By Brian Feeley and William Levine
The world of sports and sports medicine offers a valuable window into understanding key developments in the COVID-19 pandemic and the broader health and equity issues at play.
Sports medicine, the practice of keeping athletes of all abilities in their peak through a combination of surgery, rehabilitation, and medications, has grown exponentially in the past few decades, with a concomitant rise in the popularity of professional and recreational sports.
The First Wave
Developments in professional sports largely tracked or anticipated public health developments relating to the pandemic.
On March 11, 2020, the same day that the World Health Organization officially declared COVID-19 a pandemic, the National Basketball Association (NBA) halted the 2019-2020 season after a positive test by Utah Jazz player Rudy Gobert.
Two days later, on March 13, 2020, New York Presbyterian, the largest health care system in New York City, canceled all elective surgery indefinitely.
COVID-19 hit so fast and furious that our health care system was turned upside-down. NYP-Columbia had 110 ICU beds prior to the COVID pandemic. With intense modeling and remarkable speed, every available space was converted to an ICU bay. Operating rooms were converted into three-person intensive care units. before long the hospital had 100 intubated COVID positive patients, then 150, 200, and, at its peak, a mind-numbing 265 patients.
We quickly outgrew the appropriate personnel to care for such sick patients. We had shortages of intensive care physicians, intensive care nurses, respiratory therapists, and personal protective equipment (PPE), which challenged the core mission of providing care for the sickest and most in need.
So, our community of providers took action and formed alliances across the specialties. Working with Urology, orthopedic surgery leadership created a redeployment schedule pairing one attending with one resident to work in the newly created “pop-up” intensive care units in the emergency room. This expanded to include ENT, ophthalmology, dermatology and physiatry faculty and residents to expand the pool of available providers.
Clinical Care After the First Wave
Determining the short and long term effects of COVID on healthcare is a complex issue. As fewer people play sports, clinical volumes decrease, and there are fewer patients to see. Pediatric and adolescent sports medicine providers were hit even harder as their surgical and clinical volumes disappeared entirely. Currently, overall volumes are considerably less in most practices. Recent data showed that orthopedic surgery volume is still down 3% compared to pre-pandemic levels. In Manhattan, midtown offices continue to be negatively impacted with approximately 30% decreased patient volume compared to pre-pandemic numbers.
Long term, COVID has brought several changes to the practice of sports medicine. We have learned that the education of our residents and fellows has invariably suffered in many ways despite our best efforts. However, we have also transitioned to online interviews for our residency and fellow applicants, decreasing the financial burden and providing better access for all applicants who want to apply.
From a clinical standpoint, we have learned how to review MRIs on teleconference and do routine follow ups, especially for patients that live far away. As a group, sports medicine physicians and surgeons have been learning how to fine tune the marriage of in person visits with teleconference visits to suit the needs of their practice and their patients. Hopefully, these transitions will lead to more access to care for people who cannot travel or take time off from work for appointments.
Reopening for Sports
Sports and sports medicine providers again took center stage as spring and summer progressed. The WNBA and NBA reopened, albeit in a “bubble” with key sports medicine physicians providing guidance along with hundreds of primary care, infectious disease experts, and public health officials.
As the United States put sports on center stage for reopening, many questioned whether this was right to emphasize over other critical areas such as schools and small businesses.
Perhaps lost in the discussion was the risk posed to athletes, especially NCAA athletes, many of whom did not feel they had a choice. COVID has put the lives of athletes in peril for years to come, the extent of which we likely won’t know for quite some time. Perhaps the biggest question is what the long-term consequences will be for athletes of all ages that develop chronic systemic effects from a COVID infection. While the occasional cases of cardiac problems in elite athletes were well documented, the risk of future harm from high level training is unknown.
And as a sports medicine practitioners, how can we know what to screen for if we have not yet seen it? What are the risks involved in attempting sports after a known or unknown COVID infection? Will athletes be able to participate at the level they want to now and in the foreseeable future? As with so much of 2020, we will have to experience the scientific process together as a country and learn from our successes and failures over the next decade.
Moreover, we need to consider the potential risks of a return to competitive sports after the long hiatus posed by COVID-19. We anticipate many athletes returning to interscholastic sports after not playing competitively for up to 18 months.
Injury risk in these athletes will be high, and prevention strategies have rarely been implemented in the past, let alone over the past 12 months. Injury to a youth athlete can have considerable consequences. Consider a high school senior football player — their junior year was cancelled; if they have an ACL tear at the start of training, they will miss 2 years of competitive sports. ACL tears not only cause a higher risk of future injury and early development of arthritis, but also might affect potential scholarships for higher education. Sports medicine physicians today are trying to figure out the right balance of encouraging participation while mitigating risks to the musculoskeletal system in players that are not ready for training and participation.
Again, sports have served as a microcosm for the larger issues at play in the COVID-19 pandemic. The pandemic has resulted in an increase in the growing socioeconomic gap of youth sports.
Without schools open for sports, wealthier, predominantly white suburban athletes gravitated to their competitive club teams. But these options often are not available or affordable for Black and Latinx athletes living in cities, and they have been, and may continue to be, without sports and exercise.
In a time when club sports were already dominating and increasingly pulling kids away from middle school and high school teams, COVID has and will continue to make competitive sports less affordable and available for kids who want to play. The long-term effects of this phenomenon in sports medicine, and the effects on the general health of these kids, will be seen for years to come.
Some have imagined this as an opportunity to reinvent youth sports, making them more equitable, available, and even fun. Sports medicine physicians across the board support this, but implementing change will be a challenge.
Brian Feeley, MD is Chief of Sports Medicine and Shoulder Surgery in the Department of Orthopedic Surgery at the University of California, San Francisco.
William Levine, MD is Chair of the Department of Orthopedic Surgery at Columbia University’s College of Physicians and Surgeons, where he holds the Frank E. Stinchfield Professorship in Orthopedic Surgery, and serves as Chief of the Orthopedics Service at NewYork-Presbyterian/Columbia University Medical Center.
This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce.