By Mat Edelson | Photographs Keith Weller | Illustrations Adam Niklewicz
That’s the question haunting Goode as Andrew Cosgarea, M.D., gently palpates the youngster’s size-17 right foot that’s resting atop an exam table. Two pairs of eyes gaze upon the same object, seeing very different things. Cosgarea, an orthopedic surgeon and assistant director of Hopkins’ Sports Medicine Division, is probing the outside of Goode’s foot: Two-inch-long, horizontal brown scars show where the doctor operated on a stress fracture of the fifth metatarsal. It’s the same type of stress fracture that’s ruined the careers of NBA stars including Bill Walton. It is the Achilles’ heel of the big athlete, and the 300-plus-pound Goode stares at his wounded paw as though it were a lover who’d betrayed him.
“Are you still limping?” asks Cosgarea.
“A little. I can’t walk fast,” says Goode, four months removed from the surgery.
“Hurts on the bottom? Right where the scar is?”
Cosgarea’s slender fingers touch around the scar.
“How ’bout there?”
Goode’s sudden shudder speaks volumes, but the pain doesn’t worry Cosgarea. Goode’s gait does.
“Let me see you walk,” says Cosgarea. Goode lumbers down the hall barefoot in his quadruple-X Perry Ellis shirt and shorts as Cosgarea and another Hopkins sports medicine specialist, Bill Quealle, M.D., look on. X-rays show the fracture has healed. For the average patient served by the average orthopedist, that outcome might be enough.
But for the sports medicine doctor, the game’s just begun.
For as long as there have been athletes, there have been doctors studying them. Galen, Hippocrates’ contemporary, was perhaps the first “team” doc; his charges were the Greek gladiators whose battles pleased aristocracy. Those who died in combat taught Galen anatomy; the living lame allowed experimentation in suturing (Galen soon discovered not to lace skin to muscle). Flash forward a few millennia and 19th-century physicians tried improving the performance of boxers and runners using techniques discovered by 17th-century vets working with thoroughbred horses.
Indeed it is the concept of the athlete as “thoroughbred”—a commodity capable of generating profits for sports ownership—that’s driven modern sports medicine. When popular Cleveland Indian shortstop Ray Chapman died in 1920 from a beanball, there were congressional rumblings to ban baseball. Fearing their meal tickets—if not their sport—would be felled by errant fastballs, owners began working on protective headgear. They eventually teamed with Hopkins’ famed neurosurgeon Walter Dandy to develop the batting helmet (ironically, a couple decades later, eminent Hopkins orthopedist George Eli Bennett would argue fiercely against the introduction of the football helmet, correctly pointing out that the added “protection” would send spearing incidents and neck injuries skyrocketing).
By 1954, the American College of Sports Medicine was founded to bring a multidisciplinary approach to studying athletes. Cardiologists, neurologists, physiologists, orthopedists—all found in the athlete the physically optimal human subject (see sidebars). But these subjects didn’t stay subjugated long: In the late ’70s and early ’80s, free agency turned the athlete into a one-man (and one-woman) corporation. If the athlete thought of himself as a finely tuned machine, he now demanded and could afford a mechanic who understood high-performance engines, not just your average four-cylinder putt-putt.
Enter the sports medicine physician, a doctor whose very title provokes controversy. Until recently, fellowships or residencies in sports medicine were hard to come by; some educational circles considered such training redundant.
“‘Sports medicine’ is a controversial term,” says Peter Evans, M.D., Ph.D., assistant team physician for the Baltimore Orioles who helped organize Hopkins Bayview’s sports medicine clinic. “If you go to Europe there’s no such thing as a ‘sports medicine’ orthopedic surgeon. Even where I was training at [University of] Toronto they laughed. ‘What is a sports medicine doc?’ Their attitude is an orthopedic surgeon can treat [all sports injuries] anyway. And that’s a fallacy.”
The explosion of surgical technology, improved pharmacology, and sheer patient volume have created the need for the sports medicine specialist. Though not a board-certified specialty, many medical organizations from different disciplines offer fellowships and C.M.E. in sports medicine. As both research and the patient pool expand (hello, weekend warriors!), it’s not unusual to see sports-minded orthopedic surgeons increasingly focus their expertise on one or two procedures, be they rotator cuff repair, arthroscopic knee surgery or elbow tendon transplants (better known as “Tommy John” surgery after the first pitcher to return to the mound successfully after the procedure).
“My area of expertise now is shoulder and elbow problems in athletes, whereas 10 to 15 years ago, that [subspecialization] would have been unheard of,” says orthopedic surgeon Ed McFarland, M.D., Hopkins’ director of Sports Medicine and Baltimore Orioles assistant team physician (see sidebar). “For example, even though I can determine which hand injuries in athletes need to have an operation, by and large I’m going to refer them to somebody.”
Similarly, many sports medicine physicians gravitate to non-surgical specialties such as gait analysis, lumbar stress from torque, gastrointestinal reaction to exercise, even concessive injuries particular to certain sports. All this specialization makes sports medicine sound like the HMO from hell, with the injured athlete being sent hither and yon when all he wants to do is get back his jump shot. This could be the case if it weren’t for the holistic philosophy practiced by most sports docs. Biomechanically, athletes don’t function in a vacuum. The healthy pitching arm is connected to the happy big toe. The average physician may not realize that. The sports medicine doc knows he has to.
“I don’t want to be just a surgeon, just a technician. That’s not why I went into medicine,” says Andrew Cosgarea. “When I go to the training room, I might see a dermatitis in a wrestler. I might have an athlete with TMJ. I might deal with low back pain, which I normally wouldn’t see much in my practice here. But my specialty is understanding the unique needs of the athletes, and facilitating their care and return to that level of participation.”
sonal experience. Many of Hopkins’ sports medicine docs are ex-athletes: Ed McFarland was a three-time All-Ohio Valley Conference safety at Murray State, Andrew Cosgarea went to Penn State on a swimming scholarship, and Peter Evans played on Harvard’s NCAA hockey and rugby teams. They’ve lived the discipline of training, the heartache of injury, the frustration of dealing with physicians who didn’t understand their unique physical needs. “You’re really specializing in a group of people who, by their nature, because they’re highly physically active, put themselves through hell—and enjoy it—and want to go to hell and back,” says Bill Queale, M.D., a former track man at the University of Delaware. “The mentality is different. Just by that nature they’re at risk for a lot of different problems that probably the average person isn’t at risk for.”
Does this mean physicians without athletic backgrounds can’t successfully treat athletes? Certainly not. Still, jock docs feel they have a certain edge on their non-athletic contemporaries. “When a swimmer comes in and talks about training 12,000 meters a day and his different swimming strokes, if you don’t know those strokes, if you haven’t spent some time trying to learn those strokes, you can’t tell him ‘you’ve got rotator cuff tendinitis, you’ve got to stop using the paddles, you’ve got to stop pulling with the pull-buoy, and you’ve got to change your technique a little bit,’” says Cosgarea. “All of a sudden, it’s like, ‘Oh, oh, you know, you know this sport. I can’t believe I found a doctor who understands me.’”
Karen-Anne Broe’s experience bears this out. The 37-year-old Broe was one of the Mid-Atlantic’s top-ranked amateur tennis players before she tore her ACL in a recreational soccer match. Visits to several orthopedists prior to surgery proved disappointing; they didn’t seem to understand her desire to be able to return to competitive tennis quickly. One surgeon dismissed her wish to see a physical therapist, saying such exercises could be done at home. “Yes, you can do some of it at home, but if you’re serious about your athletics, the physical therapy is important. To ask them and learn from them and do different things while they get you to do various exercises,” says Broe, who found in Cosgarea a sympathetic ear.
“Before the surgery, he sent me to a physical therapist. So I was able to go to a PT twice beforehand and start rehabbing my knee before the surgery, which I think in my case was a tremendous help,” says Broe.
Treating the athlete means juggling unique concerns. To operate or not is often the multimillion dollar question, one involving player, agent, manager, owner and anyone else making a buck off the player’s continuing performance. “Once they’re professional, making money from their sport, that really changes the formula a lot. Particularly because the money oftentimes is big money,” says McFarland, who has performed rotator cuff surgery on major league pitchers such as former Oriole Brian Holton. “Is [the injury] in their dominant or non-dominant arm? How old are they? What are their expectations? How soon do they need to get back? Are they trying to lengthen their career by a year ... or 10 years? There are so many factors that determine what you do, and how soon, and how aggressive you are about doing it.” Brian Kraback, M.D., who specializes in sports medicine rehabilitation, puts it more simply: NBA superstar “Kevin Garnett is making $125 million. There’s no way he can just sit around with a sprained ankle for months.”
At least the pros have hefty nest eggs. It’s the kids with stars and dollar signs in their eyes who really give sports docs fits. The youth coach and player who believe in “no pain, no gain” need to get real. “Shoulder pain in a growing athlete is clearly abnormal. It means that they have an injury, probably to their growth plate, and that can be particularly damaging in their elbows,” says McFarland. “The treatment for that in young kids is to shut them down. It’s not to give them ice and medicine and encourage them to play through the pain, because it can cause permanent damage to their shoulder and elbow. If you don’t have an interest in sports medicine, you might not know that those are unique injuries that you see in the shoulders and elbows of kids playing baseball. You have to have an appreciation of all that’s possible.”
It is this knowledge of sport and science that is brought to bear in cases like Derrick Goode’s. Goode was injured in February, close to the end of Archbishop Spalding’s season. With the playoffs out of the question, Goode’s goal was to play in the all-star summer tournaments, attended by NCAA coaches, that often determine scholarship offers. An above-average student hoping to get into a good academic program, Goode’s first words to Cosgarea were, “Doc ... can I be ready for Las Vegas,” the Big Time Tournament?
Patient and doctor were hopeful: Instead of more radical surgery, the youngster’s foot and leg were casted. Small stress fractures can heal with rest, but, unfortunately, Goode’s worsened, necessitating surgery. Goode’s playing timetable was pushed back to next season, but one look at him awkwardly strolling the Green Spring Station clinic hall has Cosgarea and colleagues worrying about his long-term playing prospects.
medially on the right side as he does on the left,” says Bill Quealle. “Didn’t know I had different feet,” laughs Goode.
As Goode walks back into the exam room, Cosgarea huddles with Quealle and orthopedic surgeon James Michelson, M.D., who directs the Foot and Ankle Service. The trio stare at Goode’s X-rays.
“Remember [Philadelphia 76ers guard] Andrew Toney?” says Michelson. “Remember he had a whole bunch of stress fractures? You know why? A bilateral tarsal coalition that no one picked up until he started getting fractures, when it was well ensconced.”
The doctors speculate for a few moments on possible causes for the foot’s rigidity, but the underlying concern is clear: Goode may be an accident waiting to happen ... again. Cosgarea returns to the exam room knowing he’s bearing some heavy news. He gently explains that this is the first time he’s been able to watch Goode walk uninjured. A CT scan is necessary to figure out what’s going on with the foot. Two bones may be out of alignment, perhaps congenitally. A serious cast comes over Goode’s normally smiling face. Cosgarea tries to lend some quick perspective.
“This is good! We may have some answers, some solutions,” says Cosgarea, who again explains the injury, “If the fracture is healed, and I just said to you ‘nice to know you, good luck’ but didn’t find some problem that led to this, identify a problem that might be there, then you could possibly go out ...”
“and break it again?” finishes Goode.
“Yeah ... it sometimes happens,” Cosgarea says.
“Though the CT scan proves negative, Cosgarea isn’t satisfied. He continues to pursue the case, seeking the cause of the apparent weakness in Derrick’s foot. Meanwhile, he leaves Goode an Rx for swimming and running in a pool; low-impact workouts that won’t stress the foot and may help the youngster shed a few pounds. Derrick is understandably dejected but has faith in the abilities of Cosgarea and company. One look at the clinic walls, covered with autographed photos of athletes who’ve made their way back, is enough to lift his spirits. Athletes like Karen-Anne Broe. Broe pushed the rehab envelope throughout her recovery, and Cosgarea, recognizing the fire in the belly that drives so many of his patients, let her dictate the pace. The original expected layoff of six months was dropped to four; after only three months, Cosgarea okayed lightly hitting tennis balls, much to the amazement of Broe’s PT.
“My physical therapist said she had never seen a doctor authorize getting [back] into sports that early. I said, ‘It’s not really sports. I told him this is what I’m going to be doing, I just want to get my rhythm back, and I’m not running. And he said, ‘Okay, as long as you keep it to that.’ He trusted me and I really appreciated that,” says Broe, who soon realized the payoff. Her return to the court has been smooth, her braced knee steady, and she’s back in the Top 15 ranking nationally in both singles and doubles. For that, she credits Cosgarea and his Hopkins colleagues, doctors who know how the sports medicine game should be played.
“I feel like I’m back,” says Broe. “I’m very appreciative that [they] took my desire to return to tennis seriously. That even though I’m not playing at perhaps the top professional level—but at still a high level—I have a lot of good years left to play.”