Medicine Men

Sometimes, there is an emergency.

"When Aaron Rowand ran into the fence," said Michael Ciccotti, who has been the Phillies' team physician since 1999, "he had this terrible facial orbital fracture. You're going down the checklist like an emergency-room physician would do. You figure, 'OK, these are the things we have to do. This is what is safest for him. We have to get him to do this. We have to get him to the emergency room.' Only later do you sit back and think, 'This was a pretty dramatic thing.' "

Sometimes, there is a catastrophe.

"There are two things I saw," said Peter DeLuca, who has been an Eagles and Flyers team physician since 1997. "Thomas Tapeh dislocated a hip in St. Louis. Leonard Weaver's knee. When you're there on the field, you don't even think about it. People always ask me, 'Do you hear?' I don't hear the fans. I don't hear anything when I'm out there. You're just concentrating. You're a doctor. You're applying emergency care. But after, when things calm down, when you look at the MRI of Leonard Weaver's knee and examine it and you know his career is over. You know that. But you can't tell him that yet because you have to give him some hope. That's the hardest thing to deal with. Then, I step back and think, 'This poor guy, 20-some years old, done.' "

Occasionally, it is gratifying.

"Mike Lieberthal essentially dislocated his knee, which is a catastrophic event, a multiple- ligament knee injury," Ciccotti said. "It is often career-ending. But we did the surgical procedure, and he was so focused on his rehab, and he came back to play for several years. It just doesn't happen very often . . . To be able to help someone get back to what they want to do, at the most elite level, it is tremendously rewarding."

And sometimes, well . . .

"For me, it was probably John Stevens when he played for the Phantoms," DeLuca said. "It was toward the end of the year. He tore his ACL in January of that year. I reconstructed his ACL. He worked hard, rehabbed, did well, and we let him play at the beginning of April, for the playoffs. And right before the playoffs, he skated up to me and said, 'Thank you so much for letting me come back.' And we went on to win the Calder Cup that year. I can't tell you how that feels."

The team doctor. It sounds simple enough but like any profession, it is an amalgam of emotions and complications. They are paid by the teams but their patients are the players. The teams - and, usually, the players - want the athletes to get back as quickly as possible after an injury, and trained athletes are capable of more than the rest of us, and there is this constant tug between the imperatives of competition and the physical safety of the people doing the competing.

Treating a player injured in a game can be simple compared to this jumble of conflicting cues that develop as the healing begins. Can you believe a player desperate to get back on the field in his contract season? Can you easily dismiss the notion that a game ahead, or a series of games, could determine a playoff spot for the team?

The team physician is in the middle of this great whirl of forces. In their years on the job, Ciccotti and DeLuca - both orthopedists with the Rothman Institute - have seen a revolution in surgical techniques and rehab strategies. They have had suspicions about players using performance-enhancing drugs and, even though this isn't their specialty, they have witnessed the accelerating changes in how players are treated when they suffer concussions.

But it is the daily push-pull between keeping players safe, on the one hand, and clearing them to return to their sometimes-violent world, on the other hand, that never changes. As Ciccotti said, "People don't realize just how complicated these decisions can be."

On the main point, both Ciccotti and DeLuca are adamant: that they have never been asked by the management of one of their clubs to put a player at risk in order to get him back on the field.

"I want to get them back as quickly as possible but as safely possible," Ciccotti said. "In the entire time I have been doing this, I have never felt that an ownership or management or GM or coach has ever wanted me to make a decision that would put a player at risk . . .

"I would never put a player at risk. Nothing is ever black and white. It's always gray . . .

"Whether it was Ed Wade or Pat Gillick or Ruben Amaro, if I say it isn't appropriate for this player to play at this time, they may be disappointed because they want to win and want to put the best team out there, but they've never made me feel like I need to alter a decision because of that."

DeLuca is just as plain: "All I have to say to Andy [Reid] is, 'That will put him at risk.' That ends the discussion. There is nothing else said."

Nevertheless, the potential for conflict will always exist. The teams pay the doctors, and the doctors' practices also benefit from the publicity. What high school pitcher with a tender elbow wouldn't want to have it looked at by the Phillies' team physician? What 18-year-old running back with a grouchy knee wouldn't want the Eagles' orthopedist on the other end of the arthroscope?

So there is a clear incentive to stay on the team's good side. And while that is acknowledged, there is another aspect that also must be acknowledged. To disregard the player's best interests would be unethical professionally. And to have too many bad medical outcomes involving high-profile players would create the kind of bad publicity that could just as easily send the teenage pitcher and running back someplace else for a consultation.

And there is this cold reality, too:

"The legal repercussions with professional athletes," DeLuca said. "They make a lot of money. You're not going to put yourself out for the team - that's the way I look at it. They're not going to back me - I know that. I've been in this business long enough . . . They're not going to back you so you can't stick your neck out. It's your reputation and it's your livelihood."

The truth is, there are as many incentives to be cautious as not. Again, the cues are so complicated. The doctors inhabit a world - as former Flyers coach Ken Hitchcock once said - where they are dealing with elite athletes who make a lot of money and who don't make the same decisions as normal people when it comes to injuries. They are dealing with people whose personalities make them risk-takers and envelope-pushers, and whose bodies are so strong and so well-developed that their nature is to compete, to be first, to get back from whatever ails them before the next guy might.

So, they are always seeking the latest treatment. It can be something as mundane as low-light laser therapy, which, in theory, increases blood flow to an area of the body to promote healing. "But whether it works or not, we don't know," DeLuca said, laughing. "A lot of these new things that we have available to us, we don't know if they work. We know it can't hurt the athlete, but we just don't know if it works. If it has a psychological effect, or a placebo effect, that's fine, too."

In his time as a team physician, Ciccotti says that the surgical technique that has come the furthest is Tommy John surgery on the ulnar collateral ligament. For DeLuca, it has been the advancement in surgery to repair the torn ACL in the knee. But he adds to the process with an aspect of the latest wave of therapies, PRP: platelet-rich plasma.

What happens is, some of the patient's blood is drawn in the operating room and put into a device in which it is spun around until it forms a clot. Then, that clot is used during the surgery on the knee. Sometimes the ACL graft is bathed in it before being inserted into the knee. Other times, the clot is sewn onto the graft before it is put in. Some studies have shown that it decreases healing time.

In some tendon injuries, stem cells now can be harvested from a person's pelvic bone to help promote healing. Fewer and fewer metal screws are being used now on repairs, replaced instead by bio-composites which are made partly from human material and which eventually incorporate into or are replaced by the surrounding bone.

"It's so interesting how our treatments of injuries, particularly our surgical treatments, have moved toward really trying to recreate normal anatomy and how to enhance the biology of healing," Ciccotti said. "In the past, when ACL reconstructions were done, in retrospect, these very odd, bizarre procedures would be performed where you would shift something out of its normal place to try to hopefully stabilize the knee. Then we moved toward the idea that we actually should put something back in that was like what was there before."

The theory with all of these techniques is simple enough: Body, heal thyself.

But what about pain?

"We don't give narcotics to anybody so they can play - that, we don't do," DeLuca said. "Anti-inflammatory medicine, yes . . . The NFL and Major League Baseball have made it easier on us now because we are not allowed to travel with narcotics - the DEA said we're not allowed to do that anymore. So there isn't even any temptation.

"Novacaine? I think there are some indications for it, where it is safe. Do we inject it into a knee joint? Absolutely not. The only joint I will do it is into the AC joint, up here," he said, pointing toward his clavicle. "It's safe and there's been no studies that show any downside to it. It doesn't shorten someone's career or lead to any other injuries."

Nevertheless, reporters who have been around the business have heard stories for decades. Both Ciccotti and DeLuca, though, insist that they are just that, old stories.

"The perception in the past, of doing the injections and just getting the ballplayer out on the field as quickly as possible - that just does not happen anymore," Ciccotti said. "That is not a reality. Certainly, from a medical standpoint, team physicians - I feel very strongly about this - treat athletes who are our patients. They're elite-level athletes, but they're our patients. We make decisions based upon what is best for them as a person and an athlete. We always try to meet their short-term goals, which is to get back on the field as fast as possible. But there also are long-term goals, what is best for their career and their life. Team physicians make decisions with that in mind.

"There are very few instances where you would give an athlete an injection just to get them out on a field. The athletes have a better sense of it now, too, whether it's their own education or their agents or the Internet."

They likely have a better sense of how to cheat, too. Ciccotti said he would give his anti-steroids talk to players all the time, pointing out all of the side effects. But in some cases, he said, "It might have fallen on deaf ears."

DeLuca said he has said things to players whom he suspected of using a performance enhancer.

"You know what? I have said something, but almost as a joke, just to see their response," he said. "Like, 'You've got to get off the stuff,' and they look at me. But I've never heard somebody admit it. They never admit to it. But I've seen some athletes who I thought, and they did test positive."

And all the while, they keep getting bigger and faster. There are common football injuries today - such as a torn biceps - that you never saw 20 years ago. DeLuca says you would be shocked at how small a biceps tendon is compared with some of the biceps he sees.

"I'm always amazed, looking at the size of these guys," he said. "When I go to the combine every year, I see that they're getting bigger, faster and stronger. We know from biomechanical studies that our bones, ligaments and tendons can only take so much stress before they break or give. At some point, we're going to get to the point where we see a lot more injuries."

But not yet, DeLuca said.

"We might be approaching some limits," Ciccotti said. "But I'm sure if you would have asked the same question 10 years ago to team physicians, they would have said the same thing - and look at how far the athletes have come."

He said it with almost a sense of wonder.