How a Soccer Player Became a Physician for US Teams

How a Soccer Player Became a Physician for US Teams

John C. Hayes; Raymond R. (Rocco) Monto, MD

Editor's Note:
Among the teams competing for soccer gold in London will be the US Men's National Team. Although Rocco Monto, MD, won't be there, he will be rooting for the players, many of whom he knows personally. Dr. Monto is an orthopedic surgeon at Nantucket Cottage Hospital in Nantucket, Massachusetts, and a member of a group that has provided orthopedic care to youth and adult US soccer programs since 1993. He is also a former professional soccer player. Dr. Monto discussed with Medscape the orthopedic issues in team soccer and the perspective that athlete-orthopedists bring to sports medicine.
Medscape: Could you describe your relationship to the US Olympic soccer team?
Dr. Monto: I'm a member of US Soccer Team Physicians, and we are a group of doctors that cover all of the US soccer programs, one of which is the Olympic team -- but we have many teams in that corral. I am not the US Olympic team doctor for the soccer team this year, but I have represented the United States as the team physician, or one of the team physicians, since 1993.
In addition, I've been a consultant to the Real Madrid CF soccer team, the US Ski Team, and the Boston Ballet, among others.

Rocco Monto, MD (Photo by John Dorton, ISI)

Medscape: What brought you to this position?
Dr. Monto: I was a soccer player myself. I was a college All-American soccer player and played some professional ball before I went to medical school, so I've always had an interest in the game.
As a patient with many injuries during my career, going into orthopedics was natural. A lot of guys in my field are former athletes. It's what draws us to the field of orthopedics and sports medicine in particular.
Medscape: I was struck by how many names cropped up when I searched orthopedics, orthopedic physicians, and the Olympics.
Dr. Monto: You see a lot of them who are now productive orthopedic surgeons working in sports medicine. It's a natural fit for us as athletes. We know how to relate to athletic patients, and we know their sense of vulnerability. It really makes for a good match between doctor and patient.

Types of Injuries

Medscape: Could you describe the types of orthopedic injuries that are most common among soccer players?
Dr. Monto: Probably the most common injuries are the ankle sprain and the hamstring strain. There are very few players who can make it through a career without those injuries. After that would come fractures and typical lower extremity injuries. These are less common but can be more severe.
In soccer, we also have a lot of heading, and so concussive injuries and concussions have become a much more identified injury. It's probably no more common than it's always been, but we're identifying it with more prevalence now, and that's just because we're all tuned into the injury and the injury pattern more than we were before.
As for other injuries, surprisingly we see a lot of upper extremity injuries in soccer, usually from falls, whether it's shoulder dislocations or wrist injuries. After that are the ligament injuries, the anterior cruciate ligament (ACL) being the most common, particularly in female soccer players.
Medscape: Have you seen injuries that you would consider highly unusual in soccer?
Dr. Monto: I'm always surprised that we don't see more dental injuries than we do. I had my teeth knocked out as a college player. You would expect to see more than we actually do, with all the flying elbows and kicking that goes on. When we do see them, they can be quite severe. Most players don't wear mouth protection.

Avoiding Injuries

Medscape: When you're trying to teach people how to protect against these injuries, what kind of training is provided, or what do they have to do to make sure they're in condition to avoid an injury? I would imagine it's a matter of playing style but also certain types of strengthening.
Dr. Monto: The real revolution in soccer training in the past 15 years has been the addition of strength training. I think it's interesting that in our sport, there are many different philosophies, when you look at different countries, teams, and leagues and how they approach training. Despite those wide variations, however, the injury patterns remain fairly constant. Some of the things we can't change.
Things we have had success improving have been the incidence of ACL tears, particularly among women. Bert Mandelbaum, MD, of Santa Monica Orthopaedic and Sports Medicine Group, has done some fantastic work in helping women learn the risk factors that lead to ACL tears and the imbalance of the hamstring and quadricep muscles and how they land after they jump. Along with FIFA (Fédération Internationale de Football Association), our worldwide soccer group has developed training techniques to try to help the athletes avoid those injuries.
Medscape: Are there other Olympic competitions that have risks similar to soccer's?
Dr. Monto: It would be similar to men's team handball. I worked with the US handball team several years ago, and many of the injuries I see in soccer are similar to those in team handball. You see some of these in other sports as well, such as basketball.
A lot of the injuries that happen in soccer are noncontact. They happen away from the run of play, particularly ACL injuries. These injuries happen when you land after a jump or while trapping the ball, and there is a quick twist of the knee. The land-and-pivot problem is common to many sports.

Getting Back to the Field Sooner

Medscape: Are new therapies or techniques allowing soccer players to return to play earlier after an injury?
Dr. Monto: We've been much more open to the use of orthobiologic treatments, whether that's platelet-rich plasma treatments or more novel physical therapy approaches. We've gotten much better in getting our athletes back quicker, but as Freddie Fu, MD, in Pittsburgh, Pennsylvania, says, you can only heal so fast. We've pushed it without using any type of real medications or other potentially problematic techniques -- just using aggressive physical therapy and treatment and letting the body use its ability to heal. We're much better at doing that.
I'd say the biggest advance has been in using platelet-rich plasma and other types of treatments where we use growth factors to try to help people heal their muscle strains more quickly. In the past 2 years, that's been approved by the Olympic Committee and is now okay for use in Olympic athletes. It's not really a performance enhancer.
Platelet-rich plasma and bone marrow aspirate concentrate for more severe injuries are really the future in nonsurgical treatment of muscle strains, medial collateral ligament tears, and ankle sprains.

Bonding With the Athletes

Medscape: What about your experience as an athlete has enhanced your knowledge of orthopedics?
Dr. Monto: As an athlete who's become an orthopedic surgeon, I think the one thing that I took with me is the importance of the bond between the physician and the athlete and the importance of the personal relationship. A lot of trust is required, and gaining an athlete's trust is the most difficult part of being an orthopedic surgeon.
You really must have walked the walk to understand what athletes go through and the importance of decisions that might not be important to someone else. Whereas a doctor might feel that making next week's game isn't important, to an athlete it can mean the difference between completing a career successfully or not. You may be getting a player at the end of his career, and you need to understand how critical a little bit more time for him can be. You learn this eventually as a surgeon, but I think you learn it much earlier as an athlete.
Medscape: That presents an interesting dilemma.
Dr. Monto: Yes. This is where a surgeon has to have a very strong ethical and moral compass, because an athlete may be willing to take much higher risk than the surgeon will. This is where the bond and the trust come under a test, and you really have to put yourself in the athlete's shoes a little bit and understand where they're coming from, and also you have to communicate with them where you are too.
Obviously, no one wants to send an athlete to one last game that ends with them unable to walk right the rest of their lives. Nobody wants to put anyone in those kinds of precarious positions -- but again, it's all about relative value. Just as it's important to get a carpenter back to work as quickly as possible, it's also important to get the athlete back.
Then we have the pressures from fans, the media, owners, players, and other various interests -- sponsors and things like that, especially with the professionalism now that's pervasive in all the Olympic sports and test sports (women's boxing this year, and golf and rugby sevens to be added in 2016). These are all competing interests that you have to take into account to come up with the best compromise for the athlete.
Medscape: What do you most enjoy about being part of the US Soccer Team Physicians?
Dr. Monto: My favorites have always been the under-17 men's teams, because they are the stars of tomorrow. They still have an innocence and joy about the way they play and the way in which they approach the game and life, and it's always fantastic. It's just a real charge to work with those guys.
I remember being the doctor when Landon Donovan was a 16-year-old just making his way and suddenly we're playing in the Junior World Cup. [Landon Donovan is on the Los Angeles Galaxy team and is one of the world's most highly paid soccer players.] Those are fantastic experiences. They're very important to those players at that age, because they carry them for the rest of their career.
People don't quite understand how integrated the team physician is into the team and into the character and the fabric of the team. We're on the sidelines. We're with them in the games. We're with them in training. When you're taking care of the young athletes like they're children, they're part of your family, and that bond really helps them through crises when they get hurt. Those are things that people don't see. There's another whole layer of care for the athletes.