How to Treat Chronic Sports Injuries Using Minimally Invasive Methods [transcript]

Written by Christopher Kelly

Feb. 23, 2019

[0:00:00]

Tommy:    Hello and welcome to the Nourish Balance Thrive podcast. I'm here on the Husky Stadium with Dr. Kim Harmon who is Head of Sports Medicine at University of Washington and professor of Family Medicine and Orthopedic Surgery and Sports Medicine. Thank you so much for taking the time to join me.

Kim:    It's great to be here, thanks.

Tommy:    So, today, I'll mainly want to talk to you about nonsurgical approaches to sport-related degenerative joint and tendon problems because that's something you have considerable experience in. Before we get into that, maybe you could talk a bit about your background and training and what it is you do from day to day.

Kim:    I'm a primary care sports medicine doctor which means that I did family medicine residency and then did the sports medicine fellowship, so that's extra training in sports medicine. I've been here at the University of Washington for 20 years and have an interest in keeping people on the field, specifically overuse injuries, tendinopathy and arthritis, early arthritis.

 

Tommy:    That's something that we get a lot of questions about, including some of the treatments that you use like platelet-rich plasma which hopefully we'll really dig into. Can you talk a little bit about how these injuries or problems occur? What are the end of the line processes? How do they happen over time?

Kim:    I think it's easiest to divide it between tendons and arthritis. With tendons, tendons are big cables made up of a bunch of little wires, and we're always breaking that wire down. The body is designed to make new wire. So, you break down a muscle on purpose to make it stronger, a tendon really should respond to the stresses that you put on it.

    Sometimes that tendon isn't as biologically active as muscle or even bone and so sometimes that process breaks down and so the tendon doesn't actually have time to recover and so it gets into this chronic, degenerative phase. Sometimes it, after a while, just gets tired and decides to quit trying to fix itself, and that's where you get into the problems of chronic tendinopathy.

    This is a little bit different than if you go out and you play tennis or volleyball or basketball, whatever, and you overuse something to the point that there's an inflammatory response which is the first stage of healing and then your body fixes it. It's like your own intrinsic healing mechanism poop out and doesn't work.

Tommy:    What underlies some of that in terms of how that chronic tendinopathy process comes to being? Is it the wrong kind of loading, is it problems with blood flow or nutrient delivery or all of the above?

Kim:    Yeah, I think it's more like all of the above and even more basic than that, each of us probably has an inherent tendon ability to recover and so we'll see people that really get into a lot of problems with tendinopathy from one place to the other place. It's probably just that they don't have as good a tendons as the next guy, so they can thank their parents for that.

Tommy:    Do you have any way of figuring out who might be at greater risk for that kind of stuff?

Kim:    Not right now but I think at some point we will be able to look at some of these genomes and see who are these people that are more likely to develop tendon problems and then that might inform the way that you train.

Tommy:    What kinds of problems are you seeing in the clinic in terms of the day-to-day people who are coming to your practice?

Kim:    I see a lot of runners with chronic Achilles tendinopathy and in that same runner category, we also see proximal hamstring tendinopathy, so right there where the hamstring attaches into the rear end, that can be a big problem too. We see patellar tendinopathy or in the knee particularly with jumpers and then a lot of shoulder problems. The plantar fascia is really sort of a flat tendon and so we see that a lot.

    Then we'll see smaller tendons too like some smaller tendons in the foot and the ankle, the peroneal tendons, the posterior tibial tendons, the elbow tendons both on the inside and the outside, so that's tennis elbow and golfers' elbow. So any place that you've got a tendon which is, of course, the structure that hook in the muscle to the bone, you can get into problems with overusing it and then we like to try and help you out.

Tommy:    What about the joints, do you ever see separated tendons out from joint problems, but are you also seeing various [0:03:56] [Indiscernible], osteoarthritis and stuff like that?

Kim:    Yeah. We most often see knees and hips, but we also see ankles and shoulders. In golfers, we'll sometimes see the little joints in the hand, but knees and hips are the big issue that we see here in the sports clinic.

Tommy:    Maybe talk about how you approach, from the assessment, somebody coming in, to then thinking about how you might intervene as, say, the severity of the disease increases.

Kim:    When people first develop problems with tendons, the first thing that you want to look at is, actually, have they had enough time to have the body recover itself. Mother Nature is a pretty powerful thing, and sometimes it's just a matter of you just needing to give your body a chance to catch up to what you've done to it, and so to make sure people that have had adequate rest, that they're training adequately and that sort of thing.

    You can try things like Tylenol and the anti-inflammatories. By the time people get to see me, usually the issue isn't acute inflammation that the anti-inflammatories will affect. They can be helpful but they tend to be more just pain relievers and aren't actually doing anything to fix the problem.

    We might send people to the physical therapist who will look more at maybe loading the tendon in a specific way, so trying eccentric exercises using the muscle as it's elongating. When you do that to a tendon, it appears that that causes the tendon to make growth factors and so that can stimulate the healing and repair. So doing something like eccentric exercises is probably a first step when you get to the doctor if you haven't tried that already.

[0:05:30]

Tommy:    Can you do that for things like the patella fascia, is it possible to do eccentric loading?

Kim:    Well, the fascia is a fascia because it's not really attached to any muscles and so that is actually the one sort of thing that you can't really do eccentric exercises for. Some of the other tendons it's more challenging to do, but you can figure out how you use that muscle to make it contract and then to make it lengthen. You want to have it lengthen against tension and that seems to promote growth factors.

Tommy:    That's actually the step that I think most people, both those first steps you mentioned, seem to be the ones that people miss. First is that they don't actually give enough time for the body to heal and then if they do, if they give in, say, Achilles tendinopathy in runners, you tell people to do those resisted calf raises or eccentric loading calf raises or something like that to work with the Achilles tendon, and that's always something that people never really try that hard to do, that it's something, oh, well, it's not really a problem, I don't really want to fix it. That seems to be where most people get stuck.

Kim:    You want to do the first things first. Once you get to the point where your tendon has broken down, it takes six to 12 weeks to grow a new tendon, so it's not going to fix itself overnight, but you do want to give eccentric exercises a trial. Other things that are more early intervention in terms of tendon issues are some things like either Astym or Graston which are physical therapy techniques where you basically take two rolls and rub it on the tendon real hard so that can actually stimulate the tendon to heal, and it's the same principle as the eccentric exercises. It's putting some pressure on the tendon and causing it to excrete growth factors.

    In Europe and Canada, they use extracorporeal shockwave therapy which is blasting sound waves at the tendon, and that's that same mechanotransduction principle that can cause a tendon to start this healing process. We don't find that very much here in the United States because insurance companies don't pay for it and the equipment for somebody to buy it is too expensive to get a good return on investment. So even though that seems to work in Canada and Europe, apparently here it doesn't, here in the United States, or it's less available. So those are early things that you can do.

    The other step that gets skipped a little bit is probably something called nitro patches. Those are nitroglycerin patches that are an old blood pressure medication. We don't use it very much for blood pressure anymore, but nitrous oxide is a growth factor, so on tendons that are nearer to the surface like the Achilles tendon, on patellar tendon on the knee or on the elbow tendons, you can put this nitrous oxide patch on it and you wear it actually for 23 hours a day, essentially all the time. That can also stimulate the tendon to heal. Those are all things that can be done before we start sticking needles into a tendon and doing mean things to it.

Tommy:    How long can you do that for? Because I'm thinking, I used to work on a specialist hypertension team, and I worked in hospital and particularly, anything that stimulates nitric oxide production, you adapt to it, so you need high doses or you need to take it away for periods of time. So, how do you cycle that kind of thing?

Kim:    When you're using this for blood pressure, and you're right, you do get adaptation because the blood vessels get used to it and so instead of dilating, which is what the nitrous oxide does to the tendon, then they just say, oh, we're used to this being around, they go back to their previous state. We're not actually using it for the blood vessel dilation. We're using it to direct effect onto the tendon cells itself, and so you don't see that tachyphylaxis or the getting used to it, that you do when you're using it for blood pressure.

    So whenever I write a prescription for this, the pharmacists all freak out and call me because they're like, well, you can't wear this more than 12 hours a day, which you can't if it's going to work for blood pressure. We're not using it for blood pressure. We're using it as a direct growth factor effect on the tendon so it can do that. The problem is probably about 10 to 20% of people can't really tolerate the medication because they get headaches. It's probably just because a point or two of blood pressure drop. People say, hydrated sometimes you can avoid that, but there are some people that just get headaches with this and can't use it.

Tommy:    I know people listening to this are going to think about, what about all the other things that athletes sometimes do to try and boost nitric oxide production, so, arginine, citrulline, dietary nitrates, do any of those have any effect or is that too systemic compared to the localized effect that you want?

Kim:    It may but I haven't seen any literature or any evidence that, theoretically, it's a very interesting or compelling sort of thought, but I don't know of any evidence that that might work, so probably wouldn't be my first choice.

Tommy:    Yeah. I'm also thinking about the sunlight can have a direct effect of creating nitric oxide when it hits the skin, so maybe you just sunbathe with your Achilles tendons out in the sunlight and that will give you --

[0:10:06]

Kim:    Yes, we can all go to sunny places.

Tommy:    Okay, that's really interesting. I didn't know that. What about the next step? So, we've tried all this, people have made a real effort to do the exercises, maybe we've tried some Graston technique or some physical therapy but that still doesn't work. What's next in line in terms of therapy?

Kim:    Usually I think of a couple different options. One thing that you can do is something called a tenotomy. That basically means that we numb up the tendon and we use a big needle and poke the heck out of it with holes. The idea is really that you're injuring the tendon, making the body pay attention to it, say, oh, my gosh, that tendon is injured down there, I better go fix it. Some people have success with that.

    You can take that a step further. You can actually go and inject whole blood into the tendon. There are growth factors in blood and injecting it into the tendon can restart the healing process. Then taking that one step further, you can take blood out of somebody's arm, spin it down, take just the platelets out of it, concentrate the platelets and put the platelets back in. That's what platelet-rich plasma is, and that's where all the growth factors are, in the blood, or a lot of them are, so that can re-stimulate the healing process.

Tommy:    So, let's dig into platelet-rich plasma or PRP which is something that you've researched yourself, written a few papers on. You mentioned that the growth factors are in there. Can you talk a little bit about just how this is used, how it has been researched? Are there specific tendons or joints where it's more successful for? Who is it going to be most useful to?

Kim:    Again, platelet-rich plasma is not a quick fix because you're trying to grow new tendon, so it is most appropriate for people who have tried some of the other things that we talked about and it hasn't worked. The tendons that we use platelet-rich plasma are really anything that we can reach with a needle.

    The key really is that when you're putting anything into a tendon, it needs to be in the right spot. If you look at a tendon under ultrasound which is the easiest way to evaluate that in the office, you can see bad spots in the tendon, so when you're putting platelet-rich plasma, it needs to be into the bad spot or else it's not going to work.

    You can put cortisone just in the general vicinity of things and it will work because there's a systemic effect to it and it also travels through tissue points, but PRP or blood will clot and begin to work right where you put it and so it has to be in the right spot. So, anybody that's thinking about platelet-rich plasma should probably have it done ultrasound guidance or else it may be a waste of their time and money because it's not going to do anything if it's not in the right spot. So I think that's a key. Having said that, anything that we can reach with a needle and see with the ultrasound, we can put platelet-rich plasma in.

Tommy:    So, pretty every tendon where you might regularly see these sports-related injuries, so all the ones that you talked about, are there studies to show that it does work?

Kim:    There are lots of studies that show that it works. There are some studies that show that it doesn't work. Part of the problem with doing research on this is your platelets are different than my platelets. You may have more or less and then we concentrate them. If you have, say, 100,000 platelets and I have 300,000 platelets, and we concentrate it five times, I've got a lot more platelets than you do.

    The other thing is what's in your platelets is different from day to day and week to week. If this is a particularly stressful week for you, you may have bad platelets or platelets that aren't quite as good. So, comparing what platelet-rich plasma does in me compared to you may be two different things entirely because our PRP is different.     Having said that, when you look at the big picture, platelet-rich plasma tends to improve pain and function in people when everything else has worked.

    A lot of this research is done on not the easy cases but on the really hard cases. What we've seen on our own research here at the University of Washington is that when we look at tendons that really they failed multiple courses of physical therapy, most of them had cortisone at some point, they've tried some of the other things that we've talked about and it's still not working then we do platelet-rich plasma; we get 60% of people, mostly are completely better by six months, and that's a long time, and then another 20% better over the six months after that. There's probably 20% of people that just don't respond.

    So, it's not a magic bullet and it's not super quick either. So, when I'm thinking about my elite athletes, we time platelet-rich plasma. We may try to get people through the end of the season or through a particular event and then do platelet-rich plasma when we have at least six to 12 weeks to recover. That doesn't mean you have to stop exercising during that whole time but you're going to have to back off and change what you're doing, and depends what tendon you're using, and everybody heals differently too. So it's also a little bit of an art when it comes to adjusting people's activities so that they do enough activity to continue to stimulate the healing but not enough to inhibit it.

Tommy:    How long might you expect to see an improvement for? Is it something that if you actually cause the healing of the tendon such that you want it that actually you'll be fine as long as you don't start to injure again? Or is it something where you might need to go back in again in the future?

[0:15:12]

Kim:    Typically when tendons get better with this, they're better. You fixed it. Now, it doesn't mean that you can't go out there and run and run and run or cycle and cycle and cycle and over-extend your capacity again, but most of the time, the vast majority of the time, once we get these things fixed, we don't see people back again.

Tommy:    Oh, that's very cool. You mentioned cortisone along the way, and that's obviously something that people with chronic joint issues may have had exposure to or heard about previously. Is is something that you would try before platelet-rich plasma, or what might differentiate between when you would use the two different approaches?

Kim:    Speaking specifically about tendons, I think of cortisone as game time. If I've got somebody that says, "I have this really important tennis match this weekend and I need to play," cortisone typically improves people pretty quickly. The problem is cortisone is catabolic or it eats up tissue and it also tends to stop working. I think cortisone is getting me a window and so usually when you use cortisone in tendinopathy, you get about a three to six-month window where people are improved.

    Now sometimes people's elbows or knees or whatever hurt too bad that they can't do proper rehab and so if you use cortisone, it can give them a window where they can do some rehab and get the tendon better. It is rare that cortisone actually gets the tendon better. In fact, most tendons are a little bit worse off after you use cortisone. I say that cortisone is like a gun. It's not good or bad. It's how you use it and so you need to be very strategic about how you use it.

    Sometimes it's worth trying cortisone because if it works and it gives you a long-term result, that's great because when you start moving onto platelet-rich plasma, it's a longer haul. The other thing is cortisone is typically covered by insurance and platelet-rich plasma and things like that aren't. So sometimes you should just try it and see if it works. If it does, great, and if it doesn't, we've still got these other options in our back pocket.

Tommy:    Can you talk a little bit about how you build this into a general recommendation for your athletes? Say, cortisone, it's a game-day thing, they need to get out on the field, how does that fit into the bigger picture in terms of their long-term health? Do you have to counsel people as to whether actually maybe they shouldn't be trying to get back out there and shouldn't be trying to just get on top of the pain so they can keep playing? How often do you have to have those kinds of conversations?

Kim:    All the time. We talk about the risk and benefits, and it's a shared decision-making process. Most of the time, with cortisone, when you give somebody cortisone so that they can play in the big game or the big match or whatever, most of the time that doesn't really present to them any long-term risk. It may make their tendinopathy worse in the short-term and so it's a longer road to come back from, but usually it doesn't give you any longer term risk. There are a couple of exceptions to that.

    Achilles tendons tend to rupture and so you don't really want cortisone around them at all, or in them. So, I am very hesitant and actually scared to use cortisone around the Achilles tendon. The other tendon that we tend not to use this around is the patellar tendon which is the other tendon that ruptures. Some of the other ones are much less likely to rupture and it's probably just more of a matter of a longer road to get back to healthy.

Tommy:    Having covered all of this for tendons, how does that change if you're thinking about the actual joint itself?

Kim:    When you're thinking about the joint, first, I like to start by thinking about the pathogenesis or the cause of arthritis or what that is because some of us really don't have a great understanding of that. You've got, in the knee, say, you've got two types of cartilage. You've got the meniscus cartilage which are the cushioners between the knee bones and then you've also got articular surface cartilage or that gliding surface cartilage.

    When that gliding surface cartilage starts to wear away, that's what arthritis is. There are cartilage cells in there and as those cartilage cells die, they let out a lot of toxic chemicals that then go and bind to the joint lining, and the joint lining makes some more bad chemicals that go and kill more cartilage and so you start this downward cycle. As your joint lining is busy making some of these bad chemicals, it doesn't make good things like lubricants and that sort of stuff.

    So when we're using platelet-rich plasma in knees or joints instead of tendons, what we're actually trying to do is use the growth factors that are in those platelets to block some of those breakdown products and stop the cycle from happening and also, some of the growth factors in the platelet-rich plasma go and bind to the joint lining and make good things like hyaluronic acid which sounds awful, but it's actually a really nice lubricant and you have that in healthy joints.

    So, with platelet-rich plasma, it's not going to grow people new cartilage, but it improves pain and function, and there's lot of good evidence that it does improve pain and function in the vast majority of people. It may halt or slow the progression of arthritis and unlike tendons, platelet-rich plasma in joints usually wears off usually somewhere around a year.

[0:20:14]

    The worse somebody’s joints are, the less well it works. So, I talked about the biomechanical changes that happen with arthritis in the joint, but there's also biochemical changes. As that cartilage surface wears off, the bone underneath it reacts and gets irritated and as it reacts, it will grow. You'll get an uneven surface and you get bone spurs. So, once the bony changes happen in arthritis, even if you re-thread it, it's like re-threading a bad tire. It's not going to be super successful.

Tommy:    Are there any other options for people who have joints that are in that bad condition, or is that once you get to a point where you can't control it anymore, you then have to think about replacement?


 

Kim:    Well, there tends to be a huge, huge gap between when people are ready for replacement and when their knees start to hurt or joints start to hurt and give them problems. Usually that gap is 20 years. We really don't have a ton of great options for that period to keep people active and moving around.

    Most joint surgeons would consider that you should get a joint replacement so that your joints or knees don't hurt anymore, not so that you can continue to run marathons or ski or climb mountains. Most of my patients, the reason they want their joints fixed is not so they can sit on the couch and watch TV, but so that they can do what they do. So, we really need to develop more options.

    Other options that are out there, there's something called viscosupplementation that's out there. There are different brands of it, Synvisc, Orthovisc, Euflexxa, Supartz. There's a number of different options and what that is, is that's basically this hyaluronic acid that I talked about, you inject it into the knee and there, it continues to act as a lubricant, but it breaks down pretty quickly. This is actually sold and marketed as a device, but it really has a drug effect because it goes and binds joint lining and gets the joint lining to make more of your own native hyaluronic acid.

    When you look at studies that compare platelet-rich plasma and this viscosupplementation stuff together, the platelet-rich plasma usually performs a little bit better, but they both cause improvements in pain and function. I have some patients respond better to one or the other.

    The other issue is cost. Viscosupplementation became FDA-approved in the '90s, and insurance companies paid for it for a long time. About two years ago, they stopped paying for it in most people. There are still some plans that do pay for it. Actually Medicare pays for it. The stuff itself is pretty expensive and so it has limited some people's options.

    Platelet-rich plasma is actually usually cheaper than buying this drug from the drug company and then injecting it. I usually try platelet-rich plasma first, unless it's covered by somebody's insurance and then I'd do that first. In Europe, some people will combine them. It's hard to say, again, it's hard to do research on this and see what works best and what best protocol is on this, but they're both different options that you can have to try and keep people going.

    Cortisone is another one. Cortisone actually just gets rid of the chemicals that make it hurt. It doesn't really improve the joint milia. It can be a decent option, but it tends to stop working. The first time, you may get six months or a year of relief of pain from it and then the second time, three or six months, and then it's not really worthwhile to do the injection. It is a little bit hard on that cartilage and so it's not something that you want to inject five, ten times into a joint because it could actually have a detrimental effect on the joint.

Tommy:    So in terms of all the things that are out there maybe you see being recommended to people or clinics offering to people, is there anything that makes you roll your eyes in terms of that's not going to work or that's going to be a waste of of people's money? Are there things that people need to be wary of in terms of something that might be being sold to them that isn't going to work?

Kim:    Yeah, I see a lot of advertisements right now for stem cells, and stem cells can mean a lot of different things. One "category" of stem cells are the amniotic products. A lot of people are injecting different derivatives from placenta or amniotic fluid and advertising them as stem cells. They, in fact, do have stem cells in them but the stem cells are all dead because they've been irradiated. So those actual stem cells aren't going to do anything, and the FDA is actually after clinics that advertise in this way.

    In those amniotic products, there are growth factors in them and so people may get benefit from the growth factors in them, but I'm not sure that the cost benefit to the growth factors in an amniotic product versus the growth factors in platelet-rich plasma because the amniotic product tends to be a lot more expensive than PRP. I don't have a problem with the amniotic product, per se, but when it's advertised as stem cells, that seems disingenuous, and people probably aren't getting what they think they're getting.

[0:25:06]

    There are other stem cells out there too. The other two sources of stem cells that we use here in the United States are bone marrow aspirate and then fat aspirate. We can't do a lot of processing here in the United States on these and so, again, this is difficult to do research on because everybody is different. Again, my stem cells are different than your stem cells. The number of stem cells in bone marrow goes down precipitously after somebody is two years old, and there's not a lot of children that are getting these. Certainly after people are 50, it goes way down, so how many stem cells you can always get.

    I think of the bone marrow aspirate as supercharged platelet-rich plasma, and it probably does work better than platelet-rich plasma. Typically, it is exponentially more expensive than platelet-rich plasma and so people have to think about the cost benefit with that. It's not a panacea and anybody that's telling you that 90% of people get better or significantly better, you might want to take that with a grain of salt and understand what you're getting into.

Tommy:    There is a huge number of people now talking about stem cells for, obviously, this is one specific example, but then various kinds of longevity benefits and all those kinds of things. Are you saying that actually due to the regulations, there isn't that much processing or anything that can really be done with these so a lot of those potential benefits are really being oversold?

Kim:    Right. Most people would think that if you're going to really get the benefits of stem cells that they need to be expanded, and we can't even come close to expanding them here in the United States. You can spend fluid as stem cells around it but other than that, you can't do much to them. Even when you have fat aspirate, you can't even digest the fat to get the stem cells out of it. You really have difficulties getting enough, getting enough good quality ones. I think there's a ton of potential to stem cells and some of the stuff that we're doing may have benefit, but the cart is a little bit ahead of the horse on this one. It's really exciting but probably not ready for mainstream.

Tommy:    Yeah, absolutely. Is there anything in terms of that whole spectrum of how you might approach somebody with a joint or tendon disease in terms of other therapies that are worth trying, things we haven't talked about or other supplements or things outside that you wouldn't necessarily prescribe but you might recommend to people? Is there anything else that's maybe worth talking about?

Kim:    Yeah, I think we've covered most of the stuff that's really reasonable. Particularly for arthritis, it's not that many. What the American College of Rheumatology recommends for arthritis is Tylenol, the nonsteroidal anti-inflammatories like ibuprofen. That's really not changing the process, just covering it up, maybe bracing or physical therapy, now physical therapy isn't going to do anything for arthritis but it can change your biomechanics, maybe download your joint or things like that but, intrinsically, it's not going to change that arthritic process.

    So, there's not a whole bunch of options out there. Oh, I know, I just thought of one. One thing that you can do maybe particularly with knee arthritis that is between that stage before you want to get your knee replaced and maybe some of this other stuff isn't working, there are some people that are actually doing ablations of the nerves that go down there. It's not fixing anything except it allows you to continue to function because that pain inhibition is not there. Maybe put your knee replacement off, indefinitely, or until it's more in that really bony bad place. I think that's an interesting possibility.

Tommy:    Are there any potential downsides to just essentially removing the ability to feel pain in the joint?

Kim:    Well, the pain is there so you know the joint is damaged. If you know that your joint is damaged and you want to continue to run on it anyway, then are you going to do more damage to your joint? Yes, but are you able to continue to function? Yes. So, it's a trade-off.

    Usually, how most people are doing it right now is doing it with radio frequency ablation and so that may not be permanent. That will last for six months, a year then it might have to be done again. You can actually surgically remove those nerves, which some people have done for persistent pain after total knee replacement, but that's another surgery to get this done. So I think the thing that is interesting to me are radio frequency ablations of these nerves particularly if people may have arthritis in one part of their knee or another.

Tommy:    I think that's a really great summary. I think that's really useful for a lot of people having questions about when they should be doing what for their joints. I wanted to switch or change slightly and talk about some of your work with the student athletes which is fascinating to me because I've become a big Husky fan and you're the team physician for the Husky football team. I was wondering if you could talk a little bit about what that involves, to be essentially the on-call doctor for this huge revenue sport.

Kim:    Yeah, it's a great job. I'm so happy that I have a job that I love. I basically take care of everything that the football players need. A lot of the things that our athletes need are not necessarily musculoskeletal. Sometimes you think, oh, my gosh, it's going to be all -- they get sick, they have coughs, they have colds, depression, anxiety, ADD. Everything a normal young adult might encounter, we encounter in the Husky football team.

 

[0:30:13]

    One of the differences about taking care of these athletes compared to maybe you or I is that their schedules are so, so intense that making an appointment, going to the doctor would never ever happen. So, I'm there every day after practice and after every game. They can get a hold of me 24/7, literally. It's the ultimate in concierge care, and I love doing it.

    I love being part of the team and keeping these guys back on the field, if we can, and also there are times that it's just not really very smart, and then working through that because that's tough when an athlete can't do what they love, it's like asking somebody not to breathe, and so trying to make sure that they get back on the field as soon as possible, as quickly as possible but also keeping them safe.

Tommy:    Is there anything in particular that these guys are susceptible to in terms of either diseases, are they getting sick fairly frequently because of their frequency of training, or are there other deficiencies or hormonal problems? Is there anything else like that, that seems to be cropping up particularly in football players, or is it just what you see in a general college population?

Kim:    I think it's the general college population but amplified. Really a real challenge for student athletes in general is sleep. These guys get up early in the morning, they work out and then they've got class and then they come back and they go to meetings. Actually, just getting some time to have a normal social outlet somewhere and then actually sleep is a real challenge.

    We're looking at sleep as a performance-enhancer too. You'd like to think that people would just think about it just because of the health and wellness of people in general, but we know now how important sleep is to performance and so trying to find time to sleep is challenging for us all but maybe particularly for these guys.

 

Tommy:    How do you handle it? We talked previously about, if you go to an away game, it's in a different state, you come back after the game, you're back at 5 or 6 in the morning. I wonder, would it be better to stay there and then come back the next day? How do you balance all that stuff, their work schedule versus their sporting schedule? How do you find the best way?

Kim:    Yeah, it's a work in progress for football, and particularly, we'd always kickoff, noon, 1, 2, something like that. Even more, seems most of our kickoffs are in the evening and so we don't get back until very, very late or early the next morning. We typically leave right after the game or about two hours after the game, by the time media gets done and we get all packed up and loaded onto the plane.

    Right now teams are not staying overnight. It seems like that might make some sense for these late kickoffs. That involves logistics and expense because there are 150 people, 200 people that travel with a football team. So, it's a work in progress try and figure out how to meet multiple demands, demands that you have from media which creates a lot of revenue which supports not just the football team but really a big portion of the athletic department and so it's a challenge.

Tommy:    I guess a big part of that, you're the Chair of the Pac-12 Student Athlete Health and Well-Being Board, which I know has a reasonably big budget to try and do some research into how to best support student athletes. So even beyond football, is there anything in particular that you think needs to be addressed to improve the health of these guys, long-term? Guys and girls, I should say.

Kim:    Yeah, so, what we're doing with Pac-12 is super exciting. The Pac-12 is giving away $3.5 million worth of grants per year. The research is supposed to benefit the health and wellness of the student athlete. What we do, it's like an NIH grant sort of proposal. Different places put forward different grant proposals, and we find ones that we think are good proposals and are on our topics of interest which sleep and wellness is one of them. Mental health is a big thing that we're looking after as well.

    I think that maybe we've had some real luck with some conference-wide, top-down research projects that we've done, and I think that we may see more of those in the future rather than solicited research which tends to be more isolated projects just because when you put all of the power of the whole Pac-12 together, we can really do some cool things.

Tommy:    So, there are some things that you're able to talk about that you guys want to try and implement that you could put over all of these colleges at once or research that you could try and do across all of the --

Kim:    Yes. So, the first step in that is we've all been on a common injury record and so we're all using the same program so we can put it in the big database, identify it and look at trends, use it for quality improvement. That sounds like a simple thing, but the software is expensive and electronic medical records are great but they're not easier. They take a lot of effort to get everything into them.

[0:35:03]

    So, Pac-12 is funding somebody, it's not just laying it on the shoulders of athletic trainers to do more work because they're already overworked, but we're paying somebody to -- because that's part of their job, to get the injury data entered and then that database will be available for researchers. So if you have a research question, say, what's the stress fracture rate in female cross-country runners in the South versus the North where the sun is different or something like that; you could actually solicit that database and answer that research question.

Tommy:    What other information are you capable of putting in, in terms of the highest levels of certain sports? I mean, you have data on literally everything from an athlete in terms of heart rate variability and blood test data and a whole other performance metrics. Is there any central way to get all that data together yet?

Kim:    Not yet. It's a brave new world in this area of sports analytics and so we've got all this information coming in and trying to figure out how to use it and how to corral it and all that sort of stuff. Right now in our injury database, all we have is the standard, did you get hurt, how long did it take you to get back, what part was it, do you know what season, that sort of thing, but certainly we have the potential at some point to be able to put in different -- from sleep quality to the data from the heart rate variability or even a lot of the load monitors that we use. It would be great to have that all in one place. That doesn't exist yet that I know of.

 

Tommy:    With that kind of infrastructure, hopefully, maybe the Pac-12 can be some of the first to start to think about that because you know you've got that central body to look at these things. It's very exciting.

Kim:    Yeah, so we started with the injury stuff, and now we've expanded into, we have concussions. We're all collecting common concussion variables at certain time points. We're expanding the mental health variables. But, yeah, going into analytics is a big area for opportunity.

Tommy:    Yeah, very cool. This has been fabulous. I really enjoy picking your brain. Is there anything else that you'd like to talk about? Where could people find out about your work if they want to do that?

Kim:    I'm here at the Sports Medicine Clinic at the University of Washington, and it's a Sports Medicine Clinic at Husky Stadium. If you're interested in anything I'm doing, go to PubMed and look me up there, and I'm always happy to talk to anybody.

Tommy:    We'll put links to all of your papers in the show notes so people can head to the website and grab them there, and we'll put your details at the clinic as well so people can contact you if they need to.

Kim:    Great, thanks.

Tommy:    Thank you so much for your time.

Kim:    All right.

[0:37:23]    End of Audio

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