In his 30-year history at Hospital for Special Surgery, both as an attending orthopedic surgeon and as part of his role as HSS surgeon-in-chief (1993-2003), Dr. Russell Warren has seen a wildly varied spectrum of musculoskeletal ailments affecting every kind of patient. The profound experience provided by this kind of tenure is impressive on its own, but for the past 25 years, Dr. Warren has added another position to his resumé: Team Physician of the New York Giants professional football organization.
We discussed his role at length in a recent interview, in which Dr. Warren described the elements of a great professional sports health team, the importance of educational experience, the benefits of honest communication, the best course of care in dealing with the toughest injuries, and advice for aspiring athletes.
With a team as large as the Giants – girth aside, in terms of sheer manpower – there is no way for one physician to handle every kind of injury. Although he has become familiar with a broad scope of football injuries, Dr. Warren is an orthopedic surgeon, and his specialty is in treating musculoskeletal injuries and conditions of the shoulder and knee, including tears of the rotator cuff, meniscus, and anterior cruciate ligament (ACL). With help from associate team physicians Bryan T. Kelly, MD, and Scott A. Rodeo, MD, both orthopedic surgeons at HSS, Dr. Warren designates the proper specialist for any injury outside his main areas of expertise.
When a player injures his foot or ankle, Dr. Warren may consult the Foot and Ankle Service at HSS. Any injury to the neck or spine will require an evaluation by the HSS Spine Service, and specialists from the HSS Hand and Upper Extremity Service will diagnose and treat those related injuries and conditions. Likewise, in case of heart, kidney, or other issues not related to musculoskeletal health, Dr. Warren and his colleagues consult the related specialists at NewYork-Presbyterian Hospital, located just across the street from HSS.
“We’re working in a sphere in which orthopedics is the largest component of it,” explains Dr. Warren, “but there are lots of other parts. As head team physician, you have to set up a large consulting staff.” There are essential values in setting a system that enables them to evaluate players quickly and efficiently, he reasons. “There’s a game on Sunday. Will they be able to play? We don’t have a month to figure out a problem -- we have a few days.”
In tandem with Ronnie Barnes, the Giants head trainer, Dr. Warren works with a team of trainers, strength coaches, and nutritionists throughout the year, both in-season and off-season, to keep the players actively involved in a customized strength and conditioning program. In addition, players requiring rehabilitation after an injury will be assigned to a physical therapist and given a customized regimen of exercise to return them to peak game condition.
“In working with a team as a team physician,” he says, “the key is to have expert trainers who play a huge role in diagnosing and treating with our guidance. We are fortunate on the Giants to have Ronnie Barnes as our head trainer with [Assistant Athletic Trainer/Coordinator of Rehabilitation] Byron Hansen and [Assistant Athletic Trainer] Steve Kennelly.”
Early in the spring season, Drs. Warren, Rodeo, or Kelly arrive at the “combine” with two of his Sports Medicine fellows from HSS to assess players for their injury risk in the NFL. The combine, much like the farming machine with which it shares a name, weeds out the unfit players as they undergo a rigorous series of tests in order to determine both their athletic prowess and their potential for injury at a high level of play.
Shortly thereafter, the onset of the draft will require more players to be evaluated by the medical team. All players, from the rookies to the veterans, submit to physical checkups by Dr. Warren’s team. Injuries will then be assessed and treated, and conditioning programs will be fine-tuned to maximize each player’s potential while decreasing their risk of injury.
While offseason camp commences in June, final training camp begins in July, consisting of the top 85 players in the Giants organization. This intensive training period lasts for five weeks, during which time the two HSS fellows, along with a rotating schedule of the three HSS team physicians, observe the players as they get in shape for the upcoming season. After two weeks of two daily practice sessions, the team will play four preseason games.
“At this point, we’ll see a variety of injuries every day,” says Dr. Warren. “After three days, we usually have a list of 15-20 players with injuries -- usually pulled muscles at first, then more significant injuries, such as ruptured tendons and foot or ankle injuries.” Immediate attention is given to these players to have them evaluated and back on the field in good health as soon as possible.
“Players who are recovering from surgery in the spring may have an amended schedule,” he explains. “They’ll play one day, then take a session off. Usually, we take them off the double sessions until they’re in better condition and have restored confidence in their health.”
Ronnie Barnes has also set up a neuropsychiatric testing program for pre-season evaluation with which to compare results after a mild, traumatic brain injury. As a result of these preliminary evaluations, when confronted with a concussion victim during the regular season, the neurologists will be able to compare the player’s preseason test results to the new results, thereby gaining perspective on the patient’s recall ability and reaction time. If the new results are subpar, the player must then return to his prior level of neuropsychiatric response before returning to play.
After training camp and preseason play, the season begins. Dr. Warren attends almost every game, with one of the associate team physicians filling in when necessary. In addition, Warren acts as a consultant for other team physicians around the league.
“We see a lot of injuries over the course of the season, and some of them will require surgery,” says Dr. Warren. “Neck problems, back, shoulder, and knee problems are all prevalent, but the largest lost time injury is a foot and ankle injury.”
In terms of injuries unrelated to orthopedics, Warren mentions seeing kidney injuries, lung contusions, hepatitis, and even a stroke victim.
Dr. Warren explains that in the course of diagnosing and treating so many of these injuries in such an intense, accelerated environment, team physicians throughout the NFL have been able to create and share a base of knowledge about common injuries, which has helped each doctor make educated decisions based on prior outcomes.
“Our first priority is protecting the player,” he says. “We have to make decisions about ‘play/no play,’ and we make judgment calls all the time. But those decisions are usually guided by our knowledge base.”
Education is at the heart of Dr. Warren’s duties for the Giants. While his day-to-day role with the team is one of maintaining the players’ health, both in the present and future, Warren has extended the lessons learned from this rarified atmosphere to new HSS fellows as well as his colleagues at HSS, NewYork-Presbyterian Hospital, and elsewhere in the NFL.
“Basically, we’ve made the Giants into an educational situation,” says Dr. Warren. “We’re not only concerned with patient care, but with bringing our knowledge of new conditions and treatments to others involved in both professional and amateur sports medicine. It’s a large part of why I became interested in doing this.”
“My experience over the years,” he continues, “is that we’ll see two or three things that nothing’s been written about, so we’ll conduct a study on this particular issue as it pertains to pro football players, and come out with a couple papers per year about what goes on in an NFL team. It’s educational for us, and it’s educational for the orthopedic community at large.”
In Dr. Warren’s opinion, the NFL has the best databank for injuries in professional sports. “We have the luxury of going through the databank and collecting all of the information about a pertinent injury in the NFL in the last 20 years.” He says, adding that he, and other team physicians, enjoy a comfort level by knowing what the past experience has been. “We can use that databank and write good, interesting papers on it, which helps everybody. It’s been a very helpful education for us.”
Dr. Warren has trained a large number of fellows from the HSS Sports Medicine during his tenure as team physician, and a number of them have gone on to become team physicians in their own right for other NFL teams. “We’ve had good experience with that,” he says.
In the beginning of his years with the Giants, Warren had to persuade the late Giants general manager George Young to allow him to bring in the fellows to study his work with the players. It was a success, and the program quickly took off. HSS surgeon and researcher Jo A. Hannafin, MD, PhD, became the first female physician in the NFL, and another trainee, Leigh Ann Curl, MD, is currently the only female chief orthopedic surgeon in the league, for the Baltimore Ravens.
One of the more unique aspects of working with pro athletes is simply the level at which their bodies have to perform. “When you put them back in the game after an injury, they go to that higher level of play, and you find out very quickly if your treatment worked or not,” Dr. Warren explains. “For example, you’ll see whether or not their surgery was successful. They’re going to put the surgical site under high loads.”
However, he stresses, the main advantage of working with athletes in top form is that their bodies can also recuperate from injury at a much accelerated rate. “Sometimes I’ll see a player rupture his Achilles tendon and return to full activity at three months after open surgery. You just wouldn’t see that in most recreational athletes,” he notes. “Pro athletes are different. It’s a combination of motivation, physical condition, the highest level of surgical care, and a large team of health professionals that works with them. It certainly gives them an advantage.”
“What’s nice these days is that our imaging has improved also,” he adds. “We have very good MRIs so we can see things clearly, whereas 15 years ago, you couldn’t see them as well. You could use x-rays, CT, bone scans, but there was a lot of guesswork compared to now. [HSS Radiologist] Hollis G. Potter, MD, has been extremely helpful in generating protocol to expand our evaluation of athletic injuries.”
Along with the satisfaction that comes with the reliability of modern technology and a vast support system, Dr. Warren finds that he enjoys the sheer satisfaction of returning players to the field in good health:
All of us in sports medicine get a real charge out of seeing somebody going back to play. A player, for example, may have had a bad knee, then he comes back to score on a 93-yard punt return. Sure, you get a kick out of that. Just like the player did, the trainer does, everybody. You feel it at the ultimate level - that you’ve had some success there. That’s the fun part of it.
He also describes the range of emotions both the players and the health team may experience during the period of rehabilitation from an injury:
You see how the kid struggles through it. It’s different than taking care of other patients, because you see them every week. Sometimes two or three times every week. So getting over things is like watching grass grow – it takes time. That’s the frustration of trainers. They see them every day. I see them two or times a week. Whereas, with my other patients, I’ll see them at two weeks, then at six, then in three months. I don’t go through that day-to-day with them. It’s hard to go through it day-to-day. They’ll have good days and bad days, but you learn a lot by seeing them through that spectrum. By really seeing it every day, or three days a week, you learn a lot about how to manage it. It isn’t all about just getting better – you have to take the bad days with the good.
Perhaps the greatest advantage of the aforementioned databank system is the ability to apply the information back to non-professional athletes and other patients. “You see what maximum stress is like,” Dr. Warren explains, “but you’ve got it in your framework of experience as to what can work at a very high level. So that gives you the confidence to use it at a general level for patients who engage in these sports recreationally.
“That’s the real benefit of working with professional athletes: that level of application. You know the maximum level of rehabilitation you can achieve. So as a result, you know that you have to structure that rehabilitation process a certain way in order to achieve that level of success in other patients.”
Given all of the pressures placed on pro athletes to stay healthy, perform at their peak, and achieve success on the field, they may fear losing their position if they fail to recuperate from an injury fully or in an acceptable period of time. They may feel, for example, that an invasive surgical procedure may hinder their chances of a quick, full recovery.
“Since the beginning,” notes Dr. Warren, “I’ve been very upfront with them. We perform a private examination, discuss the situation, and educate them about it. I talk with them one on one, and I treat them just like private patients. I don’t do anything differently than I’d do with my other patients; I just tell them exactly what I think.”
Some conditions may warrant special precaution and may keep the player out of games, such as head, neck, and spine injuries. “Some injuries you can play with, some you can’t. With minor injuries, other things may hurt, may bother the player, but they can still play without risking long term harm. With certain injuries, though, you don’t know all the ramifications at the beginning.”
Although each player can decide for himself whether or not to play with a borderline injury, Warren has ultimate authority when it comes to more serious injuries. If an injury poses long term harm to the player, Dr. Warren will take him out of play. This authority was provided to him by the Giants general manager, and it covers the entire organization, from rookies to veterans.
“Some team physicians don’t have that authority,” Dr. Warren explains. “It’s a different level, because it involves a lot of other people besides the athlete, including the trainer, the coach, and the agent. There’s a wide range of interested parties who have nothing to do with orthopedics or healthcare, but they all have a stake in the player’s outcome.”
This system of forthright communication fostered by Dr. Warren’s medical team has worked well for the Giants. “We meet every week to go over each injury to the players, and we tell them exactly what we think. A lot of our success comes down to communication. If you have good communication with the organization, the people within the system, it solves a lot of problems.”
This particular brand of honesty also extends to the media as well. Dr. Warren contends that the press is savvy enough to know what’s going on with the players when it comes to their state of health. “They know who’s out there and who isn’t playing, so they’ll ask the coach what the story is,” he remarks. “We educate the coach and the trainers about it, but if it’s a major issue, we’ll announce it ourselves. The way the league works, they don’t want a lot of hidden information about player injuries.”
The number one piece of advice Dr. Warren can provide to aspiring footballers echoes similar advice heard from doctors and strength coaches everywhere: “Get in shape. Work out hard, but always learn good techniques.”
Up-and-coming athletes should always be aware of what their bodies are telling them. Although hard work is the primary facet of performance in the game, amateurs might work too hard – especially when they have a propensity for certain knee problems. They can lift weights excessively, aggravate the problem, and end their athletic promise prematurely.
Dr. Warren has seen some amateur athletes enter his office with torn rotator cuffs, which they generated at age 30 as a direct result of lifting weights. “They should have realized they were getting into trouble and altered their approach,” he says.
Athletes should always listen to how their body responds to the activity they engage in, and if they do have problems, they should adjust to them. “Just don’t push through them,” advises Dr. Warren. “It works the same way with a rehab program – if something bothers you, shorten the duration, change the angle, or give it up entirely. There are many different ways to do these exercises. A good trainer or therapist will help make those adjustments.”
Other members of the HSS staff serve as team physicians for many college and professional teams, including the New York Mets, Knicks, Nets, Liberty, Red Bulls, and others. Along with Dr. Warren, these specialists have a vast experience in treating high performance athletes and readily pass this knowledge on to residents, fellows and other members of the HSS staff. Members of the Hospital for Special Surgery Sports Medicine Service maintain a high standard in education, research and, most importantly, the highest standards in quality patient care.
Interview and summary by Mike Elvin