over the past several years has been injury prevention. The team physicians for the Atlanta Falcons have pioneered this trend by developing a method to score biomechanical “red flags” in athletes placing them at high risk for injury.
“We put the athletes through a battery of tests designed to pick up on biomechanical abnormalities in the athlete’s movement patterns,” says Dr. Karas. “We look for potential injuries as well as asymmetries between the two sides of the body. We have been looking at hundreds of athletes over the past several years to see if there is a correlation of different scores and asymmetries with injuries over time.”
If there are correlations with the athlete’s injury history, the team physicians can suggest preventative measures such as corrective exercises that can help eliminate the asymmetries.
“There are a set group of believers who feel that these scoring systems can fetter out biomechanical differences and correct them to maximize performance and minimize injury,” says Dr. Karas. “These tools can be used after injuries to assess whether the athlete has returned to baseline as well.”
Dr. Xerogeanes’ research focuses on additional work for jumping and landing among female athletes. The athletes are connected to a computer program Dr. Xerogeanes’ team developed to detect biomechanical abnormalities among female athletes so the team physicians can work on correcting them before an injury.
“We’re working towards the ability to put this system out there for free. It could make a big difference for student athletes around the country,” says Dr. Xerogeanes. “It won’t cost several hundred dollars for a seventh grade soccer player to undergo the testing; it only costs the price of a camera and computer equipment.”
5. Biologic solutions. Surgeons and researchers are looking into minimally invasive techniques and the role of growth factors, such as stem cells, to supplant some surgical techniques as the standard of care for athletic injuries. In the future, injecting growth factors can promote the body’s ability to heal on its own.
“We are looking into activated platelets from the patients’ blood or stem cells from the patients’ bone marrow,” says Dr. Karas. “These treatments are currently being employed, but their complete understanding and role is inconclusive.”
One of the most widely-used biologics today is platelet-rich plasma, but there isn’t strong evidence to support its use in most situations. “We know that there is promise in using growth factors in healing, especially soft tissue healing,” says Dr. Labib. “There isn’t a lot of evidence that proves PRP injections work every time and we don’t know the exact recipe for optimum results, so PRP is still under review.”
As a sports medicine specialist with special training in foot and ankle, Dr. Labib is working on a new way to repair knee and ankle cartilage using infantile cartilage allograft tissue to heal cartilage defects. There are currently 20 sites around the country treating and following up with these patients for a study.
6. Healthcare reform. Changes to the United States healthcare systems could create access to care issues similar to those in Canada, which have unique implications for elite athletes. Right now, team physicians order imaging and other tests to make sure they have all the necessary information available, but in the future physicians could be penalized for ordering tests deemed “unnecessary.”
“We’ll see if physicians get penalized for questionable tests and whether teams will pay out of pocket for treatments that aren’t covered by insurance companies,” says Dr. Xerogeanes. “Currently teams pay out of pocket for PRP treatment, and it remains to be seen whether that will continue.”
However, athletes will likely continue to have access to medical care immediately after injuries. “It will be interesting to see what happens when government healthcare becomes implemented, because that changes everything,” says Dr. Xerogeanes. “A lot of changes are going to impact the way healthcare is administered and it will take some outside-the-box ways to pay for treatments.”
7. Recovery process. The recovery process is difficult after any injury or surgical procedure, but even more intense for professional athletes. They want to return to play at the same level, or higher, than they were before.
“The difference between seeing a professional athlete from a weekend warrior is the intensity and amount of energy that goes into the injury,” says Dr. Labib. “These guys are super men and women and you want to do a good job of getting them back into a situation where they can perform. We are very aggressive in evaluating MRIs and treating these athletes.”
Injury evaluations now include ultrasound technology that allows surgeons to see the ruptured tendon or gap in alignment in real time.
Written by Laura Miller