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Letter to the Editor


Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games?

Marcus, Randall E. MD; Barnes, C. Lowry MD; Amendola, Annunziato MD

Clinical Orthopaedics and Related Research®: January 2018 - Volume 476 - Issue 1 - p 167–168
doi: 10.1007/s11999.0000000000000037

R. E. Marcus, Charles H. Herndon Professor and Chairman, Department of Orthopaedics, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

C. L. Barnes, Carl L. Nelson Distinguished Chair, Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

A. Amendola, Vice Chair, Department of Orthopedic Surgery, and Chief, Division of Sports Medicine, Duke University, Durham, NC, USA

R. E. Marcus MD, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5000 USA, Email:

(RE: Leopold SS, Dobbs MB, Gebhardt MC, Gioe TJ, Rimnac CM, Wongworawat MD. Editorial: Do orthopaedic surgeons belong on the sidelines at American football games? Clin Orthop Relat Res. [Published online ahead of print September 5, 2017]. DOI: 10.1007/s11999-017-5483-6).

One author (AA) is the Team Physician for Duke University.

The Department of Orthopaedic Surgery at University Hospitals Cleveland Medical Center is the official healthcare provider for the Cleveland Browns.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Received October 31, 2017

Accepted November 09, 2017

To the Editor,

We respectfully, but strongly, disagree with the editorial, “Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games?” by Leopold and colleagues [1]. In their editorial, the authors state: “In light of the known risk, we suggest that surgeons evaluate whether continuing to support this sport is consistent with the best values of our profession. We believe it is not.”

There is no doubt athletes risk injury playing football, particularly considering the overwhelming evidence of chronic traumatic encephalopathy (CTE) associated with high level football. However, it is our belief that, as orthopaedic surgeons, abandoning our participation in sports, whether caring for athletes in football or any other sport, is inconsistent with our mission as physicians and our obligations to patients and our profession. The modern Hippocratic Oath rewritten in 1964 by Louis Lasagna, which is widely accepted by most U.S. Medical Schools, specifically states “I will apply, for the benefit of the sick, all measures (that) are required” [4]. Therefore, we believe that it is the duty of our profession to be readily available and, if possible at the sports event, to treat athletes and make key medical decisions including critical return to play decisions in order to prevent further injuries to our patients. There is also little doubt that the more-timely these treatments and decisions are rendered, the safer for the athletes. The concept that people without the expertise of orthopaedic surgeons would render these treatments and make these critical decisions is setting a dangerous precedent and would place these athletes (patients) at unnecessary risk and reflect poorly on our profession.

Furthermore, orthopaedic surgeons should be more involved with sports to provide expertise for continued improvements in equipment and other protective devices for athletes [2]. Perhaps even more important, we as physicians should be intimately involved so that we are in a position to advocate for rule changes that will make sports safer. This is especially true for orthopaedic surgeons and football since more than 90% of acute injuries remain musculoskeletal in nature. The prevention of injury has always been a keystone of our profession and is also noted in the Hippocratic Oath [4].

The editorial also noted that “orthopaedic surgeons perform preseason physicals”. This has evolved over the years and is a critical injury- and disease-prevention activity. Not only are musculoskeletal abnormalities diagnosed and treated during these evaluations, but cardiac, endocrine, and numerous other health problems are diagnosed and the possible consequences of these abnormalities are prevented [3]. In most circumstances, these activities are performed without compensation to the physicians.

The editorial also noted that “orthopaedic departments and practice groups often are thrilled to ink brand-building marketing agreements with college and professional teams.” It is our belief that this is a very subjective and pejorative statement with inferred criticism of orthopaedic surgeons who are involved with the care of athletes. Most orthopaedic surgeons care for athletes and teams without any marketing agreements and, in many cases, without any compensation for their work. They spend time on the sideline of various athletic activities because they enjoy the sport, as well as the care of athletes. The inferred criticism that orthopaedic surgeons are taking care of athletes purely as an advertising or marketing ploy or only for financial gain is not based on any data and we believe to be false and unfair criticism. It’s unfortunate that this was part of the editorial, as we believe it diluted from the more important issue of CTE. In many circumstances, it is part of the mission of the orthopaedic department at a university to care for their teams, with often little or no additional compensation. The time and efforts that our physicians spend in the training rooms and on the sidelines, usually after work hours and on Friday nights or Saturdays, takes away from the personal time with their families and rarely is credited as part of their clinical time.

Although we believe that everyone has a right to his or her own opinions, we believe strongly that orthopaedic surgeons who participate, often at their own time and expense, in the care of athletes on the sidelines of sports activities, including American football games, are providing a service to the athletes by administrating critical treatments and decisions for their care. These surgeons represent the highest ideals of medicine, and through their actions, they fulfill an obligation of our profession. On the other hand, based on the recommendation of the editorial, not participating in the care of these athletes because of the known risks of the sport is akin to not taking care of members of our armed forces or even cigarette smokers, whose activities have well documented and known severe health risks. Making American football safer will not be accomplished by withdrawing orthopaedic surgeons from the sidelines and participation in the care of these athletes. We actually believe that greater participation of orthopaedic surgeons and health professionals in high risk sports is the best way to improve the rules, equipment, and care of athletes to make this popular sport safer for athletes. While this is happening, the decision to participate in these sports needs to be made by well-informed parents and the athletes themselves.

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1. Leopold SS, Dobbs MB, Gebhardt MC, Gioe TJ, Rimnac CM, Wongworawat MD. Editorial: Do orthopaedic surgeons belong on the sidelines at American football games? Clin Orthop Relat Res. [Published online ahead of print September 5, 2017]. DOI: .
2. Li RT, Kling SR, Salata MJ, Cupp SA, Sheehan J, Voos JE. Wearable performance devices in sports medicine. Sports Health. 2016;8:74–78.
3. McCarthy M, Voos JE, Nguyen J, Callahan L, Hannafin J. Injury patterns in female basketball players entering the WNBA combine. Am J Sports Med. 2013;41:645–651.
4. Tyson P. The Hippocratic Oath today. Available at: https// Accessed October 9, 2017.
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