Finding Road to Recovery on Fast Track

Kellen Winslow and Glenn Tsuida would appear to have little in common.

Pro football player Winslow is the Chargers’ stellar tight end whose livelihood and high salary depend on being in top physical shape. Tsuida is a Chula Vista insurance agent whose enjoyment of amateur basketball and softball is an after-work hobby.

But when each suffered debilitating knee injuries last year--Winslow while being tackled in an important game and Tsuida while cutting to the basket in a playground contest--the two received equally aggressive, advanced surgery and rehabilitation to become active again as quickly as possible.

Their treatment resulted from advances made during the past decade in sports medicine, a rapidly expanding field whose growth has paralleled the increase in the number of persons exercising and undertaking fitness programs. Southern California is a major center for sports medicine practitioners, given its moderate year-round climate which allows for a wide variety of sports participation. And San Diego alone boasts more than a half-dozen specialty clinics and a number of pioneering researchers.

Ten years ago, treatment for severe knee injuries would have been far more conservative and time-consuming, and even then would have been limited primarily to high-priced professional athletes such as Winslow, whose careers depended on the outcome.

Today, the results from much-expanded research into biomechanics, exercise physiology and other areas of body function not only have allowed the elite athlete to recover more quickly but have been applied widely to the general public.

Many family doctors have developed specialties in sports-related medicine, and clinics catering to athletic injury and conditioning have sprung up nationwide. And the vast majority of patients--estimated at 95% or greater--are now non-professional athletes, average persons who want simply to be active.

In addition, the field has expanded from its orthopedic base to encompass nutrition, psychology and internal medicine. Sports medicine increasingly merges with preventive programs designed to help people lead healthier lives, no matter whether they want to walk five miles a day or to train without injury for a triathlon or tennis tournament.

“There’s no real clear definition,” said Dr. H. Paul Hirshman, an orthopedic surgeon at the Scripps Clinic Medical Group Inc. in La Jolla. Hirshman, who heads the Scripps sports medicine section in orthopedic surgery--which also handles the Padres baseball team--stressed the heterogeneity of the field. “In sports medicine, you can potentially need every type of specialist, since the field deals with concussions on the football field, skin rashes under protective head gear, or eye injuries from racquetball.”

Dr. Mark D. Bracker teaches a six-week course on sports medicine at the UC San Diego School of Medicine, one of the few such offerings at medical schools nationwide. The course brings in experts from all areas of sports medicine--from trainers to psychologists--to give students a sense of the discipline’s breadth.

“A lot of thrust in sports medicine today is in prevention, such as avoiding injuries in starting a physical fitness program, or in helping someone to lose weight,” said Bracker, assistant clinical professor of community and family medicine at the school. “That’s why I am in family medicine, too, since what we learn in sports medicine is very much applicable in other areas.”

The term “sports medicine” developed after World War II, when certain orthopedic surgeons around the country began devoting more time to organized athletics as team physicians, leading to the development of new techniques to return pros to competition more quickly. As their skills became more widely known, the surgeons were sought out by more and more teams.

Then the running boom began in the early 1970s and put sports medicine on a faster pace.

“More people started to get hurt with running injuries and so more doctors became interested, and then the involvement of non-surgeons grew through those recreational athletes who began to have more non-surgical injuries,” Hirshman said, adding that doctors are also more concerned with fitness and health today.

Dr. Debbie Waters entered UCLA as an premedical student in the early 1970s with a strong interest in women’s basketball. While there, she found that most female athletes were treated as “freaks” when they saw trainers and doctors for sports-related problems.

“So I became interested in helping change the perceptions in the field,” said Waters, who graduated from UCSD Medical School in 1979. She now specializes in sports medicine in San Diego and also serves on the medical board of the U.S. Olympic Committee.

Waters praised sports medicine for its team approach, whether the problem involves professionals, amateurs, women or children in sports. “As a physical medicine and rehabilitation practitioner, I deal with surgeons, with therapists, with family doctors; you’re not just the Lone Ranger,” Waters said. “For example, you might design a physical fitness program for cerebral palsy kids.”

The boom also changed the situation for physical therapists and trainers.

For many years, physical therapists were centered in hospitals, working with recovering stroke victims and geriatric patients, devoting little or no emphasis to sports-related injuries except perhaps with top athletes, according to Richard L. Perozich, director of the San Diego Sports Medicine Training and Rehabilitation Center. And traditional trainers with athletic teams were taught little or nothing about rehabilitation techniques, added Perozich, who worked with college and secondary school teams earlier in his career.

“But when more and more people began getting active on their own and getting hurt more, they began demanding what the highly paid pros were getting: the best treatment to get back to activities faster and easier,” Robert W. Day, a certified trainer and assistant director of the Athletic Injury Center in San Diego said. “And since motivated people are the most fun to work with, a lot of physical therapists and trainers began to get involved in sports medicine.

“And that’s why now there are so many people who want to get involved in the field.”

Sports medicine centers today look to hire therapists who have training experience with athletic teams. The therapists at such centers work closely with doctors, particularly since by law their clients must be referred for treatment by physicians.

“Therapists are integral members of the (sports) medicine team,” Hirshman said. “There are many problems that therapists can treat short of surgery and they are essential if you want good, rapid recovery and to prevent re-injury.

“Therapists give us feedback in letting us know how patient (treatment) is progressing and how programs can be improved.”

The director of Scripps Clinic’s sports medicine center said doctors are now more aware of the abilities of trainers and therapists.

“And most patients (in rehabilitation) do better in a sports medicine center than elsewhere,” Larry P. Brown said. “There is the motivation of both the patient and of the people treating them.” Typically, a sports medicine clinic is set up as an open room where the patients can see each other as therapists work on them, allowing patients to talk with each other and compare notes on their rehabilitation.

Dr. Jim Nevins, a family practitioner with a sports medicine specialty at Scripps Clinic in Rancho Bernardo, said that such clinics extend rehabilitation beyond what would take place in traditional facilities.

“Instead of just exercises that strengthen specific muscles (around the area of surgery or injury), the center will exercise other muscles as well and get a person on a permanent fitness program, as well,” Nevins said. “In a traditional environment, we see the knee, and rotate it (for strengthening). In sports medicine, we say, ‘OK, fine, you can rotate it, but now what are you going to do with it?’ ”

So in the cases of Winslow and Tsuida, for example, rehabilitation began almost immediately--in the week following surgery--whereas 10 years ago a knee would have been placed in a cast for two months, and then leg raises for strengthening begun on a very gradual basis, with flexibility exercises following even later. And with arthroscopic knee surgery becoming possible in more cases of orthopedic injury--a procedure where a pencil-thin telescopic instrument is inserted into the knee joint--less surgical trauma often results, leading to quicker rehabilitation.

Many doctors in the field also advocate more sports medicine education for family doctors, since the bulk of sports-related injuries are seen initially by primary-care physicians. Bracker speaks around the country throughout the year, both on the need for more awareness of how such injuries should be treated and how programs can be set up for patients wanting to begin fitness programs.

“There’s more emphasis today on controlling diabetes, on controlling high blood pressure,” Bracker said. “A lot of people do not want to be depressed, do not want to be overweight, and want alternatives to pills or drugs. Those people are not training specifically for a sport or for an event.”

Bracker also said that studies are under way to learn how physical fitness can contribute to avoiding or ameliorating certain diseases, such as osteoporosis, where bones become brittle in women primarily as a result of calcium deficiency. While there are no conclusions for many of these projects, Bracker said that clearly doctors are more interested today in finding out how physical fitness promotes better overall health.

“A sports medicine doctor should be able to design a program for a person who is sedentary,” Waters said, “and bring the patient together with a trainer to try and make sure a reasonable program can be followed. In a way, we are talking here about life-style medicine, about working with someone who wants to be more active, to look and feel better.”

Nevins cautions that such programs can be more difficult to plan and carry out for patients than rehabilitation prescriptions.

“Exercising four times a week for some people is a harder discipline to follow than watching what a person eats three times a day for meals,” Nevins said. “In essence, we are saying that there should be some activity in a preventive medicine program, that it must go along with diet.

“The really hard thing is to try and get the non-active person into sustained active exercise.”

There is also a payment problem in some cases. Many health insurance programs still look askance at having to pay for preventive programs. Only in recent years have insurance companies begun to cover new types of rehabilitation.

“And if someone doesn’t have insurance, rehabilitation can be $50 a shot or more, three times a week,” Bracker said. “The group at biggest risk is the guy making, say $15,000 a year, without adequate insurance and paying out of pocket.

“For that person, is it a necessity or a luxury to go through rehabilitation and get better in two weeks on an ankle rather than hobbling around for six weeks?”

Added Nevins of Scripps: “Some of these things do not come cheap. It can cost a lot to get a real work-up on a preventive basis.”

While practitioners of sports medicine do not undertake drug rehabilitation, they concede that drug education is increasingly an important aspect of their field. Some doctors may get several calls a week, especially from high school- and college-age athletes, about the use of steroids.

But there are few organized programs by clinics to agitate actively against drug use.

“Basically, you discourage (the use),” Nevins said. “But sports medicine is a rather loose body of people from many fields and, while the rank-and-file as a group is probably vehemently against the use of drugs, it does not proselytize because of the lack of cohesiveness.”