Cutting-edge surgical techniques allow injured athletes to compete again, but it’s the post-op therapies that separate the amateurs from the pros. Six weeks before last year’s Super Bowl, Philadelphia Eagles wide receiver Terrell Owens broke his leg and damaged his ankle ligament in a football game against the Dallas Cowboys. Despite what all observers called a season-ending injury, Owens vowed to return if his teammates kept winning in the playoffs. After a grueling rehabilitation, Owens did indeed return to excel in the Super Bowl.
Sheer willpower and dramatic declarations aside, however, the strongest force behind Owens’ recovery was rooted in science—specifically, the cutting-edge surgical and reconstructive methods employed by physicians to bring Owens back in record time. Advances in techniques such as arthroscopy let surgeons illuminate and repair delicate tears and the most wrenching damage, leading to less post-operative pain and a faster recovery. The latest innovations move beyond arthroscopy, treating severe injuries and degenerate conditions that once seemed hopeless.
In theory, these methods should succeed for high-profile athletes, college competitors, and weekend warriors alike. But in practice, there are distinct differences. “People hear about all the wonderful advances that are made, and they assume that those techniques are going to be applicable to them,” says Richard Marder, Chief of Sports Medicine Service at the University of California, Davis. But elite athletes have distinct advantages, he says—before and after their radical repairs.
Getting the Open Look
From the Greek words “arthro” and “skopein,” meaning “joint” and “to look,” arthroscopy is arguably the biggest orthopedic advance of the last century. A relative of endoscopy, in which doctors send a miniature camera on a cable into the body to look at intneral organs, arthroscopy lights up joints with a fiber-optic cable threaded through a slit in a patient’s skin. The idea was proposed in 1908 by Phillip Bozzini, an Austrian physician who built a prototype instrument for visualizing internal organs. However, Bozzini’s instrument required a wax candle as a light source. He never tested it on humans, and he endured ridicule from his colleagues. In the 1950s, American Eugene Bircher became the first doctor to use an arthroscope to diagnose diseases such as tuberculosis. By the 1980s, technological advances had caught up to the design. Surgeons did whole surgeries entirely through arthroscopy.
Compared to open surgery, arthroscopy minimizes trauma to both the damaged region and the muscles surrounding a knee or shoulder joint. Marder, who specializes in knee and shoulder arthroscopy, says this difference cuts pain after surgery and helps patients heal faster. “In all surgeries, the trend has been to go to more and more of an arthroscopic approach,” says Marder, who is also the team physician for the Sacramento Kings.
That trend is clearest for high-level athletes. Most sports-related injuries occur in the knee and shoulder. They inflict damage to two types of tissue: the cushion-like cartilage surrounding a joint, or the stress-distributing ligaments that make it stable. In the shoulder, injuries to the rotator cuff—the muscle that enables circular motion—are common in “overhead” athletes such as tennis players, weight lifters, and baseball pitchers. The shoulder has the greatest range of motion of any joint. This, says Marder, means the shoulder is inherently unstable. Hence the ligaments, cartilage, and muscles surrounding this and other joints must perform careful balancing acts to maintain equilibrium. Even if an athlete doesn’t suffer a distinct injury, repetitive motions still can lead to stiff and painful joints.
“It’s analogous to trying to close a door, and it doesn’t quite fit in the doorframe,” says Marder. “Every time you push it in, it goes, but it doesn’t go easily. After a while, you are going to cause trauma within the joint.”
At his plaque-lined office in downtown Sacramento, Marder rifles through a stack of glossy 5” by 7” photographs depicting the steps in repairing a torn labrum—a flap coming off the ring of cartilage around the shoulder joint. A labral tear can cause the shoulder to painfully “pop” or “catch,” he says. One of the many glossy photos gives a striking, albeit nauseating, glimpse into the labrum repair. In this surgery, a slender plastic tube, or cannula, slips into the joint through an inch-wide incision in the skin. By scoping out the location of the tear with a pencil-sized light probe and sliding a tack down the cannula, Marder pins the dangling flap of cartilage back to the bone. Marder avoided tearing through any muscles to make this fix, so the shoulder healed far more quickly.
Although arthroscopy has worked wonders for many common injuries to athletes, Marder points out that there is still a lot of ground to cover. In the last two to five years alone, he adds, two new procedures have let surgeons move beyond repairing cartilage to actually replacing it.
Suturing One’s OATS
One such procedure may have saved the career of one of professional basketball’s brightest young stars: Amare Stoudamire of the Phoenix Suns. For Stoudamire, a sore knee turned into a serious problem that traditional arthroscopy could not have solved.
During his team’s training camp last summer, Stoudamire felt pain in his left knee, and missed two days of practice to rest the joint. In early October, the 23-year-old basketball forward signed a $73 million, five-year contract extension with the Suns and inked a shoe deal with Nike bigger than Shaquille O’Neal’s. “I’ve seen the future of the NBA,” said O’Neal at the time, “and his name is Amare Stoudamire.” But the pain in his knee persisted. Six days later, Stoudamire decided to have his knee scoped out to find the cause. Rather than an abrupt tear, Stoudamire’s pain was originating from flakes of dislodged cartilage grinding over his kneecap, inflaming the joint and slowly worsening his agony.
It was a classic example of a “chondral defect”—a joint injury where cartilage erodes off the bone and for which there is no easy fix. “We can fix ligaments, we can repair menisci, but we don’t have a surefire way of dealing with a chondral injury,” Marder says. “And that’s what causes early retirement in an athlete.”
Not ready to retire, Stoudamire opted to have something done before the injury got worse. For elite athletes, cartilage fragments really leave no choice, says Eric Berkson, a sports medicine fellow at Massachusetts General Hospital in Boston. “There are [just] two decisions to be made: When to do the surgery, and what to do in the surgery.”
The most pivotal decision, says Berkson, is whether to remove cartilage or simply repair it. Long-term studies reveal that removing cartilage can condemn a patient to arthritis within 20 years. That’s not an appealing prospect for a young person, athlete or otherwise. “We try to save the meniscus in younger athletes if at all possible,” says Berkson, who works with the New England Patriots, Boston Red Sox, and Boston-area collegiate athletes.
To circumvent this loss of cartilage, Stoudamire underwent a “microfracture procedure.” One of the newest weapons in an orthopedic surgeon’s arsenal, a microfracture procedure begins with an instrument called an awl—“literally like an old-fashioned ice pick,” says Marder—that a surgeon uses to jab a handful of holes into the bone. These holes force blood to seep out and clot. The clot then turns into a jelly of cells, which are stem cells from the patient’s own bone marrow. As these cells travel to the wound and colonize, the defects heal to form rigid repair tissue. This natural process can take up to one year. However, the newly generated tissue is very much like normal cartilage, allowing an athlete to resume full sports activity. Amare Stoudamire returned to play in April 2006, but has opted to have a second knee surgery in the summer.
The second new way to treat chondral injuries involves taking a plug of bone and cartilage from a less-vital part of the joint to fill the void. This procedure, called OATS (Osteochondral Autograft Transfer System), is akin to “robbing Peter to pay Paul,” says Marder. During an OATS procedure, a coring tool called a harvester bores a cylindrical hole in the damaged area. This plug exactly fits the hole, extracted with the underlying bone. Then the surgeon press-fits the harvested plug into the defect. The carved-out portion is from a non-weight-bearing portion of the joint, so long as the defect is not too large. Since joints don’t carry load equally, the patient will never miss the harvested portion.
“No matter what you do, you are trying to get the defect to fill,” says Marder. “These are both very promising techniques.”
After the Knife
Advanced surgery is only part of the story: athletes must recondition their joints through physical therapy, which means everything from bending the joint to building strength back into the muscles. If the therapy goes awry, it can wreck even the perfect surgery. This means the relationship between a sports medicine surgeon and the physical therapist is very important, says Marder. The next handoff, from the physical therapist to a team’s athletic trainer or strength coach, occurs when the patient can dribble, jump, and pivot again.
“It’s a gradual transition,” says Marder. “If you introduce new activities too soon, you could disrupt the repair you’ve done. If you don’t move fast enough, they might get stiff.”
Losing range of motion and feeling stiff after surgery is all too familiar to Abbie Gaylord. While playing a casual soccer game in high school in her hometown of Morgan Hill, California, she was slide-tackled by another player. Doctors told her that she had partially torn her ACL, the ligament stabilizing her knee.
“They gave me the option of doing a surgery,” she says, “but I was going to play field hockey at UC Santa Barbara and didn’t want to risk losing my scholarship.”
Gaylord says her knee was fine through her collegiate career, and she went on to coach the UCSB women’s field hockey team. Nearly ten years later after the partial tear, in August 2004, she was playing soccer when she dove for a ball that she admits she “probably shouldn’t have been going for.”
“My knee twisted and I heard a ‘pop,’” she recalls. “I knew right then that it was gone.”
A magnetic resonance imaging, or MRI, scan revealed she had almost no cartilage left to protect her knee. Her surgeon performed a reconstructive OATS procedure, but Gaylord had a reaction to the surgery. Scar tissue built up under her kneecap—a problem called arthrofibrosis that afflicts about 2% of all OATS patients.
“I was strong going into surgery,” she says. “But the scar tissue set me back. By ten months, I still didn’t have my full range of motion.”
Gaylord went to physical therapy two to three times a week for six months after her surgery. She says the therapy experience was great, but almost 18 months later, she still can’t sit cross-legged without cramps in her knee. “It’s frustrating,” she says. “I did the stretching, strength training, and was running after five months. But the range of motion didn’t come back.”
So what gets Terrell Owens back on the field while the rest of us are still on the LifeCycle?
“It’s not that [professional] athletes necessarily heal faster,” says Marder. “That’s a misconception. The healing of a ligament takes a finite period of time. However, if the level of conditioning that a patient has going into surgery is high, the drop in strength still keeps the professional athlete at a higher level than a normal person.” In essence, a professional athlete’s muscles don’t get as atrophied and were bigger to begin with, making recovery easier. That’s simple logic, but it’s just the tip of the iceberg.
A patient’s age and weight also play a role. Younger people do heal faster, says Marder. Overweight individuals may lag in their recovery due to added stress on the joint. “When you squat down,” says Marder, “you put three to five times your body weight across your kneecap joint. So if you are 70 pounds overweight, that can be up to 350 pounds of additional force across that joint.”
Perhaps the most critical difference between professional athletes and “everyday” ones, say Berkson and Marder, is the amount of time a patient can devote to rehabilitation. Stoudamire and his colleagues spend several hours a day on physical therapy. “For an athlete, that’s their job,” Marder says. The rest of us must fit physical therapy into our daily responsibilities, typically including an eight-hour workday. The average patient spends about 45 minutes in physical therapy twice a week. That’s barely enough to get a repaired joint back in shape.
What’s more, a professional athlete has access to unparalleled equipment after surgery. Aside from spending several hours a day on a stationary bike or elliptical trainer, a full-time athlete can run on an underwater treadmill, giving the muscles around the knee a workout without the added pressures of weight. Even while a player watches his teammates on TV, an electrical stimulant can contract his quadriceps for hours on end. This contraction helps maintain the muscle’s bulk. “A professional trainer puts the athlete in the best possible environment to an accelerated rehabilitation,” says Berkson.
Back in the Zone
New technology—not to mention public expectations for athletes—will keep pushing the field forward, Marder says. For instance, basic research studies are exploring ways of using natural human growth factors to stimulate cartilage repair. A growth factor is essentially a protein that acts as a signaling molecule between cells. In these repairs of the future, artificial plugs would be designed by embedding these growth factors into something that gets implanted arthroscopically, such as a sponge with a collagen matrix. Another potential technique, says Berkson, is ACI, or Autologous Cartilage cell Implantation. In this method, a patient’s cells would be harvested and amplified in a test tube outside the body, and re-implanted into a damaged region. Although the FDA has yet to approve these methods, researchers are plugging away.
Berkson says he thinks the gap between amateur and professional athletes is closing. “If you go to a specialist, you should get the same treatment as Allen Iverson,” he says. “This was not the case ten years ago.”
Beyond the short-term recovery, athletes must also consider the effect of
the years of abuse their joints absorb, from the elite athletes to the
everyday runner pounding the pavement. According to a 2004 Harvard Medical
School publication on consumer health, many joint-reconstruction patients
will experience some sort of arthritis within 15-25 years of their surgery.
Regardless of conditioning, the study warns athletes to maintain an ideal
body weight and avoid re-injury throughout their lifetimes. Although the
rebuilt professionals may thrive again in their stadiums and arenas, many
will hobble painfully in retirement. And that, ultimately, is what will
level the playing field for the rest of us. 
ABOUT THE WRITER
Aditi Risbud
B.S. (materials science and engineering), University of California, Davis
Ph.D. (materials), University of California, Santa Barbara
Internship: Stanford University Medical Center
Throughout my education, tackling a difficult topic and breaking it down to the fundamentals was the most enjoyable portion of a class or research stint. Over the course of graduate school, it was clear that rather than being in the lab, I preferred to describe research through writing, presenting, and face-to-face conversations. Being a mentor reaffirmed this notion: seeing a spark of understanding in someone’s eyes when they grasp a scientific concept felt wonderful. All these ‘data points’ suggested that my talents would be best utilized as a communicator of science, rather than a practitioner. After my training in the UCSC program, I hope to find a suitable outlet to convey my enthusiasm for science, especially to younger people who are wary or daunted by the subject.
ABOUT THE ILLUSTRATOR
Christine Elder
B.A. (biology), Sonoma State University, Rohnert Park, Calif.
M.A. (biology), Humboldt State University, Arcata, Calif.
Ten years ago, Christine Elder earned her Master’s Degree in Biology, and has
since held a variety of exciting jobs that have combined her equal passions
of science, art and teaching. Her work has included such adventures as
getting chased by a moose while studying trout in Idaho, recovering a dead
mule’s carcass while working in Sequoia National Park and having a black
bear flatten her car’s tire during a carnivorous plant research project.
She has also traveled extensively including to such exotic locales as Turkey, Israel, France, England, Hawaii, Mexico, the Caribbean, and throughout the mountains and deserts of the western United States where she has amused herself backpacking, horseback riding, scuba diving and, of course, sketching. After additional misadventures, including stepping on a wasp’s nest, being trailed by sharks and getting poison oak so severely her eyes swelled shut, Christine decided to pursue a safer profession.
She’d admired the UCSC Scientific Illustration program for years, impressed by the professional success of its graduates, nurtured by the talented team of dedicated instructors. So she trotted off to Santa Cruz.
After graduation her plans include doing freelance illustration of her favorite entomological and botanical subjects. Currently, Christine is developing workshops for children and adults that combine learning about nature’s wonders through careful observation and illustration.
To learn more about Christine and her artistic vision, visit her Web site at http://www.darlingtoniadesigns.com/.