Ep 205: Returning to college sport after ACL reconstruction, with Dr Cortez Brown

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor in chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. College sport in the US is full of young people sometimes chasing promising careers in sport. So when it comes to a serious,

[00:00:30] injury like an ACL tear, how many of these young athletes return to the collegiate level to compete? My guest today led a team that's done the hard yards of synthesizing all the available data to find an answer for us. Dr Cortez Brown is a junior orthopedic surgery resident at the University of Pittsburgh Medical Center. During Dr Brown's time in medical school at Florida State University, he collaborated with athletic trainers and sports medicine surgeons, which sparked the idea for the work he's sharing with

[00:01:02] Dr Cortez Brown, JOSPT Insights. Dr Cortez Brown, JOSPT Insights. Thank you so much. Thanks for having me. Today we're talking about something that's pretty close to my heart. I know it's close to your heart and it's definitely important and close to the hearts of JOSPT listeners. And that is supporting college athletes to return to sport and perform at their best after an ACL injury. Why don't we start by setting the scene for people who might not know about college sports in the US as well.

[00:01:31] Dr Cortez Brown, JOSPT Insights. How many athletes participate in college sports? What sorts of injuries do you typically see? And then let's talk a little bit more specifically about ACL injuries in college sport.

[00:01:42] Dr Cortez Brown, JOSPT Insights. In the States, the primary association for athletes, for college athletes is the NCAA, so the National Collegiate Athletics Association. Within that association, you have more than 1,200 or roughly 1,200 schools, so colleges and universities. And then within those colleges and universities, you have more than 500,000 college athletes. Division I schools are the ones we see often on TV. This is Oregon, University of Alabama, Florida State, et cetera.

[00:02:10] This is the highest level, the more well-known, the schools that bring in the more revenue. As you progress from Division I, Division II to Division III, it's more focused on the holistic student athletes, less well-known. And these athletes are more likely to go into a non-athletic career after college.

[00:02:31] I was a proud Division III athlete playing football and running track at the University of the South in Tennessee.

[00:02:40] And there's a scholarships level involved here as well. Cortez, can you tell us a little bit about how the scholarships work when it comes to those different divisions?

[00:02:48] From lower to higher, Division III, you don't have any scholarships. And Division II and Division I, there are partial and full scholarships as well available.

[00:02:58] It's been so interesting to me as an outsider, learning more about the college sports system. There is so much money tied up in college sports to the point where often, say, college football is a bigger and more nationally recognized competition than, say, the NFL.

[00:03:14] Oh, there's so much money, especially now with the addition of the NIL or the name, image and likeness, right? There are a lot of companies and organizations that would love to use the celebrity, if you will, or the name, image and likeness of these amazing college athletes.

[00:03:31] Even March Madness, time in which basketball is king, if you will, and sports, and that's a lot of revenue, a lot of revenue financially coming in that's, you know, supported by the college athletes and obviously the universities and institutions that are around it.

[00:03:44] I raise the scholarships and the financial side because I think it's important to understand that context, particularly when it comes to injury and the medical support around college athletes.

[00:03:58] There's very specific rules around serious injury and some allowances that are made in the college system.

[00:04:06] I'm thinking about the redshirt year that might sound a bit different to people who are not embedded in college sport.

[00:04:12] Can you tell us a little bit about the system that allows for college athletes to return after a serious injury, given that their time in college sport is limited by being in the education institution?

[00:04:26] So just give us a bit of that picture, Cortez, so that people who are not so familiar with the college system can understand what the injuries, particularly serious injuries like ACL,

[00:04:36] what the implications of those can be for athletes who are particularly close to the end of their typical college season or college period.

[00:04:46] Yeah, so I think on a 30,000 foot view, you know, a lot of folks do not finish college or university in four years.

[00:04:54] Sometimes it takes five years, right?

[00:04:56] And so using that theme in terms of athletics, if you were to have a severe injury, say your freshman year, and the team would like to allow you to stay on,

[00:05:07] the team and also the institution can allow you to have a redshirt year.

[00:05:10] So it gives you that extra year to do rehab, to get your strength back and then come back and still have, you know,

[00:05:17] the remaining four years, if you will, of eligibility to play the sports you were recruited and retained to come play.

[00:05:24] So this is important.

[00:05:26] I think all of this is important lead up because now let's get to talking about our main course here,

[00:05:31] which is returning to sport after ACL injury.

[00:05:34] You've just published in JOSPT and people can find a link to the article in the show notes of today's episode.

[00:05:41] A systematic review looking at return to play specifically for college athletes after an ACL reconstruction.

[00:05:47] So Cortez, what are the main take-home messages?

[00:05:51] What are the main highlights of your or headlines from your systematic review?

[00:05:55] The couple of things I wanted to have people take away is, you know, when we published our data,

[00:06:02] there were only nine articles available that had NCAA specific information, right?

[00:06:08] And of those nine articles, we're looking at 745 athletes, right?

[00:06:13] So we mentioned earlier that there are more than 500,000 athletes within the NCAA.

[00:06:19] And of the nine articles, 100% of the athletes are from Division I sports.

[00:06:25] And so that leaves about roughly 70% of the NCAA void of understanding.

[00:06:31] Now, after we published our article, there's a lot of great research coming out and folks are, you know,

[00:06:37] not publishing on Division II, Division III.

[00:06:38] So I love that.

[00:06:40] And so I think for us as well, you know, we found an 84% return to play proportion, right?

[00:06:46] And some factors that we found were if you have a scholarship versus not having a scholarship, right?

[00:06:52] You were more likely to return to play.

[00:06:55] And that was really for the women's soccer and men's football.

[00:06:58] If you had more eligibility remaining, kind of going back to your point about having a redshirt year, if you will,

[00:07:03] or if you're just maybe a freshman versus a senior, the freshman is more likely to return to play.

[00:07:09] If you are a starter, if you're seeing the field or you're seeing the court more likely versus someone who's on the bench,

[00:07:14] you're more likely to return to play.

[00:07:16] We don't know the why behind those things.

[00:07:18] We could speculate.

[00:07:19] But those are the things we found.

[00:07:21] And also the graft type.

[00:07:23] For many studies in the past, especially on the orthopedic surgery side of things,

[00:07:26] we've come to the consensus that autograft is probably more preferred over an allograft.

[00:07:30] And that's kind of supported by our data as well.

[00:07:34] Now, Cortez, the really cool thing about the podcast is that it gives you a license to speculate

[00:07:40] much more than what you have in the systematic review publication.

[00:07:43] So let's pick up on this idea of what might sit behind the reasons why people are not going back to sport

[00:07:50] or explain some of these relationships that you mentioned.

[00:07:53] I think for me, the starting point is given that we know return to sport is really complex,

[00:07:58] especially for people who have had a serious injury.

[00:08:01] It's not surprising to hear that there were differences in whether you're a starter or a non-starter

[00:08:06] or whether you have a scholarship or not.

[00:08:08] So tell us a little bit about what you and your team have discussed about this.

[00:08:12] And I'm sure in your work at Pitt, you're immersed in this world all of the time

[00:08:16] and hearing from lots of different colleagues and having discussions with colleagues about what this means.

[00:08:21] Being an athlete or a collegiate athlete, it's not a monolith, right?

[00:08:26] There are different versions of people, right?

[00:08:28] The freshman year, you may not be the senior year.

[00:08:31] If also, if you're at a powerhouse or a power four institution versus a smaller, more liberal arts place,

[00:08:38] maybe your interests are different.

[00:08:41] And so that will impact our bottom line of return to play, right?

[00:08:45] So we have to, I think, focus on the athlete themselves as opposed to the more general return to play rate

[00:08:53] or what are these factors.

[00:08:54] We should kind of really tailor it based on who the person is.

[00:08:58] And so I think right now there's just a lot to learn more about as we move forward within this field.

[00:09:04] And I think when we were sitting down and figuring out, wow, there are only nine papers out right now

[00:09:09] specifically for the NCAA and there aren't that many factors and variables, if you will, that are discussed,

[00:09:17] what's missing?

[00:09:18] And I think, well, mental health has not been talked about a lot inside of NCAA

[00:09:22] and that's something that we would love to explore and love to learn about.

[00:09:27] Let's talk a little bit about how these numbers compare to other competitions,

[00:09:32] other contexts outside of the NCAA.

[00:09:35] The return to play numbers, you gave us the headline number was 84%.

[00:09:39] And so let's talk about how that compares to what's already out there for other sports or for other athlete groups.

[00:09:47] Back in 2014, Ardern et al, BJSM, they published their paper.

[00:09:53] You know, they published a 81% return to play for any level of sport, right?

[00:09:58] But to be more specific, right, for a competitive level, the number was 55%.

[00:10:03] So that tells me that return to play is not a monolith as well.

[00:10:07] It's a continuum.

[00:10:08] And that's kind of what we support.

[00:10:10] When you mentioned kind of other or comparative data, there are some folks from Tulane,

[00:10:15] Bailey Ross and company back in 2020 looked at football, okay?

[00:10:19] Looked at NFL, NCAA, and high school.

[00:10:22] And they found a return to play rate of 67%.

[00:10:25] And they had a sample size of roughly 1,800.

[00:10:28] Perinelli, they were over the pond for professional soccer back in 23.

[00:10:33] Their return to play was 92%, right?

[00:10:35] So again, guys, ours is 84.

[00:10:37] So we're still in that ballpark.

[00:10:39] And Juan Chucu over, I think at HSS, published NBA return to play after ACL,

[00:10:45] and it was around 89% back in 2017.

[00:10:47] So we're still in the plus or minus range for return to play.

[00:10:53] But again, I think diving deeper into the factors and variables that are causing that

[00:10:59] is where we have a lot of room to gain and to learn.

[00:11:03] Yeah.

[00:11:04] And I think your point, Cortez, about the different divisions in the NCAA and Division I,

[00:11:10] you've got a lot of support and probably a lot more pressure on you to get back to your

[00:11:16] almost professional looking from the outside looking in.

[00:11:19] It looks like a professional setup.

[00:11:20] And in many cases, the facilities are better than in professional sport.

[00:11:24] So I imagine there's a lot more pressure on you as an injured athlete to get back

[00:11:28] to that competitive sport.

[00:11:30] Whereas if you're in Div 2 or Div 3, maybe it's different.

[00:11:34] Maybe you decide, look, I'm never going to make a career out of my sport.

[00:11:37] I love playing my sport or I love being active.

[00:11:40] So I'm going to change sports or I'm going to do something different.

[00:11:43] So what's your gut feeling on this, I guess, explaining some of the discrepancies in the

[00:11:49] numbers?

[00:11:49] As you say, in some of the work that our group had done, we'd found that 55% number across

[00:11:55] everything.

[00:11:56] My suspicion, though, is that there's a lot more context that can explain some of the discrepancies

[00:12:03] in these numbers.

[00:12:04] So what's your sense of it?

[00:12:05] With modern sports, we're talking about a time now where NIL is here, name, image, and

[00:12:11] likeness.

[00:12:12] And as a collegiate athlete, you're essentially a paraprofessional or professional athlete.

[00:12:17] And so now there is a buy-in.

[00:12:20] There is an incentive to return.

[00:12:22] You have people who have invested financially into your athletic ability and activity.

[00:12:28] NIL is typically seen for the best of the best athletes.

[00:12:32] So that's going to go stay into the Division I.

[00:12:34] So I'd imagine if you were to have an injury in maybe a Division I team or sport and you're

[00:12:43] receiving NIL funds, you're more likely to return to play.

[00:12:45] When you compare yourself to a Division III athlete who was playing football and running

[00:12:51] track but was pre-med and tore his hamstring seven times, you're more likely to say, I think

[00:12:58] I'm going to focus on the MCAT.

[00:12:59] But I think I'm going to maybe take my hand at studying some biochemistry more than trying

[00:13:07] to figure out how to do some essential training of my hamstring.

[00:13:11] Which was then...

[00:13:12] It's interesting when we bring our lived experience to research, isn't it?

[00:13:15] It helps.

[00:13:16] It just gives that different perspective of how to interpret the data.

[00:13:20] Exactly.

[00:13:21] Aside from anecdotal knowledge, I think, yeah, times have changed from 2015 when we were reporting

[00:13:26] data as well.

[00:13:27] Even from back when we were analyzing data in 2017, 21.

[00:13:31] One, you know, it's a different time and we have to really be dynamic as researchers and

[00:13:36] to figure out, okay, what is happening now with the scene and how can we help?

[00:13:40] Because at the end of the day, our purpose is to do what's best for the athlete.

[00:13:44] Whatever they want to do, our job is to help facilitate that as a team.

[00:13:48] Definitely.

[00:13:49] That's a really great message and a good reminder, Cortez.

[00:13:51] Thank you.

[00:13:52] It's a nice segue, I think, to talk about researchers.

[00:13:55] You mentioned there were only nine studies and 750-odd athletes whose data were eligible

[00:14:02] for your systematic review, which, as you say, is a drop in the bucket when you look at

[00:14:06] the overall number of athletes who participate in the NCAA at the NCAA level.

[00:14:11] What's missing from the research?

[00:14:13] Aside from simply numbers, what else are we missing, either for clinicians to know about

[00:14:20] when they're reading the research or if you're giving advice to people who are thinking

[00:14:24] of doing more research in this area?

[00:14:26] What do you see is missing?

[00:14:27] Where are the gaps that we need more research to better understand what's going on and then

[00:14:31] to ultimately, as you say, better support college athletes?

[00:14:35] For me, I would say three things.

[00:14:37] One is return to play is a continuum.

[00:14:40] And number two, I would say injury or severe injuries, we'll talk about ACLs, but it is

[00:14:47] multifactorial, right?

[00:14:48] It's not just the autographed, right?

[00:14:51] We love that as surgeons, but there's the mental health aspect.

[00:14:55] The psychosocial aspect is very important.

[00:14:57] And we're now getting some treadway.

[00:14:59] We're now being involved.

[00:15:00] We're really got to have that as well.

[00:15:02] And you got to have more than just one person on the team to help this athlete get back.

[00:15:07] It's a multi-faceted approach.

[00:15:09] Many folks should be involved in care for these athletes, where it's the orthopedic surgeon,

[00:15:13] it's the physical therapist, it's the sports psychologist, it's the coaches, it's the player

[00:15:18] themselves more importantly, all these things matter.

[00:15:21] And so we have to learn that going forward, I think.

[00:15:25] Even kind of getting more into the data, strength deficits after ACL.

[00:15:32] Postoperatively, it's very common for athletes to have quad strength deficits.

[00:15:36] And some people are saying now that it's two years postoperatively that you may now get to

[00:15:42] a point where there is a balance between the contralateral and insolateral quad, and that

[00:15:47] can decrease your chance of re-injuring your knee.

[00:15:50] But could you imagine asking an athlete, an elite athlete, hey guys, listen, I know you

[00:15:55] tore your ACL, we just fixed it, and you've been doing a lot of PT, but I think I'm going

[00:16:00] to give you another two years.

[00:16:02] They're going to go somewhere else, I believe.

[00:16:04] I think you're right.

[00:16:05] It's very hard to convince anyone to do that, I think.

[00:16:09] You know, but I know it's important to understand that.

[00:16:13] And there's a study that published the risk of re-injuring your knee within the six to

[00:16:22] nine month window.

[00:16:22] It's like four times more likely compared to, for the athletes who are level one sport

[00:16:28] athletes, right?

[00:16:28] That's the pivoting, the cutting athletes, right?

[00:16:31] If you try to return back quicker, you have a four time chance to re-injure your knee compared

[00:16:37] to those who are non-level one sport athletes.

[00:16:40] So let's not confuse division one from level one.

[00:16:42] Level one is saying, you know, you can be in division one through three as level one athlete

[00:16:46] because you're cutting and jumping.

[00:16:47] But the intense athletes who require their ACL, you know, you have to really take the time,

[00:16:54] right?

[00:16:54] It kind of goes back to our theme of alternative play is a continuum.

[00:16:58] Cortez, I can't pass up this opportunity without asking you about your experiences as the next

[00:17:05] generation of sports medicine clinician.

[00:17:07] You're finishing up your training at Pitt.

[00:17:11] How do you balance all of the knowledge and all of the skills and the stuff that you are

[00:17:17] learning as a clinician, as a sports medicine clinician with keeping on top of research,

[00:17:22] doing research yourself?

[00:17:23] How do you find, how do you, how do you put all of those pieces together and I guess make

[00:17:28] that work for you in doing your best job as a clinician?

[00:17:33] Yeah, I think the most important thing for me is mentorship, right?

[00:17:37] And now we have, I'm standing on the shoulders of giants when it comes to sports medicine here

[00:17:42] at the University of Pittsburgh and down at Florida State University in the Tallahassee Orthopedic

[00:17:47] Clinic.

[00:17:48] You know, here at Pitt, you know, we have our, our chair, Dr. Michaelis Hogan, who is

[00:17:53] supportive of, you know, being a research, researcher and a surgeon scientist.

[00:17:58] Okay.

[00:17:58] We have our program directors, Dr. Albert Lynn and John Fowler.

[00:18:02] We have the late and great Dr. Freddie Fu, who is kind of the reason why a lot of us are

[00:18:08] involved in this work.

[00:18:09] You know, I can, the list can go on.

[00:18:11] We have Dr. Jonathan Hughes and Volker Roussall, who are just amazing at what they do here and

[00:18:16] been great at assisting me.

[00:18:18] So I think mentorship is important and learning from them because they've been through this

[00:18:22] force that I'm going through now.

[00:18:24] They've been in residency.

[00:18:25] They've, you know, had the long 24-hour shifts and still got to study afterwards and

[00:18:30] showing us what to do and what not to do.

[00:18:33] And I think it's important for us to just learn from, from them and being in a space

[00:18:37] like the University of Pittsburgh, UPMC, where you have access to the abundance of resources

[00:18:43] available, the non, you know, orthopedic surgeons who add amazing addition to what we're doing,

[00:18:50] right?

[00:18:50] We have, you know, Dr. Ergang, who is chair of physical therapy here at Pitt.

[00:18:55] And, you know, without him, there's a lot of data and research that we would, we wouldn't

[00:18:58] have with an orthopedic surgery and sports medicine.

[00:19:01] And so the list kind of goes on.

[00:19:02] And so I think just my theme is it takes a team or it takes a village to do all of this.

[00:19:07] And I'm fortunate to be in a great village.

[00:19:09] The teamwork is so important, as you say.

[00:19:12] And for me, that's what makes it all the more worthwhile and makes me want to get up

[00:19:17] in the morning and work in a, in a wonderful team.

[00:19:20] As we wrap up, Cortez, you mentioned you're a surgeon scientist and that you work closely

[00:19:26] with the sports medicine team, which involves PTs.

[00:19:29] And as you know, a large chunk of JOS PT Insights listenership are PTs.

[00:19:35] How do you approach that teamwork with PTs?

[00:19:39] And how do you think about the sports medicine, sports PT relationship in supporting athletes?

[00:19:45] I think it's essential.

[00:19:47] I think the, the physical therapy, the sports medicine, athletic training trio is a requirement

[00:19:54] for success in helping folks return to sport, whether it's ACL, ankle sprain, whatever it

[00:20:00] may be, concussion.

[00:20:01] We have to be one unit and move forward and be dynamic and kind of be on the same page.

[00:20:06] It's just, I think it's just what's needed for the athlete.

[00:20:09] And if we have the mindset going forward every step of the way, the athlete is, will only

[00:20:14] get better, right?

[00:20:16] The care for the athlete will only get better.

[00:20:18] I've been fortunate enough to do work with Dr. Ergang and Pop Track here as well.

[00:20:23] Again, kind of the PT colleagues here at Pitt.

[00:20:25] I'm a supporter and an advocate of kind of a multidisciplinary team for sports medicine

[00:20:31] care.

[00:20:33] Bringing you back to the team is a great way for us to finish, I think, Cortez.

[00:20:37] Thank you for your support of sports PT.

[00:20:40] The future is bright for the sports medicine team, I think, when we, as you say, when we

[00:20:45] can work well together, PT, athletic training, medicine, and including our surgical colleagues

[00:20:50] in that team.

[00:20:51] And ultimately, we're trying to do our best for the athletes for whom we care.

[00:20:55] So thank you for joining me on JOSPT Insights.

[00:20:58] Thank you for having me.

[00:21:00] Thanks for the talks.

[00:21:01] And I've learned a lot from your work and moving forward, we'll keep on doing great things.

[00:21:10] Thanks for listening to this episode of JOSPT Insights.

[00:21:13] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

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[00:21:43] Bye-bye.

[00:21:45] Bye-bye.