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Robert Nirschl, MD, MS: challenging 'standard of care' to evolve for 45 years.

Robert P. Nirschl, MD, MS is an orthopedic surgeon and founding partner of the Nirschl Orthopaedic Center in Arlington, Virginia. For nearly half a century he has been pioneering preventive and surgical techniques to aid in recovery from sports-related injury, beginning at a time when little was known about the nature of tendon injuries--and when even less was correct.

Dr. Nirschl's now world-renowned research has even led to his acquisition of four U.S. patents, all related to intelligently guiding the movement of players in sports like tennis to improve athletic form and decrease the chance of injury. He achieved this by carefully studying professional athletes' path of motion during sports activity. The results--supportive devices called functional Count'R-Force sports braces--have, like his novel surgical techniques, been adopted worldwide.

A Curious "Tinkerer"

Bom and raised in Milwaukee, Wisconsin, young Robert Nirschl was the son of a dentist and younger brother of an eventual doctor as well. His scientific mind and penchant for "tinkering," as he puts it, were sufficiently nurtured in his home environment which encouraged him to try for medical school after his undergraduate studies at Holy Cross in Massachusetts and Marquette University back in Wisconsin.

Dr. Nirschl graduated from the Medical College of Wisconsin (the med school at Marquette University) in 1958 and began his residency in orthopedic surgery at the Mayo Clinic in Rochester, Minnesota. He holds a master's degree in orthopedic surgery from the University of Minnesota.

While he was at the Mayo Clinic, the peacetime draft was on, and the Cold War was at its height. "You could have been drafted and so lost your specialty residency program," he says. To avoid this, "what many physicians did was sign on to [the Berry program] which said the military would guarantee that you could complete your specialty training, and then you would have to go active duty for at least two years."

Therefore, after completing his residency in Rochester, he went on to serve in the U.S. Navy as a staff orthopedic surgeon at the St. Albans U.S. Naval Hospital in Queens, New York. The year was 1963, and the war in Vietnam was heating up (U.S. troop levels had tripled in 1961 and again in 1962). In his two years of service at the hospital he treated his share of injured veterans, as New York City saw many soldiers return there after injury overseas.

After the service, Dr. Nirschl discovered that an orthopedic surgeon was needed at Georgetown University. He was hired, and has been in the D.C. area ever since. Around this time, settling into career and family, he and his wife decided to take up recreational tennis. "So the next thing that happened was I got tennis elbow," he says, "and so began my trek down tendon injury lane, if you will."

Re-Examining Conventional Wisdom

He began to read the international orthopedic literature and found it repeatedly reported therein that few tennis players actually acquired tennis elbow. "At that point I already knew a lot of tennis players who had the problem, including me, and I said, 'These guys are idiots.'" He knew there had to be more going on than met the eye.

As it happened, the captain of the U.S. Davis Cup team, Donald Dell, was in Washington at the time and Dr. Nirschl wound up meeting him. He and a junior medical student at Georgetown (and fellow tennis enthusiast) arranged through Dell to observe Davis Cup players at their training center in Ohio. The two men filmed the stroke mechanics of these world-class players in 1970.

Back in D.C., Nirschl next filmed inexperienced players and compared stroke mechanics. "We found out they were very different to say the least, and so we started to form the concept of force overloads in sports," spreading the idea that there were clear injury-protective and injury-inducing ways of hitting the ball.

To help recreational tennis players steer clear of the bad form that caused injury, he developed braces to diffuse the pressure that would otherwise form in a high-demand environment. The braces were therefore functional, not immobilizing. In 1973, he introduced supportive "counter-force bracing" as opposed to rigid, restrictive braces.

This could almost be seen as the dawn of preventive care: an emphasis on keeping you out of the doctor's office, instead of fixing you once you inevitably landed there.

The Dawn of Sports Medicine

At the time, the idea that all sports were on some level injury producing was a radical one. "The goal of sport is not good health," he famously said back then, "the goal of sport is to win." And: "You need to get your body in shape to do sports. You don't do sports to get your body in shape."

In 1972, Nirschl gave a talk at the American Academy of Orthopaedic Surgeons on this concept, specifically as it relates to tennis elbow. A large crowd of about 5,000 people attended, and he could sense a sea change just beginning. "That was the era of starting to move in this direction," he says of the nascent fields of biomechanics, injury prevention, and sports rehabilitation.

A year earlier, after all, cardiologist George Sheehan had taken up running in late middle age. He was among the first to study impact forces on running injury, as others would soon do, including the Oregon pioneers who would go on to form Nike. While these men studied lower-extremity injury, Dr. Nirschl's upper-extremity work on the east coast dovetailed nicely to further advance the new field of sports medicine.

Nirschl wrote the very first article that would appear, in 1972, in the new journal The Physician and Sportsmedicine. It was titled, "Good Tennis is Good Medicine," and laid out a paradigm that emphasized "violence control" during an activity to combat injuries by preventing them.

The essential message was that an athlete's training technique, form, volume, intensity, and duration all either contribute to or deter injury by mitigating or exacerbating the inherent violent biomechanics of a given sport. Others, such as Bill Bowerman, focused on shoe design; still others looked at training surface, racquet type, helmets, padding and more, depending on the nature of the activity.

A New Consensus: The Surgery Isn't Working

What happened next led to a complete rethinking of tennis elbow surgery. The same curiosity that had guided Nirschl toward an injury-preventive model compelled him to spend a great deal of time in the Georgetown anatomy lab to define precisely "what the elbow tendons were doing," he recalls. "We found out that the important tendon, the one that was damaged all the time, was hiding under another tendon, so that the prior operative techniques never identified where the damage was."

Astonishingly, recoveries from tennis elbow after surgery were evading his contemporaries because these doctors were severing the wrong tendons. The folly of the current release operation--cutting all the tendons--became apparent to Dr. Nirschl, and he was not shy in reporting what he found. After all, without identifying the correct location of an observable pathology, the procedure was senseless.

After discovering the true location of what would be renamed "tendinosis pathology" in tennis (lateral) and golfer's (medial) elbow, in 1979 he published the new recommendations for how these operations should be performed based on where the real damage was occurring.

Eventually, Dr. Nirschl went on to become a founding member of the United States Tennis Association Sports Science Committee. He even served as an orthopedic surgery consultant to the President's Council on Physical Fitness and Sports under the Reagan administration. But the blowback from his controversial questioning of the standard of care was not insignificant.

It wouldn't be the only time. In 1984, he became, as he puts it, "a heretic in shoulder world" with his insistence that, contrary to all the widely published medical books, surgeons need to avoid acromioplasty--cutting bone away from a problematic tendon--in rotator cuff surgery. This view, which drew the permanent ire of several colleagues, has now been widely adopted.

Legacy Work in Arlington

Dr. Nirschl, who may be soon winding up his distinguished career as an attending orthopedic surgeon at Virginia Hospital Center, founded the Nirschl Orthopaedic Center in 1969. It was, and still is, here that much of his groundbreaking research on tendon injuries would flourish.

Among the many of his lasting achievements was the founding in 1987 of the Nirschl Orthopaedic Sports Medicine Fellowship program. As a result of this program, Dr. Nirschl has mentored hundreds of medical students, family practice residents, orthopedic surgery residents, family practice sports medicine fellows, and postgraduate orthopedic sports medicine fellows.

AMAA Board Member Francis O'Connor, MD, and Robert Wilder, MD, were the program's first two fellows, and have dedicated their sports medicine tome Running Medicine to Dr. Nirschl, citing him as their most influential mentor. (See Dr. O'Connor's sidebar tribute to Dr. Nirschl.)

Giving Up-itis in Favor of -osis

As the author of 51 medical book chapters and 60 medical articles, Dr. Nirschl is taking time now to organize, consolidate, and pass on a lifetime of revolutionary research. Among his most important findings, which occurred right around the time of his discovery of errors in the surgical procedure for tennis elbow, was the realization that the vast majority of tendon injuries are not at all inflammatory in nature. They are in fact degenerative.

The all-too-familiar terms "Achilles tendonitis," "plantar fasciitis," "patellar tendonitis," "quadriceps tendonitis," and "groin adductor tendonitis" are therefore all misnomers. Rotator cuff injuries and iliotibial band problems, too, are not inflammatory. Dr. Nirschl has been crusading to obliterate these terms from the medical lexicon, and replace them with the accurate "tendinosis," "fasciosis," and the like. (Bursitis--inflammation of the fluid sac near the elbow, shoulder, hip, or knee joint--remains correctly named.)

He hopes to witness this shift in terminology-and thinking--complete its course within the worldwide medical community as we continue to better understand the true pathology of the most common tendon injuries. Accordingly, he further spread the message on October 23 at AMAA's 24th Annual Sports Medicine Symposium at the Marine Corps Marathon with his well-attended lecture on "Tendinosis/Tendinitis: 45 Years of Experience & Observations."

Among many other appointments, awards and honors, Dr. Nirschl has served on the Board of Councilors for the American Academy of Orthopaedic Surgeons and the American Orthopaedic Society for Sports Medicine. He has received the Lifetime Career Award from the Virginia Orthopedic Society and The Achievement Award from The American Academy of Orthopaedic Surgeons.

Such establishment accolades are all the more striking for his having several times throughout his extraordinary career seemed the consummate outsider.

His message is simple: "What we thought we knew is not always right." Another way of putting it is: consensus opinion is different from correct science. "That's my continuing adventure," he says, "to try to educate as many folks as possible to not get stuck in consensus opinion. Very often the standard of care is not quality care." After all, standard of care is too often merely consensus opinion.

And that has been something with which Dr. Nirschl has never been satisfied.

Reflections from a Fellow

Dr. Nirschl's extensive research of sports techniques has led to many new treatments of tendon injuries of the shoulder, elbow, and knees. His operative procedures for elbow tendinosis, pain-phase classification, and microscopic evaluation of failed healing of the tendons have been adopted by physicians worldwide.

His outstanding clinical, teaching, and service achievements have been recognized by many distinguished awards, including those from the American Academy of Orthopaedic Surgeons, Uniformed Services University, the Arlington County Medical Society, Georgetown University, and the Virginia Orthopaedic Society.

I had the pleasure of serving as Dr. Nirschl's first primary care sports medicine fellow, back in 1990. His legacy of passing his great knowledge and expertise on to numerous orthopedic surgery residents and fellows has significantly contributed to better outcomes for these trainees' patients in both orthopedic and primary care sports medicine. Many of these women and men now serve as medical directors, department chairs, and head team physicians.

Dr. Nirschl is clearly an innovator and a pioneer. His early recognition of the lack of inflammation in chronic tendon injuries led to a new paradigm of tendon injury, now termed tendinopathy. Many authors cite Nirschl's early work as trail blazing.

As a potential new fellow, Nirschl promised me that if I were to come and train with him, I would be part of a team changing the way people think. I am proud of my decision in that I trained with a physician who truly made a difference, and did change the way people think.

One of the most lasting impressions on me was Dr. Nirschl's equal and complete dedication to all of his patients, and it is a standard I strive for to this day. This model clinician and teacher is worthy of the highest praise and of many, many thanks. His influence is ever-present in my patient care encounters, and I am truly honored to have had the privilege to work for and with him.

COL Francis G. O'Connor, MD, MPH, FACSM

Jeff Venables is the editor of Running & FitNews[R] and a regular contributor to the AMAA Journal.
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Title Annotation:Member Profile
Author:Venables, Jeff
Publication:AMAA Journal
Geographic Code:1U5VA
Date:Sep 22, 2015
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