Sports medicine: the last 100 years.

Sports medicine (1) has evolved during the 20th century. Before World War II, there were minor developments in the field, but in the last half of the 20th century, sports medicine has progressed to new millennium status. Sports medicine developed throughout the 50s and 60s, introducing total joint replacement, endoscopic techniques, internal fixation of fractures and the virtual ablation of polio and tuberculosis as major public health concerns.

Before World War II, there were no preventive techniques--only "padding and taping" for collision sports. There were no mouth pieces, no real training techniques, no organized youth sports and certainly no providers specifically schooled in "Sports Medicine." In these early days, the ingredients for Sports Medicine began to appear. The catalyzing factor was the local need for knowledgeable and competent physicians and surgeons who understood athletes and their injuries. Orthopedists increasingly filled that vacuum. Orthopaedic involvement was logical, since 75% of athletic injuries are musculoskeletal. There were no primary care sports medicine physicians available at that time. The athletic trainer at the college, university and professional level functioned early on as the "sports medicine team," along with the orthopedist. Across the country, organized medicine, school systems and even politicians awakened to the need to provide better and specialized care for youth and collegiate athletes.

Sports medicine as we know it coalesced from 1960 to 1980. The explosion of the speciality with orthopedists and the team physician concept was followed by the development of (a) related organizations, (b) injury prevention methodology, (c) fitness and training schema and (d) research related to sports medicine. As technology made the world smaller, the elite level athlete's profile grew larger, creating numerous role models at home and abroad. Substance and other abuses proliferated. (1) Physical fitness as a prerequisite for efficient and injury-minimized sports participation has been long known but was tardy in its projection into the athletic world.

The American College of Sports Medicine (ACSM), The American Medical Society for Sports Medicine (AMSSM), The American Orthopaedic Society for Sports Medicine (AOSSM), The American Academy of Pediatrics (AAP), and numerous other specialty and primary care organizations targeted politicians locally and nationally to carry out badly needed epidemiologic and other research.

Historically, Dr. Edward Hitchcock from Amherst wrote sports medicine "truisms" in 1854 as the first "team physician." Stevens (2) at Yale was an early sports medicine pioneer. Thomas Thorndyke at Harvard published the first text on athletic injuries, entitled Athletic Injuries; Prevention, Diagnosis and Treatment in 1938 and Thomas Quigley published The Athlete's Bill of Rights in 1940. A plethora of postwar organizations placed the care of athletes squarely in the public arena. The ACSM in 1954, the National Athletic Trainer's Association (NATA) and the American Medical Association Committee on the Medical Aspects of Sports (AMA-MAS) from 1960 to 1975 were early and active organizations. Dr. Jack Hughston of Columbus, Georgia was responsible for much progress. He worked with the National Federation of State High School Athletic Associations to effect major preventive measures in all levels of sports including rule changes, protective equipment, mouth pieces, rubber cleats, hydration science, etc.

Major strides were taken toward the sports medicine specialty through the massive CME efforts of the American Academy of Orthopaedic Surgeons (AAOS) that mobilized the manpower producing AOSSM in 1972 with its respected journal the American Journal of Sports Medicine. The American Medical Society for Sports Medicine (AMSSM) was formed in 1980, soon producing a highly competent cadre of primary care sports medicine "fellowed" physicians. I have worked with men and women from these organizations for 40 years. Their skill, work ethic, devotion and collaboration for the betterment of the athlete is unique in the world of medicine. This is continuing in the 21st century. The emphasis currently is also increasingly to train, categorize and monitor the coaches who work with our youth throughout the country. (3)

Arthroscopy

Arthroscopic surgery remains the major advance in sports medicine during the 20th century. Although cystoscopy developed steadily before World War II, arthroscopy suffered only "fits and starts," ie, the George Wolf Co. in Berlin and efforts in the 20s and 30s by Bircher, Burman, Takagi, Watanabe, and Baubel. It was the late 1960s before Dr. Bob Jackson publicized Dr. Watanabe and his arthroscope. In the 1970s, Richard O'Connor, John Joyce, Lanny Johnson, Ward Casscells and others spurred a burgeoning industry to develop the basic instruments that have evolved and are still utilized today. The evolution to either adjunctive or assistive arthroscopy in the ankle, spine, shoulder, etc., are ongoing. The high-profile patient/athlete post arthroscopy with their accelerated rehabilitation and return to play have catalyzed other specialty surgical endoscopic techniques. The ripple effect of diagnostic and procedure coding, ie, ACL reconstruction, has had considerable public impact.

The downside to the massive arthroscopic industry has been:

a. the aggregate learning curve for orthopedists has included potential abuses (4);

b. ACL revisions have been in high quantity.

One of the upsides derived as a by-product of arthroscopic knee surgery has been the understanding of the functional anatomy of the knee. The advent of arthroscopy helped point out the fact that the meniscus should never be removed in its entirety as inevitably, late degenerative changes will occur.

Prevention

There developed in the 1980s and 1990s a continuum of sports medicine expansion in:

a. the science of sports and exercise;

b. the prevention of acute and repetitive stress injuries;

c. the rehabilitation of acute and repetitive stress injuries.

These separate areas and their fund of knowledge is now universally available to youth and adults alike. Such was not true during the early and mid-20th century.

The prevention of throwing arm problems in youth, for instance, far outweigh the treatment of that arm after acute or chronic anatomic and functional problems occur. More children and women are now involved in sports. This is a positive step, but problems exist. Women who overtrain are prone to overuse injuries and may incur alterations to their menstrual cycle, osteoporosis and eating disorders. This can lead to a cascade of events known collectively as the "female athlete triad." (5) There are more adult-like injuries appearing in children, including repetitive use injuries such as stress fractures, tendinitis, bursitis, etc. The legitimate and major concern we have about our obese society can lead to over encouragement of active youth participation.

Though targeted since the mid-20th century, it is only in this new millennia that funding, further research and specific studies encouraged by the now numerous organizations noted above can veer resources toward a proper balance of prevention and treatment. It is only with this approach that we can improve the participatory, competitive and health benefits of sports and reduce the negative physical and emotional experiences. Evidence-based studies can be difficult to complete. The next 10 to 15 years will see remarkable documentation regarding sports injury prevention and injury treatment.

The future will continue to emphasize more sophisticated intraoperative techniques, better evidence-based ways to handle damaged articular cartilage, healing techniques for injured ligaments like the ACL, meniscal scalpeling of an advanced biologic type, as well as gene manipulation/therapy.

References

1. McBryde AM Jr. Giving young athletes a better opportunity. South Med J 2001;94:263-264.

2. Snook GA. History of sports medicine: part I Am J Sports Med 1984:12:252-254.

3. Barfield WR, Kirkendall DT, McBryde AM, et al. Who can coach our youth? Health Fitness J 2003;7:10-15.

4. Barfield WR, Otteni JF, McBryde AM, et al. Longitudinal study of factors affecting stress fracture risk in two distinct college female populations. J Exerc Sport Sci 2005;1:29-41.

5. McGinty JB, Johnson LL, Jackson RW, et al. Current concepts review, uses and abuses of arthroscopy: a symposium. J Bone Joint Surg Am 1992;74:1563-1577.

Angus McBryde, MD, FACS, and Bill Barfield, PHD

Reprint requests to Angus McBryde Jr., MD FACS, Alabama Sports Medicine, 608 St Vincents Drive, Birmingham, AL 35205. Email: [e-mail].