Taking a Longer-Term Perspective on Injuries
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 5 - MAY 2021
Is sports medicine a bit myopic? Much of the focus in this field has been on short-term decision making, such as how to expedite return to play for a soccer player with a ruptured ACL. This emphasis, of course, is not a bad thing. Sports medicine's approach over the past three decades has focused on the immediate, and we have learned much from the attention paid to the diagnosis, treatment, and rehabilitation that facilitate a complete and speedy recovery. Indeed, we are now reaping the rewards of this focus by applying classic sports medicine knowledge to noncompetitive active patients.
But in making short-term decisions, we have concentrated on issues related to "return to play," with less focus on the long-term health of the athlete. For example, what is the risk of osteoarthritis later in life with ACL rupture, with or without reconstruction?
Over the past three decades, most branches of medicine have conducted population-based studies to identify risk factors for disease. The Framingham Heart Study may be one of the most famous, but there are many other important studies in obstetrics, oncology, and other areas. In sports medicine, we tend to think of risk factors as those that prevent injury: protective equipment, running surfaces, footwear, break-away bases, etc. But the real culprit is the sport itself. Training, fitness, protective equipment, and even enforcement of existing rules, while reducing the incidence of injuries, will never eliminate them. In that sense, sports itself is a risk factor.
With that in mind, we need to start paying more attention to patients' well-being down the road. Not enough credible evidence exists on this very important association between sport and long-term morbidity. For example, what is the risk for osteoarthritis with continued participation in sports following an osteochondral injury to the talus? What is the outcome of playing contact sports on a lax MCL or continuing overhead sports following a shoulder stabilization procedure and evidence of rotator cuff tendinosis?
One of the concerns receiving a great deal of attention is concussion. While concussion is a very appropriate current focus, my guess is that the real impact to be felt a generation from now relates to musculoskeletal injuries. According to the American Academy of Orthopaedic Surgeons, about one in five visits to an outpatient clinic in the US is for a musculoskeletal disorder. Each year musculoskeletal conditions cost Americans about $250 billion, 21 million days lost from school, and 147 million days lost from work. Musculoskeletal health is essential to maintaining physical activity and independence throughout life.
Sports medicine needs to develop risk-factor profiles for the outcomes of common musculoskeletal injuries and the role of continued sports participation on these outcomes. Sharing risk-factor data with patients will then help them make informed decisions on return to sport and continued participation.
Editorial Board member Lawrence Hart, MB, BCh, suggests that several questions need to be asked when considering sports as a risk factor for injury and ill health: (1) Is it likely that different profiles of morbidity may result from non-weight-bearing activities versus weight-bearing activities? Contact sports versus collision sports? (2) Does "dose" play a role? For example, are high-mileage runners more likely to have later morbidity than low-mileage runners? (3) What role do genetic factors play in the general scenario of injury risks?
Of course, population-based profiles of risk for disease following an injury will be tempered by factors such as the level of participation and the patient's own biology and physiology. However, this fact should not prevent us from obtaining data and developing evidence- and consensus-based guidelines. It is our responsibility as a profession to be just as concerned with long-term health as with short-term decisions.