THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 5 - MAY 2003

Ties That Bind Sports Medicine and Military Medicine

Wartime Docs Showcase the Connections

The war in Iraq and other world events have directly and indirectly affected many military sports medicine physicians, from those stationed in battlefield medical hospitals to those in homeland clinics covering for deployed colleagues. The war backdrop provides an opportunity to highlight the contributions of military medicine to the treatment of civilians.

Responding to Deployments

Army Lt Col Francis G. O'Connor, MD, director of primary care sports medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, says that as casualties come in to Walter Reed Hospital in Washington, DC, his department is "downloading" some of the hospital's regular patients. The extra workload comes at a time when staff have been whittled down by war deployments. O'Connor says that the university's assistant fellowship director, Maj Fred H. Brennan, Jr, DO, is working in a combat support hospital, as is the university's chief of orthopedic surgery, Army Col Keith Albertson, MD.

British members of the military sports medicine community are facing similar challenges. After the war began, Lt Col Ian McCurdie, MD, a rheumatology and sports medicine specialist with the Royal Army Medical Corps, saw his work at a military rehabilitation center outside London evolve from treating peacetime military training injuries to managing battle casualties. "We have a number of our physiotherapists deployed with field hospitals and hospital ships," says McCurdie.

During peacetime, Air Force Col Elisha Powell, MD, spends part of his fall and winter serving as football team physician for the US Air Force Academy. However, the orthopedic surgeon, who also serves as orthopedic surgery consultant to the Air Force surgeon general, spent last season at a base in Saudi Arabia. Powell says there were several sports-related injuries and that he performed about 8 to 10 surgeries on sports-related injuries such as tendon ruptures and fractures during his time in Saudi Arabia. "Most airmen and soldiers use deployments to get in shape. They're away from their families and they have time to go the gym," he says.

World events have dramatically altered what would otherwise be routine assignments for some military physicians. Before July 2002, Navy Capt J. Christopher Daniel, MD, was stationed at the US Naval Academy as the head of primary healthcare services for the Brigade of Midshipmen, and prior to that was in San Diego working in adolescent medicine, covering high school sports teams and doing research on concussion assessment. Now he's at a Navy research center in Jakarta, Indonesia, doing infectious disease research and surveillance. The October 2002 terrorist attack in Bali prompted the evacuation of all but five of the Navy's medical staff, as well as his own family. Daniel and his remaining colleagues are helping wage the battle against severe acute respiratory syndrome (SARS); they're assisting the Indonesian Ministry of Health by processing and forwarding lab specimens from suspected SARS patients to the Centers for Disease Control and Prevention in Atlanta.

"There is definitely an anti-American sentiment here," he says, "but since the war began there has been no violence directed against Americans, and the Indonesian government has been very committed to our safety." He says that, along with tracking cases of SARS, the US Navy and Indonesian medical teams have been working on a $4 million antimalaria initiative and vaccines for other tropical diseases. "I hope that we are winning at least some hearts and minds as we continue to work with our own host national staff and our colleagues at the Ministry of Health," Daniel says.

Soldiers as Athletes

Sports medicine and military medicine have become increasingly complementary disciplines, because both have a strong musculoskeletal component. Navy Capt Joseph L. Moore, MD, who commands the Naval Medical Facilities at Pearl Harbor, Hawaii, says that about 80% of sick calls in the military are musculoskeletal. Moore says he noticed that injury rates increased as war drew closer and the soldiers trained with heavier equipment.

Britain's McCurdie sees direct correlations between treating troops and teams. "Our main contribution over recent months has been to get as many personnel fit for role as possible," he says. "In exactly the same way that any sports medicine support team would work to ensure that all squad members were fit to compete, we apply all of the same principles and practices to get our soldiers, sailors, and airmen fit to fight."

Powell says that the sports medicine concerns of the soldiers in Saudi Arabia were fairly similar to that of an active civilian population, particularly regarding supplement use. "We had a death while I was there that was thought to be ephedra related," he says, adding that he went on a public relations campaign and gave numerous talks to the troops on the dangers of supplement use and assisted with getting the product banned from base stores. A press release on the Web site of Public Citizen (http://www.citizen.org), a public interest group, states that between 1997 and 2001 there were 30 deaths among active duty US military personnel who used ephedra. A ban on ephedra products sold in Army and Air Force exchanges and commissaries went into effect in August; the Marines issued a similar ban in 2001.

Between the Disciplines

In a broader scope, sports medicine and military medicine have benefited one another. Military sports medicine professionals have long been members of the American College of Sports Medicine (ACSM) and presented at its meetings, and, in May 1997, the ACSM formed a military sports medicine interest group.

Military physicians have contributed much to the management of overuse injuries, such as stress fractures, often because of sheer frequency, Moore says. "If a military doctor treating musculoskeletal injuries treated 10 stress fractures a month, that might be a slow month. That type of spectrum gives you a better picture of where you can put a given patient in the treatment protocol, such as walking and resting rather than on crutches," he says.

From the surgical sports medicine vantage point, Powell says that military orthopedic surgeons have been at the forefront of developing new techniques in knee ligament and shoulder reconstruction. "Work here with incoming cadets has advanced the field of functional knee testing. We've gotten better at picking out the ones that will have problems," Powell says.

By the same token, military physicians have improved the care of soldiers by adapting several sports medicine practices. Moore says that routine use of ice for injury treatment is one example. "We've known about the benefits, but for a long time there wasn't a venue for a marine, for example, to get a bag of ice for an injury that could prevent a hot spot from becoming a tendinopathy," he says. Soldiers at many bases can now be seen more quickly for their injuries in specialized sports medicine clinics.

At Pearl Harbor, Moore's group recently took the concept one step further with the opening of a new walk-in sports medicine facility that has an open-bay training room ambiance. In the Sports Medicine and Reconditioning Team (SMART) Center, marines and sailors can be evaluated and treated the same day they are injured. They are able to undergo aggressive rehabilitation in an open setting that keeps them in contact with other soldiers in their unit. Physicians and physical therapists also use a different motivational approach--positive self-talk--at the SMART Center. "Many are fearful when they get simple soreness from routine injuries," Moore says, adding that patient education and training are vital. "It's all geared toward not even thinking about giving up," he says.

Lisa Schnirring
Minneapolis

Field Notes

Will SARS Make a Sports Impact?

News reports in March that two professional hockey players were under observation because of possible exposure to severe acute respiratory syndrome (SARS) raised the specter of disease spread among sports teams. At about the same time, other sports teams were taking aggressive preventive efforts by canceling travel to events in Asia. Women's hockey teams from both the United States and Canada canceled their travel to China to compete in the 2003 world championship.

An informal SARS survey on the e-mail listserv of the American Medical Society for Sports Medicine found that several sports medicine physicians were monitoring advisories from American and Canadian national health agencies, along with those of the World Health Organization.

James D. Carson, MD, a family practice and sports medicine physician at Sunnybrook and Women's College Health Sciences Centre in Toronto, responded that he had colleagues and patients in the hospital and under quarantine. As a staff member at The Scarborough Hospital, he is putting in extra hours treating nursing home patients who have been advised not to go to hospital emergency departments.

Carson says the public health response in Toronto means that his university sports medicine practice in downtown Toronto has been closed for several weeks. He says his suburban sports medicine practice is functioning, allowing one prescreened patient in at a time. "It is disheartening to tell sick patients that I will not see them in my office," he says. As such, he says he has regrettably had to phone in some antibiotic prescriptions to pharmacies for some patients. "I have corresponded extensively today by e-mail with one of my national team athletes over a concussion issue, so thank goodness for e-mail and fax," says Carson.

Other sports medicine physicians are bracing for problems and making other preparations. Robert Collins, MD, director of the student health center at Mississippi State University, says "Those of us who are in college healthcare are going to find ourselves on the front line with this disease." He says he's increased his hand washing and that his clinic has established a protocol for handling acutely ill patients who are in respiratory distress.