Letter to the Editor: Editorial: Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games?

To the Editor,

We are surprised and disappointed that the editors recommend that orthopaedic surgeons stop providing sideline coverage for football in their editorial [1]. To the contrary, we believe it is our responsibility to care for these athletes and work with others to improve the sport’s safety and reduce the risk of concussions and chronic traumatic encephalopathy (CTE) in all sports.

We share concern about the risk of repeat head trauma and its sequelae in contact sports. As football team physicians, we are well aware of the data, statistics, and attention rightly focused on this issue. In our roles, we have witnessed concussions firsthand from our evaluations on the sidelines within minutes of injury all the way through the rehabilitation and return to play phase during the ensuing days and weeks.

We are also well aware of the issues and we very much share the concerns raised in this and many other editorials. Concussion is not a problem unique to football, a message increasingly lost on popular media and even within our own medical journals. In fact, among 25 National Collegiate Athletic Association sports surveyed the highest concussion rates occurred in men’s wrestling, men’s ice hockey, women’s ice hockey, followed by football [3]. A recent study using the High School Reporting Information Online injury surveillance system, which captures injury data directly from certified athletic trainers at participating US high schools, reported that concussions were more common in girls soccer than any other sport based on the injury proportion ratio [2]. Are we as orthopaedic surgeons also going to withdraw our support and coverage of these other sports?

We fundamentally disagree that orthopedists should withdraw their support from sideline coverage to find solace in boycott. You are either “part of the problem or part of the solution.” The Hippocratic Oath requires us to uphold specific ethical and moral standards, and we believe that a fundamental part of this is to not abandon our patients. Rather than retreat from the problem, orthopaedic surgeons are well positioned to proactively participate in the national conversation and lead efforts to improve on sports safety.

Orthopaedic surgeons have been providing sideline care for football for more than half a century. Orthopaedic surgeons have played a central role in providing comprehensive care for football players. Although concussions are not typically the particular expertise of the orthopaedist, and we frequently employ the expertise of other physicians (primary care, neurology, and/or neurosurgery) for concussion management, the fact remains that the orthopaedic surgeon is often the head team physician, and thus plays a leadership role in the overall medical team. Who better than us to stay involved and participate in the research and discussions relative to this complex topic? As the editors note in their editorial, the game will continue even if our sideline support is withdrawn. Other medical practitioners will certainly fill the void, and it is probable that these individuals will lack the expertise, training, and experience that orthopaedic surgeons have developed over years of providing sideline care. Will that help the problem? We should also not lose sight of the fact that the most prevalent injuries that occur on the field are musculoskeletal, which is, of course, our expertise.

There are other important reasons why orthopaedic surgeons should remain involved as sideline physicians. We feel that the editors fail to recognize that the role of the sideline physician can be much broader than just evaluating and managing injury. As sideline physicians, orthopaedic surgeons are in a unique and even privileged position to serve as role models for these young athletes. The continuity of caring for a team on an ongoing basis provides the opportunity to develop rapport and trust with these athletes. Although this does not relate directly to the issue of concussions, we should not discount the positive effect that team physicians can have in the development of these young individuals. For many young healthy individuals, their only contact with medicine is with their orthopaedic surgeon through a sports injury. This provides us a unique opportunity to highlight our specialty. The life lessons learned from sports are invaluable, and these are the individuals that we want to encourage to go into our field. These positive aspects of providing on-site care can, of course, hold true for any sport, not just football. One of us has served as USA Olympic Team physician for several Olympiads, and has seen firsthand the positive effects of providing care and mentoring for these athletes.

Furthermore, the provision of on-site, sideline care is unique to orthopaedic surgery. In virtually no other area of medicine can the physician be present at the time of injury. Having the opportunity to witness the injury first hand and then immediately evaluate the athlete provides insights into injury that could not be gained in any other way. The sideline physician has a front row seat in this ongoing education process, and the collection of data and production of research papers stemming from this experience has allowed significant and fundamental contributions to the sports medicine literature. These are all further reasons why orthopaedic surgeons should remain involved in providing sideline care.

Young boys and girls will continue to play sports, and unfortunately, will continue to incur injuries. As team physicians, we strive to develop rapport, trust, and a relationship with these players (and sometime their families, agents, etc), and now is not the time to abdicate these responsibilities as our athlete-patients face this important issue. Rather, we feel it is our obligation to stay involved and to be part of the search for solutions.