Same Orthopaedic Injuries, Different Treatment Options

    A pro athlete’s livelihood is on the line when an injury occurs – and there’s no time for a lengthy rehab. Dr. Matthew Matava describes the approach to getting the elite athlete back on the field, versus managing the average patient with the same injury.

    By Susan Doan-Johnson

    Orthopaedic surgeons commonly see patients with rotator cuff injuries, torn ligaments in the knee, and Achilles tendon tears. In some cases, these are sports-related injuries suffered by “weekend warriors”; in other cases, they are simply the result of daily living.

    The difference for Matthew J. Matava, MD, is that many of his patients are elite athletes at the professional and collegiate levels. For them, a torn ligament is not just an inconvenience – it could mean the end of a lucrative career.

    Dr. Matava is the head team physician for the St. Louis Rams in the National Football League (NFL) and for Washington University, a Division III school in St. Louis, Missouri. He is also a team physician for the St. Louis Blues in the National Hockey League. In 2013, he was elected president of the NFL Physicians Society.

    Temporizing Procedures

    To the outsider, elite athletes may seem to be medical marvels. It is not unusual to hear about an athlete with an orthopaedic injury who returns to play much sooner than an ordinary person might expect to recover. These athletes must have access to better, more high-tech procedures, right?

    Not so, said Dr. Matava, who is Professor of Orthopaedic Surgery, Professor of Physical Therapy, and Co-Chief of Sports Medicine at Washington University.

    In fact, an elite athlete may undergo a more temporizing procedure than an average person with the same injury – and the reason makes perfect sense. Being professional athlete is a job; an extended rehabilitation period is not in the cards. Dr. Matava – and the hundreds of orthopaedic surgeons like him who are professional and collegiate team physicians – has to get that athlete back on the field, performing at the same level as before the injury, as soon as possible.

    “Patients often find it hard to believe that the procedure they’re having is more high tech, more advanced than an athlete would have,” Dr. Matava said. “That’s because (average patients) can take the time to rehab.”

    Short- vs. Long-term Solutions

    As Dr. Matava pointed out, an elite athlete cannot take off for a year to rehab – especially a player in the NFL, where the average career lasts only 3½ years. So the athlete may undergo a procedure that is less-invasive and provides a short-term solution, such as a knee arthroscopy for a cartilage injury. After retirement, the athlete can purse a long-term solution, such as a knee reconstruction, if the problem persists, Dr. Matava said.

    Of course, also in the athlete’s favor is his or her physical condition. Top athletes rarely have comorbidities, allowing them to heal quicker. In addition, “their pain tolerance is higher,” Dr. Matava said. “They’re willing to tolerate more pain than the average person because of the financial implications of an injury.”

    Professional athletes also have full-time care that the average person does not, such as trainers, rehab specialists, nutritionists, exercise physiology specialists, and human performance specialists, Dr. Matava said. That contributes to quicker rehab.

    Advances in Sports Medicine

    In general, Dr. Matava said, new procedures for sports-related injuries are fine-tuned on average patients, not on elite athletes – again, because the stakes are too high for the professional or collegiate athlete to risk undergoing a procedure that could end his or her career.

    The exception is ulnar collateral ligament (UCL) reconstruction, or Tommy John surgery, in which the UCL medially in the elbow is replaced with a tendon from elsewhere in the body. The procedure was first performed in 1974 by orthopedic surgeon Dr. Frank Jobe, then a Los Angeles Dodgers team physician, who served as a special advisor to the team until his death in 2014.

    Before that, Dr. Matava said, orthopaedic surgeons did not have a way of treating UCL injuries in any patient. The success of Dr. Jobe’s procedure in professional athletes has now been translated to average patients, including amateur athletes and weekend warriors.

    Two technologic advances that helped in diagnosing and treating athletes and average patients alike are arthroscopy and magnetic resonance imaging (MRI), Dr. Matava said. Before MRI, for example, patients underwent exploratory surgery of the affected joint to diagnose the injury, then a second procedure to repair the injury.

    “Twenty years from now, who knows what else we’ll have,” Dr. Matava said.

    On the Horizon

    Two of the most promising new treatments are stem cells and protein-rich plasma (PRP), Dr. Matava said. Researchers still need to define the clinical application of these treatments, such as which patients will benefit from stem cell therapy or PRP, how large the dose should be, and how many doses are needed for efficacy.

    Dr. Matava cautioned that the current use of stem cells and PRP may be a case of “putting the cart before the horse. We probably have too widespread use before we know if they’re clinically effective.”

    The “holy grail,” Dr. Matava said, is a reliable method of replacing damaged cartilage.

    “The vast majority of procedures we do are to protect articular cartilage,” he said. “Because once it’s gone, it’s gone.”

    Author Information

    Susan Doan-Johnson is Director of Editorial Content for ICJR.net.