Saturday, August 30, 2014

An interview with Dr. James Andrews, the man who's operated on all your favorite athletes

Dr. Andrews at work. The Andrews Institute.

Dr. James Andrews is America's sports surgeon to the stars.

When a top athlete gets seriously injured, the odds are overwhelmingly good that he or she will make the pilgrimage to Andrews' Pensacola office. The list of players Andrews has treated includes Michael Jordan, Tom Brady, Adrian Peterson, Albert Pujols, Robert Griffin III, Jack Nicklaus, and many, many more.

Andrews' remarkable popularity among top-tier athletes stems from his 1985 arthroscopic surgery of a young pitcher named Roger Clemens. Clemens, who would would go on to be a seven-time Cy Young winner, credited Andrews with saving his career — and began spreading the gospel of Andrews to any athlete who would listen. Those players began heading South — initially to his practice in Birmingham, Alabama, and now to his new office in Pensacola — in droves.

But Andrews also founded and runs the American Sports Medicine Institute — a nonprofit that conducts research on sports injuries, and recently released an influential position statement on the factors driving the recent rise in torn elbow ligaments among major league pitchers that require Tommy John surgery, a procedure for which Andrews is well known. And in addition to pro athletes, Andrews treats thousands of college, high school, and little league athletes annually, as well as ordinary seniors who've fallen and broken a hip.

I recently spoke with Andrews about his remarkable career, how teams spin injuries, and the alarming rise in Tommy John surgeries.

On his success

"I never consider myself anything more than an ordinary orthopedic surgeon that's interested in sports. The two things that have made me successful are accessibility and communication.

When an athlete calls, I just pick up the phone, and say 'come on down.' They've all got my number.

I had a professional basketball player from Belgium call me today, he tore his knee up, and I said 'come on Monday, we'll take care of you.' You have to do that, that's accessibility. It all starts from answering the telephone. You can't always do that, but if you don't get people in in a timely fashion, you have a lot of fences you've got to mend."

On a day in the life of Dr. James Andrews

Ai_ext_night

The Andrews Institute in Pensacola, Florida. Andrews Institute

"My day is not as complicated as you might think. I do about half the number of surgeries I did three to four years ago. When I moved down to Pensacola, I designed my practice to be more reasonable in my older age, in terms of how many cases I can do a week. I cut my practice in half.

But in cutting it in half, it actually became more complicated: I gave up a lot of the easier things I used to do, and now I do more hard things. I'm doing mostly athletes, rather than the older population — I've got other people doing that now. That athletic world is very difficult."

On the difficulties in treating athletes

"With college athletes, it becomes more complicated because you've got the school, the athletic trainer, the team physician, the coaches, the school insurance to worry about. A lot of those kids think they're automatically going to be professional athletes, but they don't understand only about one percent will be.

With professionals, it gets even more complicated, because you've still got the patient and the mother to worry about — I don't care how old they are — but also the agents, the team doctor, the trainer, the physical therapist, the coach, management. And the most difficult, nowadays, is the press. The press has no idea about HIPAA laws — about violating confidentiality. And if you don't handle it properly, they'll just say whatever they want to say. So it just gets more complicated as you go up the ladder."

On whether there are ever tensions between him and team doctors

"Well, the team physician always has the final say. Now if I operate on the patient, and the team physician didn't, then I take precedence. But if the team physician is taking care of an injured athlete, and he doesn't want to play him yet, but another doctor says he can, that doesn't mean a thing in the world. Or if I operate on him, and the team physician says he can play and I say he can't, he's my responsibility. But if the team physician operated and I'm just providing the second opinion, then he has the final say."

On the most remarkable comeback he's ever seen

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Drew Brees. Ronald Martinez/Getty Images

"One case I do have permission to talk about is Drew Brees, who had the most remarkable comeback that I've ever treated.

All expectations were that he had a career-ending shoulder injury. But he had such a good work ethic, and he so well taken care of by physical therapist Kevin Wilk, in Birmingham, who worked with him for a solid four months, that some way, some how, he got well. But I have to give him and the therapist all the credit, not me. He was an unbelievable comeback. And he's still playing."

On his failures

"Usually, the only results I remember are the bad ones. I just think on the players who don't have that kind of comeback. I saw a pro baseball player today who I've operated on three times — once on his shoulder, twice on his elbow. And he still has not been able to come back and play. Those are the ones you remember.

I wake up at 6 a.m. on Monday morning, after the weekend, and start thinking about the patients having trouble. I call it my 'worry list.'"

On teams' PR spin about injuries

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Jared Wickerham/Getty Images

"Teams, in general, will put out as little information about an injury as they can get away with. They may call something a knee sprain, when it's a complex injury of the knee ligaments. And a lot of times, the press wants a diagnosis immediately, and you just don't know.

And the press is always going to report something, from the bits and pieces they do get. And I'm not criticizing it, because that's their job."

On the next big thing in sports medicine

"The big revelation over the last 40 years was the arthroscope. We've been looking for another one ever since.

I predict the next one will be so-called "biologics": stem cell therapy, gene therapy, tissue engineering. At some point in time we'll be able to make a piece of ligament, a graft, through tissue engineering, and take it off the shelf from a sterile container and put it in a knee.

The big thing right now that people are working on is stem cell therapy. It's still experimental, but has a lot of potential. We're working on it here at the Andrews Institute. It's going to take a lot of clinical research, and trials, to figure out how exactly to use it: where, when, concentrations. But it's coming."

On the epidemic of Tommy John surgeries

174715286

Jose Fernandez, the Miami Marlins pitcher sidelined with a torn elbow ligament that required Tommy John surgery. Mike Ehrmann/Getty Images

"I think the biggest thing is overuse, especially during childhood. If you look at the major league pitchers that I'm seeing, if you study their history, you'll find that they had injuries during their youth. They may have forgotten about it — I had one in here last week, we could tell from the X-ray, and he said, "Oh, I remember now, when I was 12 I missed a month of baseball with a sore elbow." About 50 percent have some pre-existing minor injury from overuse that was ignored.

The biggest factor, at any age group, is fatigue. If they're playing with fatigue — either from too many pitches in a game, or too many innings in a season, or from pitching year-round competitive baseball — you have 600 percent increased chance that you'll injure your shoulder or elbow.

So the recognition of fatigue is extremely important. If you're a major league pitching coach, you're probably good at recognizing it. But it gets harder and harder to spot as you go down in the youth levels. Some coaches mean well, but they don't recognize fatigue when it's obvious. There's a lot being done at the youth level that needs to be under better control. So we need a better education process. We've had a tenfold increase in injuries in youth baseball since 2000. Something has to be done about it."

On whether youth football can ever be safe

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Hyoung Chang/The Denver Post via Getty Images

"Football has the highest rate of serious injuries of any sport. The safest sport, for young kids, is golf.

For me, I think the lessons learned in football still outweigh the injury risk. But I'm a football guy, and I may be too biased.

But there are ways we've got to make football safer. The first is pre-participation exams, and ruling out kids that shouldn't be playing. Another thing is having physiological age groups: two kids can both be 12 years old, but if they've matured at different rates, that's a huge mismatch. We have weight limits sometimes, but those don't always work. You've got to match up similar bodies, and that doesn't happen.

We've also got to have athletic trainers in all high schools, and everywhere youth football is being played. The trainers are there to recognize injuries when they first happen, even if they're minor, to prevent them from becoming major injuries. Right now, that doesn't happen. Some schools have them, but not all. Some states mandate it, but don't provide any funds for it. That's a joke.

The other thing is that we need more education on injury prevention, during games and practice. This includes parameters for practicing in the heat. But if you don't have an athletic trainer, the head coach can't do it — they might not know how. So we need all state high school athletic associations to have rules on when they can practice, how often, etc.

We need better emergency action plans for high schools. What you do, who you call. There should be defibrillators — like we're providing through a foundation that I'm head out — at all high schools. There needs to be a dedicated ambulance at every high school football game. Often, they have to pay for them to come, and it's expensive as hell, so the ambulance is there at the start of the game, but if they get a call to go somewhere else, they just leave. So a kid gets hurt, and he can die on the field because he has no ambulance to get him to the hospital.

So there are all these problems. And for a nation that's as sophisticated and educated and advanced as we are, those things should be automatic. But they're not."

Read the full interview

Joseph Stromberg: First off: you're by far the most well-known surgeon in American sports. How did that happen?

Dr. James Andrews:Number one: never take anything for granted. If you start planning your career to have a claim like that, you're probably not going to be successful. You've got to let it happen. Like Yogi Berra said, "When you come to a fork in the road, take it." You can't plan everything, or start patting yourself on the back and thinking you've got it made.

For me, I never consider myself anything more than an ordinary orthopedic surgeon that's interested in sports. The two things that have made me successful are accessibility and communication.

And the other thing to know is that getting to be successful is not as difficult as people think. You learn from your mistakes, and you can be successful. The problem is maintaining it, being able to stay there. Even the elite athletes in sports, they fall off — you have to really watch out to maintain your success in any profession. And if you start patting yourself on the back, you're dammed sure going to fall off.

Joseph Stromberg: What's a normal day look like for you?

Dr. James Andrews:I usually say, "go to bed early and get up early." But earlier in my career, I never did that — I went to bed late and got up early. As I got older, though, I learned to start going to be earlier.

My day is not as complicated as you might think. I do about half the number of surgeries I did three to four years ago. When I moved down to Pensacola, I designed my practice to be more reasonable in my older age, in terms of how many cases I can do a week. I cut my practice in half.

But in cutting it in half, it actually became more complicated: I gave up a lot of the easier things I used to do, and now I do more hard things. I'm doing mostly athletes, rather than the older population — I've got other people doing that now. That athletic world is very difficult.

Joseph Stromberg:What makes treating athletes so difficult?

Dr. James Andrews:Well for younger ones, you've got to make sure their parents are on the same page with what you're doing. The younger they are, the more reassuring you've got to be with their parents, and even more important, their grandparents. You've got a whole slew of people. And with young kids, you've got to be careful of being too aggressive in operating on them — a lot of times, you've got to let mother nature take its course.

With college athletes, it becomes more complicated because you've got the school, the athletic trainer, the team physician, the coaches, the school insurance to worry about. A lot of those kids think they're automatically going to be professional athletes, but they don't understand only about one percent will be.

With professionals, it gets even more complicated, because you've still got the patient and the mother — I don't care how old they are — but also the agents, the team doctor, the trainer, the physical therapist, the coach, management. And the most difficult, nowadays, is the press. The press has no idea about HIPAA laws — about violating confidentiality. And if you don't handle it properly, they'll just say whatever they want to say. So it just gets more complicated as you go up the ladder.

Joseph Stromberg:When you have multiple athletes that want to see you, how do you decide how to spend your time?

Dr. James Andrews:When an athlete calls, I just pick up the phone, and say "come on down." They've all got my number.

I had a professional basketball player from Belgium call me today, he tore his knee up, and I said "come on Monday, we'll take care of you." You have to do that, that's accessibility. It all starts from answering the telephone. You can't always do that, but if you don't get people in in a timely fashion, you have a lot of fences you've got to mend.

I just got a letter this weekend from a mother of a patient. I remember her: she was a high school USA gymnast, who had a bad elbow. She then joined the Auburn gymnastic team, but I continued to be her doctor, all the way through college. Now she's 30, and her elbow is hurting her, and she tried to get in to see me. But unfortunately, they called Birmingham, who doesn't make appointments for me anymore, and they didn't know I was in Pensacola, and they didn't tell her where I was. The mother finally sent me a letter, and I felt so bad, I wrote her a three-page letter apologizing for not having been available. That's what I call mending fences. I felt terrible about it.

Joseph Stromberg:When you're dealing with pro athletes, if a player wants to go back on the field, and the agent, or management, or team doctors want the same, but you think the player isn't ready — how do you address that tension?

Dr. James Andrews: Well, the team physician always has the final say. Now if I operate on the patient, and the team physician didn't, then I take precedence. But if the team physician is taking care of an injured athlete, and he doesn't want to play him yet, but another doctor says he can, that doesn't mean a thing in the world. Or if I operate on him, and the team physician says he can play and I say he can't, he's my responsibility. But if the team physician operated and I'm just providing the second opinion, then he has the final say.

Joseph Stromberg:I realize there are rules about confidentiality, but are there any particularly interesting cases you can talk about?

Dr. James Andrews:One case I do have permission to talk about is Drew Brees, who had the most remarkable comeback that I've ever treated.

All expectations were that he had a career-ending shoulder injury. But he had such a good work ethic, and he so well taken care of by physical therapist Kevin Will, in Birmingham, who worked with him for a solid four months, that some way, some how, he got well. But I have to give him and the therapist all the credit, not me. He was an unbelievable comeback. And he's still playing.

Now, that doesn't always happen. And usually, the only results I remember are the bad ones. I just think on the players who don't have that kind of comeback. I saw a pro baseball player today who I've operated on three times — once on his shoulder, twice on his elbow. And he still has not been able to come back and play. Those are the ones you remember. I wake up at 6 a.m. on Monday morning, after the weekend, and start thinking about the patients having trouble. I call it my "worry list." I did an ACL last week, and the patient left having some pain. First thing I did when I got to work, I had my nurse call him, and he was doing fine. I still have him on my worry list, but not as high up on it as he was before.

Joseph Stromberg:You mentioned the press just reporting what they want. Are there ever cases where the public impression of an injury are totally different than the reality?

Dr. James Andrews:Yes. That's because of a lack of communication, by everyone — not just the press.

But teams, in general, will put out as little information about an injury as they can get away with. They may call something a knee sprain, when it's a complex injury of the knee ligaments. And a lot of times, the press wants a diagnosis immediately, and you just don't know.

And the press is always going to report something, from the bits and pieces they do get. And I'm not criticizing it, because that's their job.

On the sidelines, as a sports medicine physician, you have to make quick decisions, sometimes with less than perfect information. The press will say, "pending an MRI, it's this injury." But your exam, and your medical history, are a lot more important than an MRI. The public thinks that MRIs are the name of the game for everything, but they're way over-emphasized.

Joseph Stromberg:What do you think are the big emerging technologies that we should be paying attention to, right now, in sports medicine?

Dr. James Andrews:The big revelation over the last 40 years was the arthroscope. We've been looking for another one ever since.

I predict the next one will be so-called "biologics": stem cell therapy, gene therapy, tissue engineering. At some point in time we'll be able to make a piece of ligament, a graft, through tissue engineering, and take it off the shelf from a sterile containter and put it in a knee.

The big thing right now that people are working on is stem cell therapy. It's still experimental, but has a lot of potential. We're working on it here at the Andrews Institute. It's going to take a lot of clinical research, and trials, to figure out how exactly to use it: where, when, concentrations. But it's coming.

Joseph Stromberg:Why are players going to Europe for that sort of thing right now?

Dr. James Andrews:Well the FDA controls what we do here. Over there, they can do more without controls, so some other countries are further along. For example, South Korea is pretty far along, and Japan, and Germany. We're controlled by the FDA, which is rightfully looking after the safety of the patients.

A lot of this stuff being done outside the US hasn't been proven yet, and you have to be careful to see whether it's legal within US sports leagues. My thought is that we need to push forward the research here in the US, where it's safe and under control. We'll always have the FDA restrictions, and those are for the safety of the patients, so I applaud the FDA for not letting things get out of control. So we have to work within those parameters.

Joseph Stromberg:You recently wrote a position statement on the rash of Tommy Johns' injuries in baseball right now. What do you think is causing it?

Dr. James Andrews:I think the biggest thing is overuse, especially during childhood. If you look at the major league pitchers that I'm seeing, if you study their history, you'll find that they had injuries during their youth. They may have forgotten about it — I had one in here last week, we could tell from the X-ray, and he said, "Oh, I remember now, when I was 12 I missed a month of baseball with a sore elbow." About 50 percent have some pre-existing minor injury from overuse that was ignored.

The biggest factor, at any age group, is fatigue. If they're playing with fatigue — either from too many pitches in a game, or too many innings in a season, or from pitching year-round competitive baseball — you have 600 percent increased chance that you'll injure your shoulder or elbow.

So the recognition of fatigue is extremely important. If you're a major league pitching coach, you're probably good at recognizing it. But it gets harder and harder to spot as you go down in the youth levels. Some coaches mean well, but they don't recognize fatigue when it's obvious. There's a lot being done at the youth level that needs to be under better control. So we need a better education process. We've had a tenfold increase in injuries in youth baseball since 2000. Something has to be done about it.

But let me tell you — there was one particular thing in the position statement that was a little controversial, and I'd like to clarify it.

It's about curveballs. In the lab, at the American Sports Medicine Institute, Glenn Fleisig found that the forces across the shoulder and elbow among a select group of youth baseball pitchers are no greater when they throw a curveball, compared to a fastball. And so we extrapolated that it's okay for young kids to throw a curveball before their growth plates close.

But I don't agree with that at all. Here's the problem: throwing a curveball is a highly sophisticated pitch. It takes good neuro musclar control. So if a kid can throw a curveball with good mechanics, then the lab tests are accurate. The problem is that few kids in that age group have good enough coordination and control to throw it correctly. And most of them don't have a coach who's knowledge enough to teach them to throw it with the right mechanics.

So I think it's not safe to make a blanket statement that kids, pre-puberty, can throw a curveball. If you give them that leeway, all parents will say their kids have great mechanics, but they wouldn't know that. Most kids can't do that. So I say kids should not throw a curveball until they shave. Teach them how to throw a fastball and a changeup, that's it.

Joseph Stromberg:What about everything we're learning about football and injuries — head injuries, but also the overall toll the game takes on players' bodies? What's going to happen to football? Can it ever be safe?

Dr. James Andrews:Football has the highest rate of serious injuries of any sport. The safest sport, for young kids, is golf.

For me, I think the lessons learned in football still outweigh the injury risk. But I'm a football guy, and I may be too biased.

But there are ways we've got to make football safer. The first is pre-participation exams, and ruling out kids that shouldn't be playing. Another thing is having physiological age groups: two kids can both be 12 years old, but if they've matured at different rates, that's a huge mismatch. We have weight limits sometimes, but those don't always work. You've got to match up similar bodies, and that doesn't happen.

We've also got to have athletic trainers in all high schools, and everywhere youth football is being played. The trainers are there to recognize injuries when they first happen, even if they're minor, to prevent them from becoming major injuries. Right now, that doesn't happen. Some schools have them, but not all. Some states mandate it, but don't provide any funds for it. That's a joke.

The other thing is that we need more education on injury prevention, during games and practice. This includes parameters for practicing in the heat. But if you don't have an athletic trainer, the head coach can't — they might not know how. So we need all state high school athletic associations to have rules on when they can practice, how often, etc.

We need better emergency action plans for high schools. What you do, who you call. There should be defibrillators, like we're providing through a foundation that I'm head out, at all high schools. There needs to be a dedicated ambulance at every high school football game. Often, they have to pay for them to come, and it's expensive as hell, so the ambulance is there at the start of the game, but if they get a call to go somewhere else, they just leave. So a kid gets hurt, and he can die on the field because he has no ambulance to get him to the hospital.

So there are all the problems. And for a nation that's as sophisticated and educated and advanced as we are, those things should be automatic. But they're not.

This interview has been edited for length and clarity.

Read the highlights

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