Published: Feb. 11, 2008
Updated: May 31, 2011
By S.D. Williams
One youth chases another at furious speed, and when he catches his quarry grabs him by the shoulders and flings him mercilessly to the hard earth. The contact between boy and ground creates a sound so clear you can envision it in large, bright letters: THUNK! MMMMPH!
The tackled boy, being an adolescent and thus immortal, rolls, jumps up, and trots back to his team’s huddle, probably with a smile hidden inside his football helmet that says, “Hit me as hard as you want. That was 30 yards, and I’m about to get 30 more.” And so the running, hitting, falling, twisting, and blocking -- the continuous, jarring impact -- rolls on into a cold autumn night as boys from Charles E. Jordan High School in Durham and Garner High School battle for glory in the state’s high-school football playoffs.
On the sidelines pace a number people who understand the possible consequences of that impact, have helped the boys prepare for it, and are ready to respond if a boy can’t jump up from a blow.
Claude T. Moorman, MD -- who goes by his middle initial -- is the director of the Duke Sports Medicine Center and professor in the Department of Orthopaedic Surgery. Just before halftime, he squats before a boy on the bench who had come out of the game with a neck “stinger” several minutes earlier. He supports the boy’s wrists lightly and has the boy raise his arms to shoulder level, with his elbows at horizontal 90-degree angles. The boy doesn’t wince, but he looks tired and disappointed. Moorman gives him the OK, and the boy trots to the locker room with his teammates.
Seven years ago, Moorman helped create Duke’s outreach into area high school athletic teams. Duke supplies them with orthopaedic physicians, primary care physicians, and certified athletic trainers or physical therapists, for free. Depending on the needs of the school, they might consult with coaches and school-based certified athletic trainers during the week, but at the least every Friday night in autumn they’re at football games, either at home or away, and they often attend the home games of a school’s other sports.
The program now reaches nine high schools in Durham County and one each in Orange and Wake, and Duke certified athletic trainers are at Durham middle school football games every Wednesday during the fall. Duke also supplies physicians for North Carolina Central University (NCCU) games -- and, of course, for the Blue Devils.
Usually orthopaedic residents also attend the high school games, but on this night the residents are studying for their training exam the next day. It’s a rare night off -- they must serve at 20 sporting events during their residency year, whether or not they intend to practice sports medicine as a subspecialty. Why? It’s simultaneously a service to the community, a living lab of bone-jarring impact, and way to form connections between Duke and the world beyond its walls. It’s also good preparation for the sports-related injuries the residents will likely see in their future practices.
“Hit ’em again, harder,” chant the cheerleaders to a cold crowd, as if to remind the absent doctors that they will have no shortage of patients.
The Duke Sports Medicine Center is built around four pillars: a sports medicine clinic, physical therapy services, a sports performance program, and research in the Michael Krzyzewski Human Performance Lab -- the K-Lab. The center, in various forms, dates back 70 years and has pushed the boundaries of orthopaedic medicine through its focus on people placing maximum stress on their musculoskeletal systems. In recent years it has greatly expanded its efforts along a continuum that ranges from research through clinical treatment to sports performance training.
Among its newer components is the 10-year-old K-Lab, directed by Robin Queen, PhD. On this particular day, participants in a K-Lab study are preparing to perform simple exercises, such as climbing a step. Small reflective markers are attached to the outsides of their knees, ankles, and hips. Eight cameras around the room capture the movement from the markers and feed computers that create digital representations of the motion of their joints.
Queen, with a doctorate in biomechanics, and researchers from Duke University Medical Center are studying several orthopaedic issues in the K-Lab. For example, three Duke specialists in hip replacement surgery utilize three different surgical approaches for reaching the hip: posterior, direct lateral, and modified anterior lateral. Each involves cutting different muscles. Outcome studies to date -- by various researchers around the country -- have been based on patient satisfaction surveys.
In this study, for which Queen serves as the principal investigator, patients who have undergone hip surgery will be examined to determine whether they have returned to walking normally. Their movement will be compared to that of a control group measured in the K-Lab. Members of the control group have been chosen to match the age, weight, gender, and other characteristics of the group that has undergone surgery.
Initially, Queen’s group is looking at patients post-surgery, but eventually the gait and movement of patients will be examined before surgery in order to compare movement before and at several milestones after the operations.
The logic is as clear as the sound of high-school athletes hitting hard ground. Patients will be compared to healthy, normal controls in order to evaluate the success of their operation in returning them to normal movement. “We’re looking at what the numbers say in addition to what the patients say,” Queen says.
Few if any similar studies have been undertaken anywhere -- likely, as Queen notes, because scientific disciplines often operate independently. “It’s a novel concept to combine biomechanics with clinical outcomes,” she says.
The same idea drives studies of hip resurfacing. Patients who have undergone either hip replacement or hip resurfacing will be compared to healthy controls, with researchers examining such indicators as hip flexion angle, range of hip flexibility, and degree of hip hike.
A similar study is evaluating ankle replacements. And as the K-Lab builds databases of movement of various aspects of the musculoskeletal system, they could be applied to future studies.
The K-Lab also plays a vital role in collecting kinematic and kinetic movement data on patients who have knee osteoarthritis in an attempt to understand how the disease alters movement patterns. “We’re looking at gait mechanics as a functional outcome following a clinical intervention of weight loss and pain management,” says Queen. This work is part of a larger NIH-funded Program Project Grant directed by Farshid Guilak, PhD, who heads Duke’s Orthopaedic Bioengineering Lab.
The knowledge generated by these studies is published in scientific journals and makes its way into the practice community through traditional routes. But the K-Lab itself also is used for immediate clinical applications, such as assessing athletes to help them improve sports performance.
With the attention paid to athleticism at Duke Sports Medicine -- and its location in the heart of the Duke athletics complex, right next to Wallace Wade Stadium -- it is almost a surprise to walk through the clinic, with its standard-looking examining rooms, nurses’ station, and x-ray rooms. But while the Center has an obvious focus on sports-related medicine, it is not just for competitive athletes -- the team here can help anyone with musculoskeletal injury or pain who seeks to be more active than his or her medical condition currently allows.
In addition to straightforward sports-related orthopaedic services, the medical and therapeutic staff provide services specifically focused on women’s sports medicine, pediatric sports medicine, sports psychology, primary care, and rheumatoid arthritis treatment, plus an extensive on-site physical therapy program that enables seamless post-surgical care and rehabilitation.
In fact, the majority of the patients seen here aren’t professional athletes, or even necessarily serious amateurs. Most patients are self-referred, many of them simply active people who have injured themselves or people looking for help with medical problems such as osteoarthritis. On a recent day an older man with a leg brace was leaving his appointment while a young father with his elementary-school age boy were checking in.
“We’re somewhat like a ‘space program’ for orthopaedics,” says Moorman from his office overlooking the football stadium. “Athletes are always looking to break barriers that you and I don’t generally approach, and in sports medicine you get to work with problems and treatments at the edge of the scientific field. One of the results is that sports medicine has driven the development of treatments that have eventually become the gold standard for the rest of us, like minimally invasive surgical techniques and early motion, minimal stress recovery therapies.”
For example, recovery from ACL repair once took a year but now takes three to four months, thanks in many ways to practices developed for athletes. Sports medicine has also supported advances in soft-tissue healing, such as contributing to findings that the body overshoots the mark in healing and causes overinflammation, which can be mediated by anti-inflammatory agents.
Some sports medicine research even makes its way into the commercial arena. The K-Lab, for example, has provided data to help Nike improve the safety and performance of cleats and other athletic footwear. And recently Duke Sports Medicine has been involved in testing a new way to deliver electrolytes -- via an oral strip against the gums.
“When you’re active, your blood goes to your extremities, away from your GI tract, which cuts down on your body’s efficiency in absorbing electrolytes delivered through drinks -- which, of course, is the way they’ve traditionally been delivered,” explains Moorman. “People have wondered if there was a more efficient way of delivering them so that they would spread to your muscles more effectively. This strip appears to do that and decreases cramping significantly.”
The need for better delivery systems for professional athletes, who spend hours in intense activity, seems self-apparent, but the same need may exist among boys and girls who are physically active, especially those in warm climates. The number of school-age athletes has doubled over the past 10 to 15 years, says Moorman, due in large part to the influx of young women into sports.
That growing population of young female athletes has resulted in the need for more sports-medicine research and treatment focused on women. Just down the hall from Moorman’s office is the office of Alison Toth, MD, who launched Duke’s Women’s Sports Medicine Program in August 2001.
The program quickly became a national hub for the growing movement to teach women and clinicians to recognize and prevent problems that plague active females -- whether they’re young Olympic hopefuls or senior citizens who want to resume a walking program after a fracture.
The Duke program was one of the first three in the country to focus specifically on women in sports and has the capability to diagnose and treat injuries that are unique to women, that manifest themselves differently in women than they do in men, or that require interventions specific to women.
Like the rest of Duke Sports Medicine, the Women’s Program isn’t just for jocks. “Our practice is for anyone who has musculoskeletal problems and wants to stay active, whether through sports, walking for exercise, or simply being able to reach overhead and comb her hair,” says Toth. “We can help people maximize their ability to stay active and remain injury-free.”
That’s the common thread among people who come to Duke Sports Medicine, it seems, whether they’re pro athletes, active seniors, or soccer-crazy kids. All seek to improve their physical capabilities in an atmosphere that helps them push their limits.
Though Dr. Toth tends to female patients' needs in the Women’s Program, she cares for just as many male athletes. In fact, she can be found on the sidelines as the head team physician for NCCU football and other NCCU teams.
On the football field, boys are pushing their limits in order to keep their season alive, one game at a time. Ron Olson, MD, walks the sidelines of the field on that cold Friday night. Olson, the Duke primary care physician working the game this evening, has a long history in sports and sports medicine and describes himself as a semi-serious athlete. In addition to helping with the outreach program and the Duke primary care sports medicine fellowship, he looks after a few other teams and travels with the U.S. Ski Team to Europe for a week each year. As Moorman attends to a player on the bench, Olson jokes, “We let the orthopaedics people be the first responders at these games.”
Not far away is Alanna Cooley, a Duke physical therapist and certified athletic trainer assigned to the Jordan teams. In the mornings she sees physical therapy patients at the Duke Sports Medicine Center, but afternoons are often spent at the large Durham high school, working with Jordan’s athletic trainer, Gail McMurry. At the game, both she and McMurry carry packs containing bandages, tape, scissors, gloves, and other tools to take care of small injuries.
This evening all the injuries are minor. The staff get to enjoy the game. Jordan loses, however, and so its season -- and the Duke staff’s attendance at its Friday night games -- are over for the year.
But basketball season is starting. And wrestling.
“We may even see some of these kids at the Saturday clinic tomorrow,” says Moorman as the game winds down.
Then his own team packs up and heads home for the weekend.
This article was first published in the Winter 2008 edition of DukeMed Magazine.