Thirty years ago, the inspiration for The Physician and Sportsmedicine (PSM) was born during a conversation between McGraw-Hill publisher Harry L. Brown and current PSM editorial board member James G. Garrick, MD, on an airliner. From mile-high baby to world-traveled thirtysomething, PSM has seen—and played a role in—much change in the field of sports medicine. And we see the years ahead as even more breathtaking.
In the past 30 years, sports medicine has grown from a fledgling, mostly orthopedic-centered field to a bustling enterprise embracing multiple disciplines. When asked about specific milestones that have shaped the practice since the 1970s, PSM editorial board members offered a range of events and breakthroughs. Some of the watersheds have predominantly affected a segment of practitioners, but most cut across the entire field.
As we celebrate this trifecta of decades, we feel that a synopsis of years past demonstrates why we love sports medicine—and helps us prepare for a no-less-exciting future.
An Ever-Changing Field
"When I first started reading about sports medicine and attending sports medicine meetings," says Jack Taylor Andrish, MD, whose orthopedic career began just a bit before PSM was launched, "the subject matter was primarily 'locker-room medicine.' The 'science' was anecdotal, and the papers were mostly testimonials and observations. There were, of course, notable exceptions, such as those that founded the American Orthopaedic Society for Sports Medicine." In the late 1970s, according to Andrish, sports medicine witnessed both an explosion of talent and a recognition as a subspecialty interest. Key issues included safety, mechanism of injury, and biomechanics, and research became more rigorous.
The next two decades saw involvement growing into the team approach we now have, which incorporates orthopedists, primary care physicians, athletic trainers, physiatrists, physical therapists, exercise physiologists, cardiologists, nutritionists, and others. Major milestones included the development of a certificate of added qualifications in family medicine and widespread postgraduate training programs.
Reaching Unreached Populations
As sports medicine's scope broadened, its reach into previously untapped populations also grew. While initially focused almost exclusively on competitive athletes, the field has expanded to include recreational athletes. As Nicholas DiNubile, MD, describes it, "The sports medicine philosophy is being applied elsewhere to nonathletes in nonsport situations. Our concepts of prevention, early recognition and treatment, and early mobilization have been applied to other areas of medicine. We now have seniors 'pumping iron,' elderly patients with hip fractures having immediate surgery, and instant ambulation." This "outreach" approach spurred the launch of our Practice Essentials series in 2021.
Besides the elderly and recreational athlete, other populations that have received increased attention over the years include children, adolescents, and female patients. "Now," says DiNubile, "we even talk about the 'industrial athlete.'"
Perhaps no area has seen more dramatic change than women's health. Owing in large measure to Title IX in 1972, girls' and women's participation in sports has climbed dramatically. (Remember, the women's marathon was not an Olympic event until 120214.) Topics garnering little attention in 1973 but now studied extensively include the higher prevalence of ACL injuries in female athletes (crystalized by Arendt and Dick1 in 1995), exercising during pregnancy, and the female athlete triad.
A major part of this expansion in sports medicine philosophy arose from studies that demonstrated exercise's significant impact on fighting and preventing many chronic diseases such as heart disease, diabetes, and osteoporosis. A key milepost here, says Jack Wilmore, PhD, was "the recognition of physical inactivity as a primary risk factor for coronary heart disease by the American Heart Association in 1992, by the Centers for Disease Control and the National Institutes of Health in 1994-95, and, finally, by the surgeon general in 1996." DiNubile turned this concept of "Exercise Is Medicine" into an acclaimed PSM series in the late '90s.
Evolving Care of Athletes
While expanding sports medicine's scope beyond the tradition athletic model, its practitioners by no means ignored the key responsibility of caring for athletes. Over the past 30 years, fine-tuning the preparticipation physical exam has helped identify untold at-risk participants. Another change, as Nicholas Mohtadi, MD, MSc, describes, is that "athletes [today] are more protective of their careers and are much less willing to take chances with their health." Current editor-in-chief Gordon O. Matheson, MD, PhD, has expounded on this health-first model in recent editorials.
But change can have its downside, too. Several board members commented on the encroachment of profiteering. Andrish says, "I have seen sports medicine struggle for recognition and validation in the '70s, only to become the crown prince of medical marketing. Quality of institutional medical care is often judged by the public by the number of professional teams prescribing to their care, disregarding the cost—to the institution and ultimately to the patient—required to obtain and maintain the 'privilege' to render that care."
Each specialty within sports medicine can boast of key advances that have propelled the field and even revolutionized medical practice. The development of arthroscopic surgery is a prominent landmark. Two other oft-cited advances are the development of CT and MRI and progress in ACL treatment, which once was a career-ending injury. As Barry Boden, MD, points out, "Most athletes are now able to return to full sports activities after ACL reconstruction."
Other notable achievements include anatomic reconstruction in general, a more aggressive approach to rehabilitation, the explosion of research on the effects of ergogenic aids on performance, advances in drug testing, and the effect of excessive physical activity on the immune system.
Referring to the changes in rehab, Garrick calls it "more active management of sports injuries, discontinuation of immobilization, and the employment of earlier and more active rehabilitation programs." J. Preston Wiley, MPE, MD, cites as a significant milepost the study by Stanish et al2 on the role of eccentric strength rebuilding in managing chronic tendinopathy.
As to research on ergogenic substances, Melvin H. Williams, PhD, says, "When I wrote my first two books in this area in 1974 and 1976, there were very limited studies regarding the effects of pharmacologic and nutritional substances on sport performance. Today, literally thousands of studies are conducted each year. To highlight one area, blood doping was mentioned briefly as possibly being used in the 1972 and 1976 Olympics, and its use was acknowledged by US cyclists in the 120214 Games. Not long after, recombinant erythropoietin was manufactured in bulk and used extensively by athletes at the international level."
A Promising Future
What do the upcoming years hold for sports medicine? Several editorial board member cited the importance of evidence-based research, which will lead to improvement in the preparticipation exam and concussion management, to name a few. Other areas destined to gain more attention in the immediate future include tissue engineering and cell manipulation to speed healing and for soft-tissue replacement, and the continuing need to promote exercise as medicine, especially among the burgeoning older population. Such a focus, Garrick reminds us, "will be less glamorous than caring for college or professional athletes."
Other areas to watch:
As for the evolving field of sports medicine, Warren Howe, MD, zeroes in on "better education of medical students and in postgraduate programs on the use of exercise in the care of patients and in evaluating lifestyle, etc. One would hope to see basic medical education taught from the standpoint of the exercising human." He also hopes for "acceptance by insurance companies that what primary care sports medicine offers is valuable and compensable."
Whether the focus is on the field as a whole or specific advances within it, Andrish provides an encouraging endnote. "I see," he says, "a bright future. There will be better quality of outcomes research because young physicians in this field understand the difference in study designs. And we are now inheriting the ability to apply principles of molecular and cellular biology to all the many aspects of sports medicine, such as treatment, prevention, and human performance. What a future to behold."
Jim Wappes is the executive editor of THE PHYSICIAN AND SPORTSMEDICINE.