Caring for the Complex Human Body

On a sun-drenched Sunday afternoon in late September, the Duke women's varsity soccer team trails Virginia Tech 0-1. Seven minutes into the second half, forward Kelly Cobb '15 falls to the field clutching her right leg. Cobb is considered one of the best goal-scorers in the country; she played on the 2012 U.S. World Cup team that won the gold in Japan. But she’s also been plagued by injuries that have warranted surgery, physical therapy, and rehab.

For a few tense minutes, the team’s athletic trainer assesses her condition, probing for pain and measuring stability as team physician Alison Toth M.D. ’94 looks on. As play on the field continues, Cobb gets her ankle taped and gingerly puts weight on the foot. She takes a few tentative steps and quickly progresses to jogging along the sidelines. Within ten minutes, she’s got the green light to go back in the game. A short time later, she spots an opening in the Hokie defense and launches a twenty-two yard kick to score Duke’s only goal for the day.

Also clocking major game time are teammates Kaitlyn Kerr ’14 and Kim DeCesare ’14. Midfielder Kerr helped lead her high-school team to four state championships and her club team to a national title, but she’s also suffered multiple setbacks—a torn quadriceps tendon in high school and subsequent surgical repairs to her left knee (torn meniscus) and right ankle (broken). Forward DeCesare tore her anterior cruciate ligament (ACL) and meniscus her senior year of high school and was red-shirted as soon as she got to campus (she’s a fifth-year senior), yet she managed to come back strong and was part of the 2011 team that made it to the NCAA finals.

Soccer fans familiar with the players’ struggles could be forgiven for cringing whenever Cobb, DeCesare, or Kerr wind up horizontal on the Bermuda grass. (Late in the second half, DeCesare gets tangled up with a Virginia player and lies prone for a few seconds as her teammates start yelling: Get up! Get up!) But all three say that they have been able to resume playing—and get even tougher physically and mentally—thanks to Duke Sports Medicine.

“Soccer has been my life since I was two,” Kerr says a few days before the Virginia Tech game. “My lifelong dream has been to play soccer in college and then professionally. So even though I’ve had a lot of injuries—it feels like I’ve been in rehab the whole time I’ve been at Duke—I can’t get distracted by them. If you go out there worried about getting injured, or if you’re at all hesitant, that’s when things go wrong.”

Duke Sports Medicine is based in the Finch Yeager Building overlooking Wallace Wade Stadium, but its reach extends far beyond the Duke campus. Its resources are illuminated under the Friday-night lights of Durham high-school football games, in innovative orthopaedic surgical techniques that deliver better outcomes, through sports equipment whose design is informed by quantitative data to reduce injuries, and on military battlefields where soldiers’ physical durability is crucial.

From his office on the third floor of Finch Yeager, Claude T. Moorman III ’83 has a view of the field where both he and his father, Claude T. Moorman II ’61, M.D. ’66, played varsity football. Like his father, the junior Moorman is an orthopaedic surgeon; he’s also Duke’s head team physician. As director of Duke Sports Medicine, Moorman is at the helm of a growing interdisciplinary enterprise focused on what he calls “the world’s most complex machine—the human body.”

“We’re involved with everything from primary care—helping people avoid and manage injuries—to developing new surgical and rehab protocols. On the research side, we’re exploring how things like genetic and metabolic testing can help determine an athlete’s peak performance capabilities. We work with trainers and coaches, nutritionists and psychologists, surgeons and researchers, and everyone from people who just do sports on the weekend to professional athletes.”

Former varsity basketball player Jay Williams ’03 came to Durham for three of the many surgeries he required following the motorcycle wreck that nearly killed him. Moorman was the lead physician on a team overseeing Williams’ care, which included extensive musculoskeletal and microvascular repairs, as well as intense rehab and physical therapy.

As a division of Duke’s orthopaedic department, Sports Medicine employs state-of-the-art surgical techniques such as minimally invasive arthroscopic joint reconstructions and extracellular matrix reconstructions for massive rotator cuff tears. For Kaitlyn Kerr, whose knee injuries had left her with little cushioning cartilage between her tibia and femur, doctors recommended micro-fracture surgery. The arthroscopic procedure involves making tiny fractures in the bone, prompting stem cell-rich blood and bone marrow to seep out and create new cartilage.

Other non-surgical interventions such as PRP (platelet rich plasma) injections also use the body’s repair mechanisms for maximum therapeutic effect and reduced recovery time. When an injury occurs, the body produces platelets that speed the healing process. With PRP, a patient’s blood is extracted, platelets are isolated, and the concentrated plasma is injected directly into the injured site, thus expediting and amplifying the body’s natural healing process. The procedure is relatively fast—a couple of hours—and carries almost no risks.

Moorman says that the optimal approach to sports medicine combines high-tech solutions with a low-tech, patient-centered approach. “No athlete is any more valuable than another athlete,” he says. “We look at where that athlete is physically and mentally and decide the best course of treatment, whether that’s cellular therapies or working with nutritionists and trainers.”

For varsity players like Cobb, Kerr, and DeCesare, Duke Sports Medicine is one of the first places they go upon arriving on campus. All varsity athletes receive a host of diagnostic screenings, including an intake history and a physical; a biomechanical assessment to gauge any imbalances, restrictions, or weaknesses; an EKG; a ferritin test to determine iron levels in the body; and a concussion baseline test that can be repeated if an athlete sustains a blow to the head. Those arriving with pre-existing injuries go straight to physical therapy and rehab.

“Almost from the second I got here I was in the weight room doing rehab,” says DeCesare. “That year there were seven of us with season-ending injuries, so at least we had each other to go through it with. Now when a player on our team tears her ACL—and it seems like everyone at some point tears their ACL—there are so many of us who know exactly what she’s in for and what every step of her rehab will look like.” Despite her scars and setbacks, DeCesare and teammate Kerr, both of whom graduate in December, are hoping to be drafted into the professional National Women’s Soccer League.

Robert “Hap” Zarzour, the director of athletic medicine, says that Duke’s integrated approach is designed to attend to the physical and emotional wellness of athletes throughout their time on campus. “Our coaches, staff, and trainers spend a lot of time getting to know each individual athlete,” he says. “It’s not just about fixing a broken ankle; it’s about getting them psychologically ready to go back on the field. Or if it’s a kid who had a serious enough injury that they won’t be able to play again, how do we help them emotionally? The psychological impact of an injury is huge.

 “We look at where that athlete is physically and mentally and decide the best course of treatment, whether that's cellular therapies or working with nutritionists and trainers.”

You can’t isolate a physical injury from how it affects an athlete’s outlook and attitude.” But it’s not just Blue Devil athletes who benefit from Duke Sports Medicine expertise. The Duke Sports Medicine Clinic offers a range of services to the wider community, including diagnostic services, surgical and non-surgical treatments, and physical-therapy regimens. On any given day in the clinic, patients might include a high-school lacrosse goalie with a sprained wrist, a septuagenarian marathon runner suffering from tendonitis, or a tennis league player with rotator cuff inflammation. Once physical ailments are addressed, people who want to enhance their athletic capabilities can work with the staff in Sports Medicine’s sports performance division to set personal goals. That was the case with breast-cancer survivor Jan Croft, who was determined to celebrate her seventieth birthday by trekking to base camp at Mount Everest. Working with a team that included a sports-medicine physician, a nutritionist, and exercise physiologist Greg McElveen M.B.A. ’93, Croft embarked on a training and nutrition plan that included cross-country hiking with a weighted backpack, climbing stadium steps in Wallace Wade, strength training, stretching exercises, and a specially designed carbohydrate-rich diet. The eighteen-week training program paid off: Croft arrived at the end of the 111-mile hike feeling “on top of the world.”

“You don’t have to be an elite athlete to come here,” says McElveen. “Our clients include endurance and pro athletes, but we also work with clients who have recovered from cardiac bypass surgery and want to build fitness. We start by asking people what their goals are and then work with them to reach those goals.”

On the research side, Duke Sports Medicine faculty members are engaged in refining the diagnosis and treatment of conditions that have traditionally been handled through subjective and imprecise measurements. For example, concussions are the most vexing injuries an athlete can sustain. Symptoms may be obvious (dizziness, headaches) or absent. A star player may claim she’s fine—put me back in the game, coach!—but not disclose that she blacked out for a few seconds after getting tackled. Diagnosing a concussion, which is a form of traumatic brain injury, is an imprecise science. And there are no quick-and-easy diagnostics for determining the severity of a concussion or how long a player should wait before getting back on the field.

Osteopathic physician Jeff Bytomski is Duke’s head medical-team physician and team physician for the U.S. Women’s and Men’s Basketball teams. An authority on concussions, he’s a member of the National Football League Players Association’s Mackey-White Traumatic Brain Injury Committee, which is exploring the negative long-term effects of sustaining multiple concussions over a career, as well as developing research protocols and standardized return-to-play recommendations to make the game safer.

“If we think a player tore her ACL, we can do an MRI to confirm that it’s torn, but there is no MRI or CT scan equivalent for concussions,” says Bytomski. “Right now we are diagnosing and treating concussions based largely on subjective information—what the player tells us they are experiencing—but that isn’t always accurate. Our treatment recommendations are also dependent on subjective feedback, so we’ll start with cognitive and physical rest and then slowly begin adding specific activities back into a person’s routines.”

When Duke varsity student-athletes arrive on campus, they’re required to take a cognitive screening test called ImPACT. Originally devised for NFL players, the ImPACT model has been adopted by a growing number of schools, club teams, physicians, and coaches. It’s a computer-based screening that measures reaction time, verbal and visual memory, and other mental functioning. The results serve as a baseline so that if a concussion is sustained (or suspected), a second ImPACT test can indicate the degree of impairment.

Sports-medicine and health-care professionals are exploring how to prevent or reduce the risk of concussions in the first place. For example, some neurologists have begun to question whether there should be age thresholds for certain contact sports, since children’s neurological and musculoskeletal development puts them at greater risk for concussions than college and pro athletes.

As these conversations continue to play out on the national and international level, Bytomski and his Duke colleagues are promoting educational-awareness programs in the Duke and Durham communities for parents, players, and coaches; medical-school students and primary-care physicians; and emergency-room staff.

“One of the biggest things we’re focusing on right now is education,” he says. “It’s like hydration thirty years ago. You used to hear about coaches who would withhold water, not give water breaks if the team or a certain player wasn’t playing hard enough. That would never happen in this day and age. But we continue to let kids play who have had concussions because some coaches might not know what to look for or think that a kid isn’t really injured. You can’t see a concussion. So part of education is changing the culture that says that if you can’t see an injury you’re fine, or that if you’re injured you play through it.”

Bytomski has launched the multidisciplinary Sports Concussion Clinic, a collaboration between Sports Medicine and the medical center’s neurology and neuropsychology departments. Duke Sports Medicine can assess and triage members of the Triangle community who may have sustained concussions. A patient needing short-term care would be seen in the Sports Medicine practice, while those exhibiting more concerning symptoms would be referred to the medical center for more extensive neuro-imaging and intensive follow-up.

As part of its educational and community outreach, Sports Medicine also has joined with nearly a dozen public and private middle and high schools in the Triangle, assigning a dual-certified physical therapist/athletic trainer to work with the schools’ trainers and coaches. These individuals not only share the most up-todate information and protocols for preventing injuries, they’re also on the sidelines for varsity home football games.

Physical therapist and athletic trainer Alanna Cooley Baker, the Sports Medicine liaison with Durham’s Jordan High School, coordinates the community outreach program. “We’re often the first line of care for these athletes,” she says. “We can assess and treat injuries as soon as they happen.” The community outreach initiative also works with the Triangle Futbol Club and the Triangle United Soccer Association.

“You can't see a concussion. So part of education is changing the culture that says if you can't see an injury you're fine, or that if you're injured you play through it.”

Injury prevention is a central focus of the Michael W. Krzyzewski Human Performance Laboratory, known as the K-Lab for short, as musculoskeletal injuries are one of the most common problems in sports medicine. A component of sports medicine, the lab was launched in 1997 and conducts studies that examine everything from injury risks associated with certain types of field turf to better orthotic design and understanding the risk factors associated with osteoarthritis and stress fractures. Nike is a major industry partner, funding a range of research on foot, ankle, and knee injuries in order to design more protective cleat and athletic-shoe design.

K-Lab research also contributes to a broader understanding of kinetics and kinematics—how bodies move and the patterns associated with those movements. Those studies are informing policies and practices in settings ranging from the suburbs to war zones. Assistant professor of physical therapy Robert Butler says that augmenting routine physicals with movement screenings has a range of beneficial effects.

“Every year the U.S. military spends about $560 million on musculoskeletal injuries,” he says. “In fact the number-one reason for medical evacuations from the front line in Afghanistan and Iraq was non-battle specific injuries— knee, hip, back, or ankle injuries that happened as part of training exercises or other activities to get ready for battle.” Researchers at the K-Lab form part of a research group aimed at designing, implementing, and refining an economical and efficient screening protocol that can assess athletes’ ability to move efficiently and to remain durable.

Butler says that “industrial athletes” such as firefighters, police officers, and sanitation workers are another population where movement screening can benefit employer and employee. “We work with towns and municipalities to reduce injuries because that can help reduce the massive costs associated with worker’s compensation claims. But more important, we can encourage people who have minor problems to seek treatment before it gets worse. No one wants to be out on permanent disability.”

Whether it’s expediting an athlete’s return to the game she loves or developing preventive health techniques for blue-collar workers, Butler says he and his Sports Medicine colleagues always keep the longterm perspective in mind.

“Human bodies are designed to move. When people don’t engage in physical activity, you see things like a rise in obesity, higher blood pressure, and a whole host of things that reduce lifespans. So we want to find ways to get people moving and reduce the risk of injuries so that they are active and healthy throughout their lives.”