Tuesday, March 30, 2010

Sports Injuries - Go to a Doctor or Tough It Out? - NYTimes.com

You have been playing a lot of tennis recently, and now you think you have tennis elbow. Or you're a swimmer with an aching shoulder. A cyclist with sore knees. A runner with pain in your heel.

Do you go to a doctor, or tough it out?

Now, before you read on and decide I'm a therapeutic nihilist, I have to tell you that the idea for this column was suggested by a doctor-athlete, Paul D. Thompson, who is a marathon runner and cardiologist at Hartford Hospital in Hartford.

And his answer to his own question?

"I think most folks should not go, because most general doctors don't know a lot about running injuries," he said, adding, "Most docs, often even the good sports docs, then will just tell you to stop running anyway, so the first thing is to stop running yourself."

In fact, he said, since you probably will have to make a co-payment if you see a doctor, you will be adding insult — the fee — to your injury.

Dr. Volker Musahl, an orthopedist at the University of Pittsburgh Medical Center, had the same sort of response. He competes in marathons and triathlons.

"If you want to continue to run, don't see a doctor," Dr. Musahl said. He, like Dr. Thompson, said that if you were one of his patients, coming in with a sports injury like a sore knee or hamstring or heel or hip, he would just tell you to rest.

Dr. Musahl added a caveat, however. When he recommends staying away from doctors, he is talking about staying away if you have the usual sort of aches and pains that plague almost everyone who exercises regularly. But there are red flags that should prompt you to get medical attention, Dr. Musahl said: pain that gets progressively worse, pain at rest or at night, joint swelling or bruises that do not get better, and knees or elbows or other joints that lock or seem unstable.

Dr. Thomas Best, the president-elect of the American College of Sports Medicine and director of the division of sports medicine at Ohio State University, advises seeing a doctor if you are not recovering in your usual period of time from whatever injury or soreness you typically get. For example, he said, every weekend after his usual 10-mile run his knees are sore. He is not sure why.

"Lord knows what's going on in there," Dr. Best said. But the pain goes away in a day or so, and he has grown used to it. That's his usual recovery time for that kind of knee pain.

"Know how you typically recover," he said. "When you are not recovering as you typically do, that's the first warning that something more is going on."

The problem with rushing to see a doctor for common injuries, according to Dr. Musahl and others, is that doctors have a limited arsenal. For a typical sports injury — pain or tenderness in a muscle or tendon — they can't make you get better faster. And some of the treatments doctors dispense, like cortisone shots for injured tendons, can actually slow recovery, albeit providing temporary pain relief.

There are some helpful treatments for run-of-the-mill injuries, but they often do not require a doctor, and doctors often know nothing about them.

Rigorous studies have shown that eccentric contractions, in which a muscle lengthens as it works, seem to speed the healing of tennis elbow and of injuries to the Achilles tendon, which attaches the calf muscles to the heel. They involve, for example, doing heel drops for an Achilles tendon injury — standing on a step and dropping your heel, then raising your heel to the level of the step again. In one recent study testing an experimental treatment, which turned out not to work, heel drops were used as the standard of care — the presumed-to-be-effective alternative to the treatment being tested. Participants getting the experimental treatment, as well as those who did not get it, did 180 heel drops a day.

Sometimes going to a doctor for a diagnostic workup can be a precarious thing, with scans that can show all sorts of apparent abnormalities and injuries that are not really causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.'s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.

"M.R.I.'s are so sensitive," Dr. Musahl said. "They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn't mean you have to have the particular symptoms."

The same is true for rotator cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Dr. Best, though, said that when an athlete has an injury that does not go away in the expected time, skilled doctors could help by finding the cause of the injury in the first place. Knee pain, for example, might actually be caused by a tight iliotibial band, which stabilizes the knee, and weak gluteus muscles. He always watches athletes move to see if he can spot biomechanical problems. And, he said, doctors who do not watch athletes move may never understand the causes of their injuries.

"You as a runner, coming into my office and lying down on a table — that's a pretty nonfunctional exam," Dr. Best said.

But, he conceded, his practice may be somewhat different from most. He is also a professor of bioengineering, and said he could help with many overuse injuries by studying an athlete's biomechanics.

"A lot of sports docs don't have a clue," Dr. Best said.

In the meantime, doctors who advise you to avoid doctors follow their own advice.

Dr. Thompson went to an orthopedist about five years ago for knee pain that plagued him whenever he ran. He said he knew the doctor well because they mountain-biked together. He had an M.R.I. that showed that his iliotibial band was inflamed. Dr. Thompson stretched it, and the pain eventually went away.

The visit before that one was 25 years ago when Dr. Thompson had plantar fascitis — heel pain caused by an inflamed tendon at the bottom of the foot. He went to a podiatrist who gave him expensive orthotics and cortisone injections, but they did not help.

Then a podiatrist for the Celtics basketball team told him to tape his foot, and the problem went away. While a review by the Orthopedic Section of the American Physical Therapy Association classified the evidence for taping as "weak," Dr. Thompson swears by it.

"The fact that experts think the taping evidence is weak means they are not seeing enough runners and is the best argument for not seeing them," he said. "If I stop taping," he added, the problem "comes back in a month."

As for Dr. Musahl, he says he never sees a doctor for his sports injuries. When he feels pain, he cross-trains awhile until the pain goes away.

And that is how most experienced athletes behave, Dr. Musahl said. They know their injuries and know that the injuries will get better with or without a doctor visit.

"Athletes who are older usually have had that problem before," he said. "They are smart about it, they know it is self-limiting."

"Younger people come in immediately," Dr. Musahl said.

Then, if they continue with their sport, they learn about the limits of medicine.


Sunday, March 28, 2010

More Doctors Taking Salaried Jobs - NYTimes.com

A quiet revolution is transforming how medical care is delivered in this country, and it has very little to do with the sweeping health care legislation that President Obama just signed into law.

But it could have a big impact on that law's chances for success.

Traditionally, American medicine has been largely a cottage industry. Most doctors cared for patients in small, privately owned clinics — sometimes in rooms adjoining their homes.

But an increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries athospitals and health systems. And a growing number of older doctors — facing rising costs and fearing they will not be able to recruit junior partners — are selling their practices and moving into salaried jobs, too.

As recently as 2005, more than two-thirds of medical practices were physician-owned — a share that had been relatively constant for many years, the Medical Group Management Association says. But within three years, that share dropped below 50 percent, and analysts say the slide has continued.

For patients, the transformation in medicine is a mixed blessing. Ideally, bigger health care organizations can provide better, more coordinated care. But the intimacy of longstanding doctor-patient relationships may be going the way of the house call.

And for all the vaunted efficiencies of health care organizations, there are signs that the trend toward them is actually a big factor in the rising cost of private health insurance. In much of the country, health systems are known by another name: monopolies.

With these systems, private insurers often have little negotiating power in setting rates — and the Congressional health care legislation makes little provision for altering this dynamic. If anything, the legislation contains provisions — including efforts to combine payments for certain kinds of medical care — that may further speed the decline of the private-practice doctor and the growth of Big Medicine.

The trend away from small private practices is driven by growing concerns over medical errors and changes in government payments to doctors. But an even bigger push may be coming from electronic health records. The computerized systems are expensive and time-consuming for doctors, and their substantial benefits to patient safety, quality of care and system efficiency accrue almost entirely to large organizations, not small ones. The economic stimulus plan Congress passed early last year included $20 billion to spur the introduction of electronic health records.

For older doctors, the change away from private practice can be wrenching, and they are often puzzled by younger doctors' embrace of salaried positions.

"When I was young, you didn't blink an eye at being on call all the time, going to the hospital, being up all night," said Dr. Gordon Hughes, chairman of the board of trustees for the Indiana State Medical Association. "But the young people coming out of training now don't want to do much call and don't want the risk of buying into a practice, but they still want a good lifestyle and a big salary. You can't have it both ways."

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