Considering Non-surgical Treatments for Sports Injuries

When athletes get injured, they often have one major worry: will I need surgery? Surgery, while often necessary for certain sports medicine injuries, is far from the only option. There are many considerations for the care of an acute injury or chronic pain. Your care team will work with you to determine the best plan of action to get you back out there as quickly as possible, and to optimize your future performance.

In this Q&A, Dana Kotler, MD, Mass General Brigham Sports Medicine specialist and founder and co-director of the Cycling Medicine Program at Spaulding Outpatient Center, describes how she assesses and treats athletes, and in particular, cyclists—from pro racers to weekend riders—and shares her perspective on healing from sports injuries.

Q: How do you help athletes who have experienced a sports medicine injury understand the various treatment options available to them?

A: I look at everything through the lens of what I can offer as a physician, and I explain to patients that the most important thing is getting to the right diagnosis. For example, if your hip hurts, is it always a problem with your hip? Or is it a problem with your muscles or tendons, or something coming from your back? So first, we have to get to the bottom of what the diagnosis is, or at least get a good sense of what the contributing factors are. 

I divide treatment into four categories: medications, physical or occupational therapy, interventional procedures (joint injections, etc.) and surgeries. Sometimes you need a medication to help settle things down. If you're in acute pain, you can't sleep at night or otherwise can't function, that's where medications come in. And then there's physical therapy, occupational therapy or sometimes speech therapy. Some athletes may work with an athletic trainer or a massage therapist, or even a chiropractor.

If I want someone to have more hands-on treatment versus more exercise, then we go to interventional procedures, and that's also kind of a big category. There are joint injections. You can put cortisone in any number of places, usually joints.

Lastly, there are surgical referrals. For me, the surgical referral comes when there's a problem that we still couldn't successfully tackle. Obviously, if I see something really wrong right off the bat, I will get patients to a surgeon right away. But if it's someone, for example, who's had years of progressive shoulder pain and is now having trouble lifting their arm, that's the kind of thing we can treat more conservatively at first. And then there may be a role for surgery down the road.

Q: How do you discuss treatment options with patients who are unsure about whether they want to undergo surgery?

A: If it's something like an ACL, for a young active person, surgery is probably going to be done sooner rather than later. That being said, nobody has to get surgery. And if their decision is not to get surgery, I'm going to work as hard as I can to make sure that they have the best possible outcome outside of surgery. I always tell my patients that it's never a bad idea to meet a surgeon, get their opinion, have a conversation, see if you have a connection and see if it's a good fit.

Q: How do you collaborate with your team and your network to treat athletes?

A: Most of the time, I would say the most direct collaboration is between physician and physical therapist, but certainly also between physiatrist and surgeon. Concussion is also a condition that requires a collaborative effort, so we communicate a lot with traumatic brain injury specialists who focus on that.

Just recently I had a patient who came in with a foot injury. He was a college athlete and he had seen a couple of different people around the network for foot pain and was referred to me. We were just wrapping up, and we'd come up with a plan and he burst into tears and just started sobbing. It became apparent that there was a lot going on in his life relative to the pressures of being a college athlete. So he ended up seeing one of our pain psychologists at the Newton-Wellesley Pain Center. One of the values of coming to Mass General Brigham is the vast network of medical professionals who can help treat the whole athlete.

"Being an athlete is part of your identity. And when that's taken away due to an injury, it leaves a sort of hole in your life. I understand that and want to help my patients get back to their sport as soon as they can."

Q: In the Cycling Medicine Program, how you work with cyclists assess and treat injuries and optimize performance?

A: I started the Cycling Medicine Program early in my career, because I knew that it was something that I wanted to try and do. I met Greg Roboto, about six or seven years ago—he's a physical therapist who is also a very accomplished bike fitter and runs a bike fitting school. Our physical evaluations at the clinic are 90 minutes, and they are collaborative, so we are both present, with both of our sets of eyes on the patient. Usually I start with a history and a basic physical exam. Greg takes over and assesses the things that he's looking for as a physical therapist, as well as looking at their bike. When we look at the bike, we document all the measurements; then we get the athlete on the bike, and we do basically a biomechanical assessment.

We've seen racers, we've seen pros and we've seen competitive athletes, but mostly we see commuters trying to get to work more quickly. They just need to make it 20 minutes on their bike and they're having so much knee pain or back pain that they can't do it. We've seen every kind of bike that you can imagine. We've seen lots and lots of road bikes, mountain bikes, hybrid bikes—we've seen people coming in on their old bike from the seventies or the bike they pulled out of their garage that hasn't been touched in forever. I'm pretty sure we even saw a tandem bike. So, we've seen every type of cyclist.

Q: How do you think being an athlete yourself affects the way you communicate with patients who come in for treatment?

A: I am an athlete, but I'm also someone who's been injured a lot, and that informs the way I work with patients. I know what it feels like to get an MRI. I can tell you that how long it takes and how loud it is. I had back surgery a couple of years ago and I was at the point where all I could do was ride my bike, but I couldn't even really get on and off my bike. My experience is mostly in cycling, and triathlon by extension. I don't know that much about rowing, for example, but I know where to look. And I think patients really respond well when they meet with someone who knows the specific nuances of their sport.

Being an athlete is part of your identity. And when that's taken away due to an injury, it leaves a sort of hole in your life. I understand that and want to help my patients get back to their sport as soon as they can.