Random Thoughts from a Restless Mind

Dear Coaches and Parents,

For more than 30 years I have had the good fortune to be a volunteer assistant coach for boys and young men playing football, basketball, and lacrosse, sports I played in high school and/or college. In this capacity I became very familiar with the particular dangers of concussions suffered while playing these contact sports. Indeed, one of my sons suffered a severe concussion as a high school lacrosse player, effectively ending his competitive career. I applaud the recent efforts being made at all levels of competition, especially in the area of gratuitous headshots in football, lacrosse, and hockey.

As a fitness coach for the last 10 years or so I’ve learned of another, all too common injury in sports, one that is disproportionally concentrated in the younger athletes: ACL tears in girls and young women. There is a veritable epidemic of ACL injuries in soccer, basketball, and volleyball. Girls are 4-6X more likely to tear their ACL playing these sports than boys. The numbers are quite simply appalling, and yet I hear not a word about this from any media source. Girls are being felled by this injury in droves but it seems no one is talking about how to prevent it.

Can anyone tell me why that is?

It’s not like this is a new phenomenon. A brief Google search turns up academic articles published in 1999. It’s also not as if these injuries are only of historical importance. The daughter of a friend was the third girl playing the same position for the same U17 soccer team for the same coach to suffer a non-contact ACL tear in 2015. Nor were they the only girls on that team so afflicted. When asked what changes had been made by the team or the coach in response to these injuries my friend shook his head. Crickets.

Can anyone tell me how this is OK?

The answer, of course, is that it is not OK. Not even a little bit. The causes underlying the increased risk to suffer an ACL tear in which a female athlete does not come into contact with another player are relatively well known. Studies have been done examining the way girls jump and land. As it turns out, girls tend to change direction and land with an outstretched, straight leg. Boys, on the other hand, do so with a flexed leg, reducing tension on the ACL.

If you watch girls running you can’t help but be struck by the valgus position of the knee when their foot lands on the ground; the knee is markedly inside the foot.  Girls tend to have stronger anterior muscles and therefore tend to be quad-dominant runners. They pull their upper leg forward through the contraction of the thigh muscles. Boys, on the other hand, are posterior chain-dominant runners, pulling their legs up through the contraction of their glutes and hamstrings. Without a strong posterior chain to counteract the effect of the quadriceps, the ACL is again under increased tension, magnifying the risk caused by knee position.

We know why the injuries occur, and as it turns out we also know how to prevent them, or at least reduce their frequency: teach young female athletes safer movement patterns, and put them in strength and conditioning programs that specifically train their posterior chain. If you see this type of training you will recognize it immediately: it’s how we train boys.

Can anyone explain to me why this is not occurring with young female athletes right now?

Even at the highest level of women’s sports we still see non-contact ACL injuries. For example, in 2011, 6 of the 21 members of the U.S. Women’s National Soccer Team had suffered an ACL tear at one point in their careers. However, in more recent years there has been a decrease in these injuries at the professional level because teams are training their female athletes in better neuromuscular recruitment patterns, which creates sounder movement. Athletes are doing strength and conditioning programs that emphasize strengthening their glutes and hamstrings. Hence, we are seeing dramatically fewer ACL tears at the highest levels of women’s sports. There is no way to justify not doing the same thing for girls early in their careers.

Proven templates already exist to do just this. Simply utilizing the off-the-shelf PEP program of stretching and plyometrics has demonstrated meaningful decreases in the incidence of ACL tears. Rather than use such a basic program when it comes to high quality movement patterns, why not look to someone like San Francisco’s Dr. Kelly Starrett? The founder of Mobility WOD and author of “The Supple Leopard”, Dr. Starrett is a consultant to dozens of collegiate athletic departments. He recently took over training for an elite 150-member girls volleyball program with the specific aim of reducing ACL injuries in those athletes. His teachings on proper movement mechanics are peerless, as a quick perusal of his book will attest. Perhaps we should be looking at what he is doing.

Jeff and Mikki Martin have been training kids in Southern California, the epicenter of youth soccer, for well over a decade. Their protocols include meticulous attention to the type of mechanics taught by Kelly Starrett and emphasize the importance of strengthening the posterior chain beginning around age 10. As the developers of the original CrossFit Kids program and more recently founders of The Brand X Method™, they have trained hundreds of young girls who play soccer without a single one of their athletes suffering an ACL injury while under their care. They arguably have the longest track record of successfully and safely training youngsters. Perhaps we should be looking at what they are doing.

One thing is for sure: it is not OK to continue with the status quo. Simply doing what you have always done is nothing less than condemning a high percentage of your girls and young women to suffering an ACL tear and all that goes along with it. The nature of the sports in which we see an epidemic of concussions is such that the only way to prevent them is not to play those sports. This is not the case with non-contact ACL tears in soccer, basketball, volleyball and other sports played by girls. Prevention is possible through the institution of training programs that emphasize the teaching of new, safer movement patterns, as well as strengthening the muscles of the posterior chain.

I’d like to propose a 3-part solution to this problem. First, we would like to offer training to coaches in how to teach better basic movement patterns. One of the most fundamental goals for those of us who utilize The Brand X Method ™ to train kids and teens is to create a cadre of coaches who can do this. We hope that this can become a core part of in-season team training. Secondly, we wish to make available our coaches, and coaches who share our concerns and philosophy, to train your athletes to have a stronger posterior chain. The data supporting the inclusion of weighted squats, deadlifts, and power cleans both in season and out of season is compelling. Our coaches are experts in teaching the proper mechanics involved, and our athletes progress in a safe and measured fashion.

Lastly, the data supporting the inclusion of full-body functional movements executed at relatively high intensity is equally compelling when it comes to not only injury prevention, but also in developing stronger, faster, more durable athletes. The Brand X Method ™ is a proven program that emphasizes proper mechanics and safety. It is the latest version of a program that has been creating highly athletic youngsters and teens for more than 10 years. This type of physical fitness directly translates to more capable and confident athletes in all of the sports mentioned. At CrossFit Bingo our Alpha X Youth Athletics program is available to train your athletes all year round, either individually or in team settings.

It’s time we all start talking about these non-contact ACL injuries in girls’ sports, just like we have been talking about concussions in boys’ sports. Parents should be asking what is being done on behalf of their daughters. Coaches should be committed to stopping the epidemic of non-contact ACL injuries in their female athletes.

We can help.

Darrell E. White, M.D.

Co-Founder, CrossFit Bingo

Co-Founder, Alpha X Youth Athletics

Transparency is the new buzzword in medicine. Systems should be transparent with regard to prices, if not costs. Doctors and other providers of healthcare services should publish their costs and fees, too. Various ratings and measurements have been developed in an attempt to measure that nebulous and elusive entity “Quality”. Calls have been made for transparency here as well; hospitals, doctors, and others are browbeaten to release any and all manner of quality measurements so that we might create something one could call an “informed patient”.

The first, and therefore most important challenge in the quest to measure quality is to agree on a definition of just what quality is. Like all rational discussions the first order of business is to agree on terms and the terms of engagement.

Let’s take the question of evaluating the quality of an individual surgeon. What are the salient metrics? Are we concerned with only outcomes? You know, success rates, complication rates, stuff like that. Is there more to the measurement? Should we be concerned with EFFICIENCY, the ability to obtain high quality outcomes in a more timely manner? How about VALUE, the soft and difficult to measure combination of quality and COST? In this day and age of “economic credentialing” in which doctors, hospitals, and other providers are held responsible for the cost of care, not only on an individual basis but also a societal one, it seems as if value is an inescapable aspect of quality, at least in the eyes of our government and the people who actually pay for healthcare.

Quality measures will be different for surgeons of different stripes; we will want to evaluate different complications and their rate of occurrence for an ophthalmologist versus, say, a cardiothoracic surgeon. Even similar adverse events like infection rates will have a different meaning across specialties. One classic example of a surgical complication is post-op infections. From my limited reading about heart and chest surgery it appears that the post-op infection rate is around 1-2%. This would be scandalous in eye surgery where the post-op infection rate is 100X lower, closer to .01-.02%. Stuff like this should be fairly easy to uncover, or at least you’d like to think so. It turns out that even this metric is rather hard to come by since multiple doctors will participate in the treatment of post-op infections, and literally no one offers up these stats uncompelled. Similar issues apply to specialty-specific complications (vitreous loss, graft leak) for similar reasons.

Right away the difficulty of measuring quality is obvious: even the simple quality measures appear to be something other than simple to discover right now.

Outcome measures are even trickier. Since I know eye surgery best let me stay in that arena and use cataract surgery as my example. For our discussion let’s assume that we have magically been granted unfettered access to every eye surgeon’s charts (and that they are all legible, and that they all contain the same basic information). It should be a rather simple proposition to draft meaningful criteria–let’s say “how well do the patients see after cataract surgery.?”  Would that it were so. The answer to that very simple question–how well do you see after surgery–depends on several variables, and further varies if you ask the question slightly differently. How much improvement did the patient achieve compared with pre-op? How fast did the improvement come? How well does the patient see without eyeglasses?  Is the patient more or less dependent on eyeglasses following surgery? What level of vision constitutes a success? Does the surgeon get the same results with complex cases?

I imagine these issues are not specific to ophthalmology. I can see the same types of questions and complexities in orthopedic surgery, for example. Think about hip replacement–along with cataract surgery and cardiac bypass surgery, hip replacement is arguably one of the most significant medical developments when we think about the quality of life enjoyed by an older person. What defines success in hip replacement? How long do you allow for success to occur for it to be deemed one for the  “win” column? Do we give bonus points for speed in the OR, both from a patient’s standpoint and an economic one? How about a surgeon’s ability to achieve the same level of success in a thin 70 year old tennis player and an obese, cart-riding smoker?

Seriously, if docs can’t come to an agreement about what constitutes “quality”, how can we in good faith measure it? Furthermore, if we WON’T define it we have no one but ourselves to blame when some nameless, faceless 30 year old sociology major in D.C. does it for us.

Nobody asked me (again), but as long as I’m here let me offer up a 3-part proposal to measure and promote quality using surgeons as a theoretical template. Let’s start with a thought exercise borrowed from CrossFit. Fitness training using the CrossFit methodology involves high intensity exercise while trying to maintain near-perfect movement and form. One is shown three targets from a shooting range. The first has random bullet holes all around the bullseye, the second has every shot dead-on perfect, and the third has 95% of the shots within the center bullseye and 5% on-target but not perfect. Which one represents the most desirable CrossFit training strategy?

In CrossFit the answer is “C”, 95% accuracy with the misses still close because this represents the optimal combination of form (accuracy) and intensity (speed). Is this directly applicable to surgery? Well, that depends on how far outside the bullseye the misses land, doesn’t it? And in surgery I think we also need a more accurate measurement of intensity; we need a clock. Speed matters, from both a medical standpoint and a financial one. The shorter a surgery lasts while still hitting the target, the less physically and mentally taxing it is for the patient, and the fewer costly resources (OR time, staff time, doctor time, supplies, etc.)  you are consuming during surgery. All things being equal, the surgeon who achieves the desired outcome faster without increasing her complication rate is the better surgeon.

Put surgeons on the clock.

A successful outcome must be explicitly defined for each common surgical procedure. Pre-operative factors that reduce the likelihood of success should certainly be taken into account (e.g. a morbidly obese cart-riding smoker and hip replacement), but care needs to be taken so that a measurement can’t be gamed (two guttata do not constitute a corneal dystrophy and increased likelihood of swelling) in order to work with a lower standard. Surgical societies should show some spine and make a call, define what constitutes a high-quality outcome, regardless of the howling that will emanate from the mediocre and the incompetent. It’s gonna happen anyway, and physicians making the call would be orders of magnitude better than MBA’s and philosophy majors.

Lastly, quality should be measured, publicized and praised, and those surgeons (and other doctors) should be explicitly rewarded with as many cases as they can (or wish to) handle. They should also be paid more. Once we decide what constitutes quality we can measure it and publish the data. People will understand this, just like they understand the data in a box score. Why is it so OK for the baseball player with the highest batting average or lowest ERA to be paid more based on his success, yet somehow the most efficient surgeon who has the best outcomes is labeled a “money grubber” who must somehow be doing something wrong if he is also very busy? We want that high batting average guy at the plate in the 9th inning of a tight ballgame, and we pay him more because of his higher quality outcomes. Why aren’t we doing the same thing with surgeons? The very least we can do is stop accusing surgeons of being successful!

It’s time that we apply basic theories about quality to medicine in general and surgery in particular. Indeed, it should be easier to do it with surgeons. Make a call–define a successful outcome. Pull out a stopwatch. Faster, more efficient surgery is less expensive and generally less taxing physically for patients. Once the data is available be transparent and publish the results. I know what Miguel Cabrera is batting this year; my patients (and potential patients) should know my “batting average” in the OR. While I hold out little hope of being heard on this last point, uncountable articles support the benefit of the carrot at the expense of the stick when it comes to promoting excellence. Higher quality should beget higher pay. At the very least we should stop with the assumption that the busy surgeon is somehow “getting over”, guilty of somehow gaming the system (eg. doing unnecessary surgery) until and unless proven innocent.

She may just be better.