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Managing Pro Teams in the COVID Era
ADULT ORTHOPAEDICS
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Managing Pro Teams in the COVID Era

HSS team physicians share their experiences from inside the bubble

Doctors and physical therapists from HSS have the distinction of being the team physicians and athletic trainers for more than 25 professional and collegiate sports teams. During the COVID-19 pandemic, many were called on to play integral roles in shaping and enforcing policies and procedures, monitoring player health, and enabling play to resume safely.

What was your role during the COVID-19 pandemic?
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DR. CALLAHAN:

When this all started, everything was new — there was no playbook. Information was coming fast and furious and was often contradictory. We had to sort through what was real and what was not. My role was to make sure that everyone from players to coaches to management received the information they needed to help them stay safe and healthy, and to make sure that anyone who contracted COVID or was exposed to it got the care they needed.

there was no playbook. Information was coming fast and furious and was often contradictory.
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DR. McElheny:

As a primary care sports medicine team physician for the New York Mets, I stepped into the roles of Infection Control Prevention Coordinator and Compliance Officer. This involved regular collaboration with MLB, our Medical Director, and an internal task force comprised of representation from all facets of the organization. Our charge was to implement and enforce safety protocols in accordance with directives from the league and our team.

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DR. Lingor:

Once the NHL started to announce the reopening, we had to look at all our procedures to make sure that when we were bringing players back, it was safe and consistent with league’s policies. Also, more than half of NHL players are international, so it was important to keep tabs on what was happening in Europe with travel restrictions and other developments. We had to allow time to get players back in a timely manner so they could quarantine and be tested appropriately.

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DR. DiFiori:

As the NBA’s Sports Medicine Director, I began monitoring the developments in late December, and we as a group began to implement prevention and identification strategies in early February. On March 11, we made the decision to suspend the season. From that point forward, we began to explore if it would be possible to resume play. We built a team of experts from across the country and spent considerable time reviewing testing platforms and how we could potentially apply them in a professional sport. Throughout, our priority was maintaining health and safety. We were also very attuned to the need to not divert resources from healthcare workers, COVID-19 patients and the public. Ultimately, we developed a 113-page policy manual to restart the season.

We were also very attuned to the need to not divert resources from healthcare workers, COVID patients and the public.
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DR. Nwachukwu:

I was one of the defacto orthopaedic surgeons for all 22 teams in the NBA bubble, which was daunting. But it was a unique challenge, and it really allowed me to operate at the peak of my ability. During my time there, I covered a total of 46 games. Team physicians typically cover 41 games during the course of the entire season.

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Dr. Rodeo:

The NFL continues to study the ever-changing environment around COVID-19 infections. We have a number of expert consultants who help us to follow the evolving data on COVID-19, and to use this to continually update and optimize our protocols. The NFL has developed very detailed protocols for testing, use of PPE during travel and game day, contact tracing, and other risk mitigation strategies, and these protocols are discussed regularly amongst our NFL Team Physicians Society.

Dr. Nwachukwu was chosen to participate in the NBA bubble season through his role as a medical consultant for the NBA Players' Association.
The scene at Citi Field, home of the New York Mets, was a little different during the shortened 2020 season.
The New York Rangers played their abbreviated season in the NHL bubble in Canada.
Even essential services, like haircuts, were moved inside the NBA bubble to keep players and staff safe and allow them to follow guidelines.
As part of health protocols, staff and players received testing for COVID-19 at on-site facilities before they were allowed access.
Precautions in place at the NBA bubble in Orlando, Florida, during the shortened 2020 season.
What were precautions and preparation like?
DR. McElheny:

MLB instructed us to risk stratify about 300 people deemed to be essential on-site employees into one of three tiers based on access to players, facilities, and testing. We created a home and facility screening process and developed specific hygiene protocols for our facilities as well as an emergency action plan for if someone were to test positive at home or on the road. While the testing was consistent across the league and directed by MLB, acute testing plans were the responsibility of each individual team. HSS provided tremendous support for our acute testing needs. Return to play protocols for athletes who tested positive for COVID-19 also had to be developed.

DR. DiFiori:

Given the highly infectious nature of the virus, we felt that daily testing with rapid turnaround time was essential. The strategy was to test frequently enough that if a player or a coach were to test positive, we could proceed as long as everyone else continued to test negative, otherwise we would not be able to resume competition. We also established health and safety protocols and infection control protocols for facilities. These concepts and strategies were employed in slightly modified ways across the different sports leagues.

DR. Lingor:

Similar to the NBA, the NHL also implemented a bubble, in which we were confined to the hotel, practice arena and game arena. We were bussed to the training facilities — everything was very strict, as you’d expect. People were by and large following the rules because they didn’t want to compromise the bubble.

Did you see a noticeable difference in the rate of injury?
DR. Nwachukwu:

Although there were some high-profile injuries and surgeries, there was not a rash of injuries. Safe restart was achieved largely by load monitoring, a customized approach to increasing playing time and basketball activity. With the shutdown, there was a disparity in access to basketball and conditioning. Some players could stay in shape because they had access to private gyms and workout facilities, while others did not touch a basketball between March and July. As such, it was necessary to understand where those players were and to develop a customized approach to their restart.

DR. Lingor:

We were curious and somewhat concerned that we would see more hip strains and other issues specific to hockey. During a normal off-season, players do have access to ice, but this year we didn’t until the league said it was OK to open up. But the season wasn’t that different from an injury standpoint.

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it was necessary to understand where those players were and to develop a customized approach to their restart.
DR. RODEO:

There has been some concern that there would be more soft-tissue and overuse injuries due to the lack of a normal off-season program, but we’re waiting for the final numbers to see if there has been a statistically significant increase. But it could have been a lot worse. The NFL was very good about planning and implementing a very gradual ramp-up, cautious and slow, anticipating that players would come in suboptimally conditioned. That might have helped.

We collect so much data in the NFL, on every single thing, including injuries. The players all wear a GPS device during practice so we know how much they run, their distance, volume, velocity, frequency, and intensity, so there’s a treasure trove of data. It’ll be great to look back and really correlate all this once the season ends.

Can you see any of the changes staying in place moving forward?
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Dr. Nwachukwu provided medical coverage for all teams in the NBA bubble.
DR. Nwachukwu:

There are a number of solutions that were crafted for the NBA bubble that I could envision becoming a part of regular NBA team coverage, such as on-site imaging. In some scenarios, a player would get hurt in the first quarter and by the end of the game, an MRI had been performed and a diagnosis established.

To a certain degree HSS’s collaboration with the Brooklyn Nets serves as a prototype for this type of expedited healthcare delivery. The team’s practice facility is at the same place where physicians see patients. An injured athlete can have an MRI, CT, or x-ray and see a physical therapist, orthopaedic surgeon or primary care sports medicine physician, all on-site.

HSS’s collaboration with the Brooklyn Nets serves as a prototype for this type of expedited healthcare delivery.
DR. Rodeo:

The simple emphasis on hygiene is so important. Flu is a real issue for athletes. Many years ago, when I began working with the US Olympic Swimming team, I encouraged flu shots. Because those athletes live together, work out together, and do so much else together. We’ve seen flu rampage through a team. You’re only sick for two or three days, but if it’s the wrong two or three days during a major competition, you can really decimate your team.

What personal or professional lessons did you come away with from this experience?
DR. McElheny:

Obviously, major orthopaedic injuries are crucial to prevent whenever possible as they can be season-ending. However, I think COVID-19 has shown us that illness containment and prevention must also be a priority. While the average length of time a player is out for illness is typically much shorter than that for a major musculoskeletal injury, multiple players out due to lack of communicable illness containment leads to an exponential rise in time, performance, and financial loss. Our goal as sports medicine physicians is to keep players on the field, and this includes both injury and illness prevention.

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The health and safety of athletes is always the priority. But that includes things like addressing mental health needs.
DR. DiFiori:

The health and safety of athletes is always the priority. But the challenge of ensuring that in a pandemic demanded a level of detail, collaboration and execution that was unprecedented. We worked together with the Players’ Association to ensure that all aspects of care were addressed, from nutrition to mental health to injury prevention. The players did a fantastic job of adapting to the bubble, and in the end it was successful, with the season being completed, a champion crowned, and health and safety maintained throughout.

DR. Callahan:

I’ve always been a big believer that communication is paramount, and this situation certainly proved that. It’s important to stay nimble, flexible and resilient, and be able to pivot quickly. It’s also important to stay as humble and transparent as possible, to maintain a level of humility. This experience reinforced for me how wonderful it truly is to work in healthcare. I’ve never been more proud of the group of physicians I work with at HSS. Every one of them stepped up. And I’ve also learned you can get a lot done through Zoom!

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