That’s Gotta Hurt: The Injuries That Changed Sports Forever

Dr. David Geier

THAT’S

GOTTA

HURT

THE

INJURIES

THAT

CHANGED

SPORTS

FOREVER

ForeEdge

ForeEdge

An imprint of University Press of New England

www.upne.com

© 2017 Dr. David Geier

All rights reserved

For permission to reproduce any of the material in this book, contact Permissions, University Press of New England, One Court Street, Suite 250, Lebanon NH 03766;

or visit www.upne.com

Library of Congress Cataloging-in-Publication Data

Names: Geier, David, Dr., author.

Title: That’s Gotta Hurt : The Injuries That Changed Sports Forever / Dr. David Geier.

Description: Lebanon, NH : ForeEdge, 2017. | Includes bibliographical references and index.

Identifiers: LCCN 2016042501 (print) | LCCN 2017007926 (ebook) | ISBN 9781611689068 (pbk.) | ISBN 9781512600698 (epub, mobi & pdf)

Subjects: LCSH: Sports injuries—History. | Sports medicine—History. | Athletes—Health and hygiene. | Athletes—United States—Biography. | Sports—United States—History.

Classification: LCC RD97 .G44 2017 (print) | LCC RD97 (ebook) DDC 617.1/027—dc23

LC record available at https://lccn.loc.gov/2016042501

For Marshall and Madeline

CONTENTS

Introduction

1 Joan Benoit: The Advent of Arthroscopic Surgery

2 Bernard King: Return to Elite Sports after ACL Injury

3 Hines Ward: Use of Platelet-Rich Plasma and Stem Cells for Active People

4 Phillip Hughes: Use of Protective Equipment in Sports

5 Marc Buoniconti: Catastrophic Injuries in Football

6 Sarah Burke: The Dangers of Extreme Sports

7 Dave Duerson: Long-Term Brain Damage in Football

8 Sam Bowie: Medical Evaluation and Clearance of Athletes to Play

9 Michael Jordan: Return-to-Play Decisions in Sports

10 Hank Gathers: Sudden Cardiac Deaths and Universal Screening

11 Korey Stringer: Exertional Heat Stroke

12 Brandi Chastain: Prevention of ACL Injuries

13 Tommy John: Tommy John Surgery and Youth Sports Injuries

Conclusion

Acknowledgments

Notes

Index

About the Author

INTRODUCTION

March 7, 1970

I realized that something was wrong, Bogataj would recall years later to Philadelphia Daily News columnist Rich Hoffman. I tried not to go, tried to stop myself. But the speed was too big, about 105 kilometers an hour [roughly 65 miles per hour]. So I did everything I was able to do.¹

You might not know the name Vinko Bogataj, but you know who he is—or at least you know his crash.

Earlier that day, Bogataj had left the chain factory in Yugoslavia where he worked, along with his three friends, to drive to Oberstdorf, West Germany. Growing up on a farm in a family with eight children, the 22-year-old set out on that snowy day to compete in a passion of his: ski flying.

Despite working full time, Bogataj was fairly accomplished in the sport that would later become known as ski jumping. He competed more for fun than prize winnings, as his greatest career paydays included $200, a stove, and a color television.²

Little did he know as he set out for Oberstdorf that he would soon become famous—or infamous—depending on one’s perspective.

Having already fallen once, Bogataj faced worsening weather conditions heading into his second jump. Now he faced swirling winds and new snow on the ramp. Race officials shortened the jump out of safety concerns. These days, they wouldn’t even compete in those conditions, Bogataj told Dave Seminara of Real Clear Sports 40 years later.³

Bogataj sped down the ramp, but he lost his balance before he reached the end of the platform. He placed his right hand down, but his legs gave way. He flipped off the side of the jump in a spectacular fashion. He somersaulted through the air, ripping through a sign that read OBERSTDORF at the bottom of the ramp, and nearly crashing into nearby broadcasters, spectators, and race officials.⁴

I could’ve gotten up, I didn’t feel hurt, but they wouldn’t let me, Bogataj told Seminara. They insisted on carrying me off on a stretcher, which I wasn’t happy about because my family was watching on TV.⁵

His family would soon learn that Vinko would be fine, despite crashing at over 60 mph. Bogataj told Hoffman that the violent appearance of what happened had scared the medical staff and onlookers.

I didn’t feel any pain at first. I was just angry it happened. People kept telling me that it had to hurt. It looked so dangerous.⁶

The video footage of that dangerous crash would immortalize Vinko Bogataj. As he would ask in a ceremony to honor the 25th anniversary of the show on which Bogataj’s crash was broadcast, legendary sports host Jim McKay asked the audience, Do you know this man? Probably not. He doesn’t even own a credit card.⁷

Each Saturday for 37 years, Wide World of Sports opened the same way. It featured video clips of a variety of athletic competitions to an instrumental musical fanfare. Host Jim McKay read a narration that became timeless:

Spanning the globe to bring you the constant variety of sport.

The thrill of victory

and the agony of defeat.

The human drama of athletic competition.

This is ABC’s Wide World of Sports.

Vinko Bogataj and his spectacular crash were the agony of defeat.

When Wide World of Sports first aired in 1961, producers ran footage of Irish hurlers colliding during the agony of defeat. In 1970 Dennis Lewin, the coordinating producer for Wild World of Sports between 1966 and 1996, and executive producer Roone Arledge decided to pair Bogataj’s crash footage with the words agony of defeat.⁸

Despite frequently changing the clips throughout the remainder of the opening montage, the show kept the footage of Vinko Bogataj to represent the agony of defeat for the next 28 years. It is difficult to imagine anyone thinking of Wild World of Sports without recalling Bogataj spinning wildly off the ski ramp in Oberstdorf, West Germany. Not everyone appreciated that fact, though.

Doug Wilson produced the show in Oberstdorf for ABC. He recalled that leaders in the sport of ski jumping were never particularly happy about Bogataj’s crash being prominently featured in the Wide World of Sports opening montage. They believed it created a ripple effect week after week, causing hesitation among athletes considering the sport.⁹

Ken Anderson, founder of the website SkiJumpingUSA.com and a former ski jumper himself, argued that ski jumping has never recovered from the damage inflicted by the Wide World of Sports opening montage. Well, absolutely, Anderson said about the damage done by that footage. It’s a well-known sport everywhere else in the sports world, but in North America, the U.S. and Canada, it’s not a sport that is very well known. Because people see something like that, that becomes their whole perception. They don’t see much of the sport. It’s poorly covered here, so that’s all they know about it. It definitely affected recruiting.¹⁰

According to Anderson, ski jumping has struggled in the United States for reasons other than the Wide World of Sports footage. Only a few sites maintained their jumping facilities, and most eventually closed them. Only a handful of ski-jumping clubs currently exist in the country. They are spread out across the United States, so young athletes rarely compete against each other. Travel costs for competitive jumpers, a lack of recreational participants, and the growth of winter sports like snowboarding and freestyle skiing have all contributed to the sport’s decline.¹¹

Despite the widespread perception that ski jumping is dangerous, Anderson argued that it is a safe sport. He noted that a study by the International Ski Federation (Fédération Internationale de Ski, FIS) tracked six snow sport disciplines, including Alpine, freestyle, snowboard, ski jumping, Nordic combine, and cross country, and according to the FIS Injury Surveillance System, only cross-country skiing is safer than ski jumping.¹²

ABC never did a good job of saying, ‘Yeah, but he wasn’t really seriously hurt, and he went back to jumping.’ They just left it there, left it hanging and let people’s perceptions be whatever they might be, Anderson complained.¹³

Wilson recognized the value of the crash footage. Instantaneously, as it happened, I thought it would be a great ‘Agony of Defeat.’ He pointed out that Bogataj could have been very, very badly hurt. If that had happened, it would have been inappropriate to show week after week as the ‘Agony of Defeat.’ ¹⁴

That’s Gotta Hurt examines the intersection of sports and medicine over the last 50 years. While millions of people have seen the footage of Vinko Bogataj’s ski-jumping crash, few viewers saw its outcome. Aides carried the Yugoslav jumper away on a sled and transported him to a local hospital, where he was admitted overnight. Amazingly, Bogataj suffered only a mild concussion.¹⁵ The video of that high-speed trauma, though, might have changed a sport forever.

In the ensuing chapters, I explore a series of injuries that changed their sports—or sports in general—forever. I examine how emerging surgeries, treatments, and prevention strategies affected athletes in many sports.

I discuss how sports medicine has had a tremendous influence on athletes and sports—perhaps more than any change in coaching or training has had. I also examine how sports medicine will continue to influence sports and the athletes who play them for years to come.

It would be fair to say that sports and medicine have always been closely associated. In a 1984 article in the American Journal of Sports Medicine, George A. Snook, MD, presented a thorough review of the history of sports medicine from ancient Greece to the mid-1900s. He asserted that the first recorded sporting competition, the first incident of rule breaking, and the first sports injury were described in the book of Genesis:

And Jacob was left alone; and there wrestled a man with him until the breaking of the day. And when (the man) saw that he prevailed not against (Jacob), he touched the hollow of his thigh; and the hollow of Jacob’s thigh was out of joint as he wrestled with him.¹⁶

In the second century AD, Galen of Pergamon, a prominent surgeon and philosopher of the Roman Empire, was appointed as the first team physician. Pontifex Maximus appointed Galen to serve as physician to the gladiators. He was reappointed to that position five times. He later served as physician to Emperor Marcus Aurelius. During his career, Galen performed extensive anatomical dissections and physiology research, publishing numerous works.¹⁷

Sports medicine likely owes its American origins to Amherst College. In 1854 Edward Hitchcock, MD, became Amherst’s first instructor of physical education and hygiene. Dr. Hitchcock created a physical education system that included running, basketball, and baseball, earning him the label father of physical education. He collected data on sports, diseases, and injuries at the college, publishing a textbook and well over 100 articles. As such, it’s fair to say he was America’s first sports medicine physician and team doctor.¹⁸

In the early 20th century the sport of football faced intense scrutiny for its high injury rate. The government considered banning the sport altogether. Dr. Edward Nichols published two papers on injuries in football, one in 1905 and a second in 1909 after the National Collegiate Athletic Association (NCAA) adopted changes to its rules to make the sport safer. Nichols’s work largely helped to save football.¹⁹

Dr. Mal Stevens played football at Yale University and later became the team’s head coach. Stevens coached football during medical school and while working as an intern, resident, and fellow. He later became president of the American College Football Coaches Association and coauthored a textbook on football injuries. In that work, he advocated pneumatic padding in football helmets. Stevens later became the team physician for the New York Yankees.²⁰

Dr. Augustus Thorndike of Harvard University published what is considered to be the first American sports medicine textbook in 1938, Athletic Injuries: Prevention, Diagnosis, and Treatment. Harvard developed a model for athletic care that largely represents the modern sports medicine team. Harvard’s sports teams had team physicians, athletic trainers, and therapists to treat and rehabilitate injuries and educate the athletes about proper fitness and equipment.²¹

Another key member of the Harvard faculty, Dr. Thomas B. Quigley, served on the American Medical Association’s Committee on the Medical Aspects of Sports. As the committee’s chair, he helped to publish The Bill of Rights for the College Athlete, which pushed for preseason physicals, doctors at sporting events, and physicians being closely involved in the care of the athletes. Dr. Quigley emphasized the need for quality equipment, facilities, officiating, and coaching. He stressed that the medical needs of the athlete should take precedence over any other concerns.

From gladiators in ancient times to gladiators on the gridiron, we know that injuries occur. As Dr. Quigley explained whenever asked about his interest in sports medicine, Whenever young men gather regularly on green autumn fields, or winter ice, or polished wooden floors to dispute the physical possession and position of various leather and rubber objects according to certain rules, sooner or later somebody is going to get hurt.²²

Wide World of Sports aired from 1961 to 1998. The program usually featured sports other than mainstream American sports like football and baseball. Instead, it featured Olympic sports such as skiing and figure skating as well as less traditional sports such as Mexican cliff diving, powerlifting, and firefighters’ competitions.

The show first broadcast sports competitions that went on to become noteworthy in their own right. Wimbledon, the British Open, the Daytona 500, the Indianapolis 500, and the Little League World Series are just a few of the events first broadcast on Wide World of Sports.

As television coverage of sports exploded in the second half of the 20th century, broadcast and cable networks siphoned off much of the programming that had made Wide World of Sports habitual Saturday viewing for decades.²³ Wide World of Sports alone did not cause the increasing prominence that sports acquired in American society, but it certainly accompanied that growth.

A few statistics from different sports reveal how sports—and society—have changed since 1970, the year Vinko Bogataj crashed in West Germany.

In 1970 the average player salary in Major League Baseball (MLB) was $29,303.²⁴ The game’s highest paid player, Willie Mays, earned $135,000 that season.²⁵ Contrast those numbers with 2013, when the average salary reached $3.39 million,²⁶ and Alex Rodriguez collected $29 million.²⁷

The Buffalo Braves National Basketball Association (NBA) franchise was founded in 1970. The team moved to San Diego in 1978. Three years later, Donald Sterling bought the San Diego Clippers for $12.5 million. Steve Ballmer bought the Los Angeles Clippers in the summer of 2014 for $2 billion.²⁸

On January 11, 1970, approximately 44.3 million viewers in the United States watched the Kansas City Chiefs defeat the Minnesota Vikings in Super Bowl IV. Approximately 111.5 million people tuned in to see the Seattle Seahawks crush the Denver Broncos in Super Bowl XLVIII on February 2, 2014.²⁹

Many more kids play sports today than played decades ago. In fact, more than 1 million young athletes currently play high school football, and 2.58 million children between the ages of 6 and 14 played tackle football in the United States in 2013.³⁰

As any National Football League (NFL) fan can tell you, injuries are a normal part of sports. It should be no surprise that along with the growing popularity of the athletes comes a heightened prominence for the doctors who treat their injuries.

Doctors travel with their teams as they play all over the country. They obtain magnetic resonance images (MRIs) minutes after injuries occur. Websites feature medical analysis of injuries and try to predict when athletes will return to play. And fans can rarely watch an hour of ESPN’s SportsCenter without hearing that a player will travel to undergo surgery by Dr. James Andrews.

In fact, I will be doing an interview on SiriusXM Fantasy Sports Radio later today (on the day I am writing this introduction). We will discuss all of the injuries in the NFL this weekend: Robert Griffin III, Jamaal Charles, DeSean Jackson, A. J. Green, and others.

The fact that fantasy sports exist at all and are so popular—and that people want to hear from an orthopaedic surgeon to explain the injuries—shows how much sports and sports medicine have changed.

That’s Gotta Hurt discusses the injuries that brought sports—and sports medicine—to where we are today.

I examine key injuries that changed the athletes and subsequently the treatment of athletes and active individuals: Joan Benoit’s arthroscopic knee surgery 17 days before she competed in the US Olympic marathon trials; Bernard King’s anterior cruciate ligament (ACL) injury and unprecedented rehabilitation and return to sports; and Hines Ward’s use of a novel treatment—platelet-rich plasma—for a medial collateral ligament (MCL) injury of the knee days before playing in the Super Bowl.

I also discuss injuries that changed their sports, leading to rules changes, adoption of protective equipment, or even calls for the elimination of the sport: the death of cricket star Phillip Hughes and severe injuries from the ball striking players in cricket and baseball; Marc Buoniconti’s quadriplegia after a tackling injury and changes to decrease catastrophic cervical spine injuries; the death of freestyle skier Sarah Burke and snowmobiler Caleb Moore and the dangers of extreme sports; and Dave Duerson’s suicide and the role of concussions and repetitive subconcussive blows to the head, leading to chronic traumatic encephalopathy (CTE).

The discussion then turns to injuries that have impacted athletes and sports generally and will affect treatment of future athletes in all sports: Sam Bowie and the complex evaluation of athletes to try to predict whether they will stay healthy; Michael Jordan’s navicular fracture and the difficult issues that arise when trying to determine appropriate return to play for professional athletes; the sudden cardiac death of college basketball star Hank Gathers and the intense debate over mandatory cardiac screening of athletes; Minnesota Vikings tackle Korey Stringer’s death from exertional heat stroke; ACL injuries among Brandi Chastain, other members of the US Women’s National Soccer Team, and young female athletes generally, and the development of injury prevention programs to decrease them; and Tommy John’s landmark elbow surgery and the epidemic of youth pitching injuries decades later.

I wrap up this journey by exploring what could lie ahead for sports and the field of sports medicine, looking ahead not only to new treatments and prevention strategies, but also to where we could be headed in terms of ethics, legal dilemmas, and conflicts of interest.

And within this entire discussion of the influence of sports medicine on sports—and vice versa—at the elite level, I show how these changes have influenced and will continue to influence the far more numerous youth athletes and adult weekend warriors.

Wide World of Sports remained a staple of American sports for 37 years. The umbrella title ABC’s Wide World of Sports was used for a number of years after that, so the footage of that crash in Oberstdorf remained in the opening montage decades after the event happened.

Maybe it was 10 years later, about 1980, there was a suggestion that maybe it was time to replace Vinko’s fall, Wilson recounted. Roone Arledge, in his brilliance, sort of tugged at his sweater, as was his habit when he didn’t want something to happen or wanted to make a point. Basically he said, ‘Why are we doing that?’ What that meant was we shouldn’t do it, and we didn’t. It stayed in the rest of the history of Wide World. There was a moment where people were talking about replacing it, and Roone put a stop to that. He knew what he had. He had a signature thing. I mean, everybody remembers it. Everybody who ever watched the show. You mention the ‘Agony of Defeat,’ and people think of the ski jumper.³¹

Bogataj became somewhat of a celebrity, although it was years before he realized it. He found out that he was famous, or his fall was famous, in Oscar’s, the coffee shop in the Waldorf, Wilson recalled. We brought him over with an interpreter and his wife, and put them up in the Waldorf. He was a forklift driver in an iron foundry in Yugoslavia. He was speaking Serbo-Croatian in the coffee shop, and some of the waiters coincidentally in Oscar’s were Serbo-Croatian. They don’t normally hear their language, so when they stopped and they heard that language, they inquired. When they found out who he was, they went nuts. They went over to the restaurant saying, ‘See the guy in the booth there? He’s the ‘Agony of Defeat.’ ³²

We might not remember Vinko Bogataj by name, but we will always remember the agony of defeat guy. In fact, at the 20th anniversary celebration for Wide World of Sports in 1981, Bogataj received a standing ovation and the loudest applause, more than Nadia Comaneci and the 1980 US Olympic hockey team. Muhammad Ali asked Bogataj for his autograph.³³

Vinko Bogataj has settled back into his life as a forklift operator and a painter in Lesce, Slovenia. Despite his relative fame, he hopes that athletes take home one message from watching his crash: Every time you fall, you have to get back up.³⁴

1 / JOAN BENOIT

The Advent of Arthroscopic Surgery

May 12, 1984

Olympia, Washington, was the site of what would be a historic race. In all, 238 runners left the starting line in the US qualifier for the 1984 Olympic marathon. That marathon would soon become a milestone as well, marking the first ever women’s marathon in the Olympics.¹

One of those 238 competitors made the race historic for an entirely different reason. Joan Benoit left the starting line only 17 days after undergoing knee surgery.

Benoit started the race quickly, staying in the front of the pack. Due to her recent injuries, she ran cautiously for the first 12 miles.

After running 5:40 miles for almost half of the race, Benoit increased the pace and quickly built a large lead. She knew, though, that the race wasn’t over. Three days before the trials, Benoit had told Kenny Moore of Sports Illustrated, Those last six miles are scary. Anything can happen.²

Benoit had a 400-yard lead at the 17-mile mark. There, standing on the side of the road, stood her Athletics West coach, Bob Sevene. Sevene, who had helped guide her through her race preparation and recovery from surgery, tried to gauge her status.

Sev, I’m all right, Benoit told him.

Her coach jumped for joy right there on the side of the road. When she says that, Sevene told Moore, you can go wait in the bar. The race is over.³

Benoit might have been all right, but the race was far from over. With those last six scary miles left, Benoit’s legs became weak, including her surgically repaired right knee. She slowed her pace to six-minute miles, but she hung on to win the race in 2:31:04.⁴

Many years later, in an interview with Amby Burfoot of Runner’s World, she called the 1984 Olympic trials the race of her life.⁵

Sevene professed that Benoit’s mental strength, especially in races, was unlike anything he has ever seen. The sport is 90% ability and attitude, 5% coaching, and 5% luck. In her case, her ability is mental as well as physical.⁶ Benoit’s ability to fight through 26.2 miles and beat the entire field of healthy runners serves as a testament to that mental strength.

With her win, she went on to compete in Los Angeles against many of the best marathoners in the world. In 1984 the Soviet Union and its satellite states in Eastern Europe boycotted the Olympic Games in response to the US pullout from the 1980 Games over the Soviet invasion of Afghanistan. Even without the athletes from the boycotting Communist nations, Benoit would soon face some of the top female athletes in the world, including Norway’s Grete Waitz and Ingrid Kristiansen and Portugal’s Rosa Mota. She knew she still had work to do.

I feel I’ve really been tested, said a relieved Benoit to Moore after the trials. The knee, the operation, the hamstring, the emotional ups and downs. Somehow, with all the people who helped, all the people who love me, I made it. I can’t believe it. Now I’m looking forward to two months of solid training.⁷

Sevene became emotional as he described the end of the Olympic trials and Benoit’s TV interview after she won. He still has a picture of her in his arms after that race. He held her because she didn’t want to be seen on television crying.⁸

Bob Sevene knew Benoit could train and win the Olympic marathon, since she had just overcome a bigger obstacle than any competitor. As she crossed the finish line, Sevene held Benoit and exclaimed, The greatest damn athlete in the world.⁹

Often considered the greatest marathoner of all time, Joan Benoit was widely known to be a religious trainer early in her career. She ran about 200 miles each week. Perhaps it was that volume of training that led to the knee injury that almost kept her out of the Olympics.

As the 1984 Olympic trials approached, Benoit quit her job and moved to her home state of Maine to train full time. Rumors spread throughout the running world that she was training 130 miles per week with sub-five-minute interval miles.¹⁰

Sevene claimed that Benoit was doing some scary workouts to prepare for the trials. Since it was winter in Maine, she trained on the flat 200-meter indoor track at Bates College. I would tell her to run 4:55 in practice, and she was running 4:40s for the mile, he remembered.¹¹

On March 16, just under two months before the race in Olympia, a normal training run threatened to derail her quest.

When she was 14 miles into a 20-mile run, Benoit felt a catching sensation in her right knee. Within a mile she developed pain that completely shut her down. It was the first time she had ever quit a training run.

Joanie was training in Maine, and I was out in Eugene, Oregon, with Athletics West, Sevene recalled. I got a call at 7:00 in the morning of all things. Joanie had just gone out on her run. She told me that her knee locked up, and of course I just said, ‘Don’t worry about it. It’s probably an IT band problem,’ because it was on the lateral knee. Of course Joanie knew her body.¹²

As many runners do with new onset pain, Benoit took a few days off. The pain improved, but it returned quickly once she resumed training. She decided to try a cortisone shot, which gave her 10 days of relief. But soon she had to stop another training session and walk.

After a second cortisone injection into her ailing knee and five more days of rest, she still had pain.¹³ She flew to Eugene, Oregon, the hometown of her coach. Sevene arranged a consultation with an orthopaedic surgeon in Eugene, Dr. Stan James.

Dr. James prescribed five more days of rest and Butazolidin, an anti-inflammatory medication. Benoit, who had finished 10 marathons and risked missing the 11th, was not pleased.

Joanie immediately came outside and for the first time I ever heard her swear in her life, Sevene remembered. She was so pissed off because she said, ‘Sev, there’s something in my knee.’ ¹⁴

After five days of rest, Benoit’s fears proved to be true. During the 10-mile test run Dr. James had suggested she do on April 24, she only completed 3 miles before she had to walk. When she told him of her setback, he gave her a final option.

He said I only had one option—surgery, she told Moore. Actually I was hoping he’d say that because I thought there was something there. But to do it with so little time …¹⁵

They chose to proceed with arthroscopic surgery the next day, April 25, just 17 days before the Olympic trials.

As the surgery approached, Dr. James remained pessimistic that the 26-year-old world record holder could recover quickly enough to qualify for the Olympics. He told Frank Litsky of the New York Times, It is possible, not probable, she can run in 12 to 14 days. We’ll have to play that by ear. It would be nice if the trials were six weeks away and not three weeks, so we’re pressing the issue.

Benoit’s record time of 2:22:43 in the Boston Marathon a year earlier would have won every Olympic marathon contest before 1960—for men. And it was fast enough to earn her a spot on the 1980 Olympic team, only four years earlier, based on the times finished by the men’s qualifiers.

Now knee surgery threatened to keep her off the team that would compete in the first-ever Olympic marathon for women. But she entered the operating room that day with a backup plan.

If I don’t qualify for the marathon, Benoit told Litsky prior to going under the knife, I think I’ll try the 3,000. I have a possibility of making the team. But it’s not the same. My chances in the Olympic marathon are pretty good, but in the 3,000 I’m not world class.¹⁶

At the time, she held the American record for 25 kilometers, 10 kilometers, 10 miles, and the half marathon in addition to the world record for the marathon. She had her heart set on the marathon, though. Now this knee injury threatened her chance of winning a gold medal for her country.

This injury is bad, Sevene warned Litsky ahead of the procedure, not so much for her as for the country. She had the best chance of any American woman, even Mary Decker, to win a gold medal in track.¹⁷

Arthroscopic knee surgery was practically unheard of in the world of athletes and orthopaedic surgery until the mid-1970s. Its use grew quickly in the years leading up to Benoit’s surgery.

Traditionally when an athlete suffered a musculoskeletal injury, such as a torn ligament or meniscus in the knee, the orthopaedic surgeon sliced open the knee, making an incision six to eight inches long to look inside the knee, determine what structures were damaged, and treat them.

Many of these open surgeries served their underlying purpose, but they were invasive. Recovery took months—not just time spent overcoming the ligament or meniscal work, but also to recover from the skin and muscle damage the surgery inflicted.

Arthroscopy promised to deliver equal ability for surgeons to fix whatever damage had led to the surgery with less trauma to the knee. Instead of one or more long incisions, the surgeon made two or three small incisions barely big enough to insert instruments the size of ink pens. Theoretically, with less soft tissue trauma, the patient would regain range of motion and strength much more quickly than after an open surgery.

The role of arthroscopy in the repertoire of orthopaedic surgeons was just developing around the time Dr. James used an arthroscope to look into Benoit’s knee.

One of the challenges facing an orthopaedic surgeon treating an athlete’s injury in those days was figuring out exactly what the injury was. X-rays only show bones. They are very helpful, to be sure, but often a young competitor has a more complex injury than simply a broken bone around the knee or arthritis.

What X-rays do not show are the soft tissue structures of the knee. These structures include the meniscus, or the C-shaped piece of cartilage between the femur and tibia that serves a shock-absorbing function. Articular cartilage, or the cartilage lining of the bones, also plays a role in absorbing impact and helps the bones glide over each other smoothly as the knee goes through a range of motion. The ligaments that stabilize the knee are likewise not visualized on X-rays.

Orthopaedic surgeons often used arthrograms to improve their diagnostic capabilities. An arthrogram is a radiology test in which contrast material injected into the knee is used to enlarge the joint and provide better images of small structures within it. Arthrography gave physicians a better ability to confirm or refute their impressions of injuries based on an athlete’s history and physical examination, but it still did not diagnose many joint injuries.

Magnetic resonance imaging was first available for use in health care in the early 1980s, but it was not a commonly used diagnostic tool by orthopaedic surgeons in Benoit’s day.

Now a minimally invasive surgery provided surgeons an opportunity to look inside a patient’s knee and figure out exactly what the cause of his or her symptoms was. If the surgeon found the cause of the pain, popping, or buckling, it could be treated on the spot.

This diagnostic and therapeutic option would change the care of athletes—and the field of sports medicine—forever.

If a marathon runner developed a sharp knee pain and catching sensation in her knee today, as Joan Benoit did on that training run, how might the diagnosis and treatment differ?

First of all, nagging knee pain with running can be a very common malady for avid runners. She might notice a localized pain in one part of her knee only with activity—pain with jogging but also physical activities like going up and down stairs or with squats or leg presses in the gym. She likely wouldn’t have pain at rest. There also could be symptoms other than pain, like a catching or snapping sensation in a specific location in her knee. Swelling could accompany these symptoms.

Thinking her pain is not serious, she probably would take a few days off from running or switch to biking or swimming to see if her troubles resolved. To be fair, many runners are extremely determined—some might even say stubborn—so she might try to run through the pain. She might use over-the-counter anti-inflammatory medications, ice, or a knee sleeve. Only when she cannot run at all or at least can’t run as well as she would like does she decide to see her doctor or an orthopaedic surgeon.

In that first orthopaedic surgery visit, the surgeon performs a history and physical examination. The surgeon asks a number of questions and performs a host of exam tests to determine the cause of the pain. He will usually obtain X-rays of the knee as well. Often the X-rays are negative, but they can show bony changes like osteoarthritis or stress fractures in runners.

Depending on the location of her pain and other knee symptoms, the orthopaedic surgeon might suspect an overuse condition such as patellofemoral pain, iliotibial band syndrome, or a painful plica. Often the surgeon does not order an MRI at the first visit unless he suspects an injury that requires surgery, like a meniscus tear. Occasionally though, the surgeon might obtain an MRI for a high-level athlete to ensure that he or she is not doing any further harm to the knee.

The surgeon might send the runner to work with a physical therapist if he does not suspect structural damage. In