Spring 2010: Features
Back in the Game
Sports medicine isn’t just for the pros anymore
Be Sports Smart
Some tried-and-true rules still apply in sports injury prevention and treatment:
- Don’t increase activity levels too fast.
- Rest, eat properly, and stay hydrated before and during exercise.
- Listen to your body, especially when it hurts.
- When injured, apply ice. Cold therapy is most effective for the first forty-eight hours. Ice the injury for twenty minutes every hour or two.
See video of Hall of Fame football pro Fran Tarkenton at www.youtube.com.
By Mary Loftus
David Meador, a thirty-two-year-old mutual fund wholesaler in Atlanta, was hustling hard in his regular Monday night basketball game—driving the lane and going up for a jump shot—when he both heard and felt it: the distinct, unwelcome pop in his right knee.
“It felt like warm syrup running down to my right ankle,” he says. “I got up off the ground and limped over to the bench. Then I walked it off and went back in the game.”
He went back in the game?
“Sure,” says Meador, who has played regularly for five years at his local gym. “My team was winning. We got slaughtered in the second half, though.”
Meador rested up that night and walked to work the next morning, and the more he walked, the better his knee felt. Still, that audible pop, as well as several of his friends, told him what he didn’t want to admit: he had torn his anterior cruciate ligament, or ACL.
An ACL tear is one of the most common sports injuries, especially in sports that require running, jumping, or pivoting movements. Akin to a fibrous, thick rubber band made of collagen, the ACL runs through the center of the knee and connects the femur to the tibia, allowing the knee to bend and flex—but not too far. When it tears, the knee can become destabilized. So, for anyone who wants to continue to play sports, surgery is required.
Which is why Meador is now lying in a bed awaiting surgery at Emory’s Sports Medicine Center. He points to where his leg has been flagged with a marker to ensure that the surgeon operates on the right (and correct) knee.
In half an hour, Meador will be under general anesthesia, and his knee will have a tiny fiber optic camera inside it, guiding the arthroscopic surgery as a surgeon uses a cadaver ACL to replace his torn ligament.
The Sports Medicine Center is housed in Emory Healthcare’s Orthopaedics and Spine Center, tucked into an office park just off Interstate 85 in Atlanta. The center has four operating rooms, three surgeons, four sports medicine specialists, and ten certified athletic trainers, as well as a rotating roster of fellows and residents.
The waiting room’s walls are filled with autographed posters from dozens of professional athletes and celebrities who have been treated there, signed with sentiments like, “The knee is back!” and “Thanks for keeping us on the field.”
Once a narrow subspecialty of orthopaedics with a focus on professional athletes, the field of sports medicine has exploded in the last decade. The evolution of ACL surgery is just one of several advances in the treatment of athletes and their injuries that have started to serve not only the pros who make a living from their skills, but also the weekend warrior who gets hurt in the heat of a pick-up game, the neighborhood league player with tennis elbow, the college runner who pulls a tendon, or the high school football player with a possible concussion.
“What revolutionized sports medicine was arthroscopy—instead of opening up the joint completely, we can go in through a little poke hole, observe the injury, and repair it,” says surgeon Spero Karas, director of Emory’s Orthopaedic Sports Medicine Fellowship Program and consulting team physician for Georgia Tech and Emory Athletics. “It’s like the space program: These technologies were developed for the pros, but have filtered down to everyone. All of society benefits now.”
Although Meador plays only recreationally, the former high school basketball player and Louisiana State intramural athlete takes the game seriously. “I want to get back to playing basketball as soon as possible,” he says.
As an operating room is being prepped for Meador, John Xerogeanes 92M, or “Dr. X,” as his patients call him, is finishing up another ACL surgery. On an average day, he’ll have three or four surgeries; the most he’s ever done in a day is nine.
Xerogeanes is chief of the Emory Sports Medicine Center and associate professor of orthopaedic surgery. A linebacker at the University of California-Davis when he was in college, he’s head orthopaedist and team physician for Georgia Tech and Emory Athletics, and has provided care for scores of college and pro athletes. Not surprisingly, “Dr. X” has seen his share of torn ligaments. But when he performed Meador’s initial examination, his injured knee failed to exhibit some of the classic symptoms of an ACL tear, which was puzzling. After an MRI confirmed a tear, however, Xerogeanes decided to perform exploratory surgery.
Meador is wheeled in, and his leg is prepped. As the fiber optic camera is threaded into his knee through a tubular metal port, the OR’s color monitors show an internal landscape that resembles a cave. Once tissue is pushed aside with surgical instruments, the white fibrous ACL becomes visible. “Ah, there it is,” says Xerogeanes. The tendon is torn, but not completely, which explains the mixed signals during the exam. Since partially torn ligaments don’t heal, however, and most likely will continue to cause problems in active people like Meador, Xerogeanes decides to proceed with the surgery.
Working with researchers at Georgia Tech, Xerogeanes has created a three-dimensional model of the knee that helps pinpoint where to drill in order to anchor the replacement ACL closest to the spot where the original was attached. Having performed about 450 of these new placements, he’s happy with the results. “It restores more of the biomechanics in the joint, there’s less pressure, and it wears down less,” he says, which means a lower chance of arthritis later.
After cleaning up the remains of Meador’s torn ACL, he threads the cadaver graft (originally freeze-dried but now thawed) through a port. The new ligament has been coated with sterile mineral oil to make it slippery, since it’s a tight fit. Sometimes, especially in younger patients, a patient’s own tendon or hamstring graft can replace a torn ACL; in Meador’s case, a donated ACL was the best option.
Xerogeanes attaches Meador’s graft with screws made from an absorbent, coral-like substance that will use water and blood from Meador’s own body to transform itself into a facsimile of bone. After the new ACL is inserted, Xerogeanes pulls the slack out of the graft and puts the knee through its full range of motion, watching on the monitor.
“Looks good,” he tells the surgical team. “It’s right where it’s supposed to be—completely anatomic.”
Less than an hour has passed, and Meador is back in the recovery room. Xerogeanes hands him a DVD of the operation, gives him post-op instructions, and emphasizes the importance of rehab. “You’ll be back to playing basketball in six to eight months,” he says.
There is never really an off season for athletic injuries; if it’s not soccer, basketball, or football, it’s tennis, skiing, or Ultimate Frisbee. Just 20 percent of the center’s patients are collegiate or pro athletes; the other 80 percent are those who enjoy sports as hobby, exercise, or recreation.
Xerogeanes’s most famous patient, in fact, wasn’t a pro or an Olympian but a former president: Jimmy Carter came in for surgery on a torn rotator cuff, which he injured on a turkey shoot.
Thanks to the proven benefits of adding exercise to one’s daily routine, staying physically active and fit has become a priority even for those who didn’t play sports in high school or college. Regular exercise extends longevity, reduces disease and obesity, and improves mental and emotional health. If the advantages of exercise could be stuffed into a gel cap, that would be one valuable little pill.
But with an increase in exercise and sports participation comes an increase in exercise- and sports-related injuries—and sports medicine specialists. The American College of Sports Medicine, founded in 1954, now has more than twenty thousand members internationally.
Since people are remaining active well into their seventies and eighties, says Karas, it’s a multigenerational specialty. “It’s not unusual for me to see an eighteen-year-old baseball player, his fourteen-year-old sister who plays soccer, his dad who plays tennis, and his grandfather who plays golf,” he says.
A wrestler while at Notre Dame, Karas has three children who are involved in multiple sports. Along with the center’s other surgeons—Xerogeanes and Assistant Professor Sam Labib, head orthopaedist for Oglethorpe University and Perimeter College—Karas performs ACL reconstructions, meniscus repair, rotator cuff repair, and shoulder reconstruction.
A few years ago, Karas treated NFL Hall of Famer Fran Tarkenton. “Dr. Karas operated on me that morning, and I walked out an hour and a half later. Three days later, I was playing golf,” said Tarkenton, adding that sports medicine surgery has advanced light years beyond what existed during his years of pro ball.
Karas has contributed to advances in rotator cuff repair surgery that allow the shoulder to heal more dependably. He performs “double-row” arthroscopic repair, which secures the tendon to the bone at two sites rather than one. “It’s much stronger and does a better job restoring normal rotator cuff anatomy,” he says. “There is more tendon attached to the bone.”
Not all sports injuries require surgery. Some, such as concussions, need only a proper diagnosis and rest, so the body can heal itself. But the right diagnosis can be trickier than it seems—especially with athletes eager to play down their symptoms.
Assistant Professor of Orthopaedics Ken Mautner, head physician for Agnes Scott College’s sports teams and a team physician for Emory Athletics, was the first sports medicine doctor in Atlanta to use Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), a computer-based test that eliminates much of the uncertainty. “We can finally objectively evaluate what has always been a very subjective decision,” Mautner says. “It’s the equivalent of giving the brain a physical exam.”
Concussions, caused by sudden and violent rocking of the brain inside the skull from a traumatic blow to the head or upper body, are common in contact sports—about one in ten athletes will experience one. Most will recover completely as long as they don’t return to play too soon. But the danger of cumulative brain damage to pro football players has been the subject of recent debate in the $6 billion-a-year industry. In a study of NFL retirees ages thirty to forty-nine, it was found that a player’s chances of being diagnosed with dementia, Alzheimer’s, or another memory-related disease was one in fifty-three, as opposed to one in a thousand for the average man in that age range.
An even greater concern, says sports physician Jeff Webb, is the three million children who play football at the youth level and 1.2 million teens who play for high school teams. Young players’ height, weight, and technique make them susceptible to head and spine injuries, according to the National Athletic Trainers’ Association, and they suffer about fifty thousand diagnosed concussions each year.
Webb also sees young players exhibiting overuse injuries. “If kids show talent in a particular sport now, their parents or coaches think they’ll be the next big thing, and they play the same sport year-round,” he says. “The body, especially a preadolescent body, is not set up for that. You’ll see growth plate injuries, tendonitis, stress fractures.”
Guidelines from the American Academy of Pediatrics now say that young athletes should have a two-month break from their primary sport each year, and two days’ break each week. Also, they should not be on two teams for the same sport at once, such as the high school baseball team and a traveling baseball league.
Sports physician Amadeus Mason knows all about athletes who overdo it. As team physician for Georgia Tech’s track and field team, USA Track and Field, and the Nike/National Scholastic Sports Foundation Track and Field and Cross-Country meets, Mason cares for sprinters with torn hamstrings and distance runners with chronic tendonitis. Mason is a specialist in high school and early college athletics with the National Scholastic Sports Foundation’s MedTeam, helping to prepare the top high school athletes in the country for the next level—often the Olympics.
When he ran track in his home country of Jamaica, he was injured, which inspired Mason to help other athletes “get back to where they need to be.”
A little preparation goes a long way toward preventing most running injuries. “Call it pre-hab,” Mason says, smiling. Loose, warm muscles will perform better than cold, stiff muscles. And runners should use common sense: stay on familiar ground in a safe, well-lit environment, set realistic goals, and have a program for getting there.
One of the most common injuries the center treats is tendonitis, and a new procedure used by both Mason and Mautner is helping athletes who have chronic tendon pain. Platelet Rich Plasma (PRP) therapy has proven successful in rebuilding damaged tendons and jump-starting the healing process when traditional treatments like rest, ice, and anti-inflammatory medicines no longer provide relief.
The patient’s blood is drawn and placed in a centrifuge to separate out a layer of platelet-rich plasma, which is then injected into the weakened portion of the tendon with the guidance of an ultrasound machine. “A majority of patients find that by three months they can return to most or all of the activities they were doing before the pain started—sometimes activities they have not been able to do in years,” Mautner says.
Assistant Professor of Orthopaedics Brandon Mines, head team physician for the WNBA Atlanta Dream team, sees a wide range of athletes at the center and says the well-known rules still apply: Don’t increase activity levels too fast. Rest, eat properly, and stay hydrated before and during exercise. Listen to your body, especially when it hurts.
And one of the most familiar home remedies is still the best: ice. “It’s true. Icing the injury actually prevents it from getting worse due to inflammation and helps with pain, swelling, and healing,” Mines says. “The first forty-eight hours is when cold therapy is most effective. We recommend twenty minutes of icing every hour.”
Then, before you know it, you’ll be back in the game.