John C. Hayes interviews Dr. Carol Frey

Editor’s Note:. Carol Frey, MD, is a former NCAA Division I swimmer and an orthopedic surgeon. She is the Director of Orthopedic Foot and Ankle Surgery at the West Coast Center for Orthopedic Surgery and Sports Medicine. Dr. Frey maintains close ties to the athletic swimming and sports medicine communities, and she knows how to get an athlete back in the game. Here, she provides some insights on some of the pressures facing orthopedists and athletes in a professional setting and some of the advances that are producing faster and faster swimmers.

Medscape: You were a NCAA Division I swimmer. What insights does an athlete at that level bring to the practice of orthopedics?

Dr. Frey: It helps in understanding not only the type of injuries they have, but also their motivation and desire to get back to the team after an injury. They’re like injured warriors.
It is such a part of their identity and how they define themselves that their first motivation is to get back to the team or get back to the sport, as the case may be. They don’t want to hear, “Maybe you shouldn’t swim again,” or “Maybe you shouldn’t do this again,” or “Why don’t you take 6 months off?” To an athlete, that is code that that person who is speaking has never played sports or is not an athlete. You need to understand the motivation — the core personality of an athlete. People don’t become athletes as adults. As a swimmer, for example, I became very competitive when I was about 9 years old, and today, it begins at 7 years. People specialize much earlier, and when they do, it becomes much more than physical. Athletes drop out of competitive sports for many reasons. They may lack the heart or the discipline, or they get injured. And often times all they want is to be back in the game.

Medscape: I talked to an orthopedist who works with soccer teams, and he mentioned the same thing: the underpinning of the motivation of the athletes and that, when injured, they want to get back to the game or to the team. One question that it raises is, do you have a responsibility to the athlete that extends beyond the team? How do you manage being pulled in different directions?

Dr. Frey: You don’t do anything that is dangerous or bad for the athlete. As a physician, I will tell you the most difficult thing to do is not the diagnosis or the surgery; it’s the rehabilitation and the return to the sport. It helps being a former athlete. I’m not saying that nonathlete physicians can’t do it, but it takes more work and you need to invest more time to get to know your patient — that is the first thing.

The second thing is that there are ways to do rehabilitation without the athlete losing strength or no longer being part of the team, and ways to do it without further injuring the athlete. In my opinion, many physicians do not know how to properly rehabilitate an athlete.
For example, let’s say the athlete has a stress fracture. The easy way to treat it is to put the athlete in a cast and tell him or her not to do the sport for 6 months. It will work. The patient will get better, but there is another way. Immobilize the athlete for a couple of weeks, and then kick-start the process by getting the athlete in a pool doing really good pool exercises, with high kicks, side steps, a noodle workout, and core work. Get the athlete doing Pilates, using the core ball, and working on core strength and upper body strength. Use physical therapy to your advantage, and even do deep soft-tissue work to get the muscles loosened up.

It takes a lot of time to get to know the patient and explain and prescribe these exercises. Not every doctor has the time or the motivation. It takes a level of knowledge and specialty to know how to rehabilitate a patient. It is the more difficult part of orthopedics. It certainly takes the longest. You really have to listen to the patient. You really have to get to know the patient and the patient’s motivation.

Resisting the Pushes

You also have to be immune to the pushes. The coaches and the parents get involved, so you have to handle them as well. When you have an athlete at that high a level, especially Olympic level, division I level, or even club level or high school varsity, the parents and coaches can be more difficult than the athletes. Furthermore, other athletes may treat the injured player differently. He or she is not ostracized, but is not quite a member of the team. The injured athlete is sitting on the bench or in the stands, not playing and not functioning as part of the team. And all he or she wants to do is to be back in the game. You have to be confident, too, because some of those coaches are pushy and they have their own ideas. They also have the ear of the athlete more than you do. The physician comes in as a satellite member of the team. You only see the athlete when the athlete is injured. The athlete sees the coach every day. You have to convince the coach to be on your side, as part of the rehabilitation program. You have to get the coaches on board.

Medscape: I can see how it would be a very difficult challenge, particularly the professional one.

Dr. Frey: Yes, and the parents have so much invested. By the time a kid becomes an Olympic athlete — swimmer, tennis player, volleyball player — think of the tremendous amount of time and money they have invested: the 5-AM wake-ups, the meets, the $300 swimsuits, and the private coaching. It is a very expensive enterprise to produce an Olympic athlete.
When a child gets injured, the parent doesn’t just say, “My poor son. He isn’t going to be able to realize his potential,” but also, “Oh my God, I wasted all that money.” All these thoughts are going through their heads. “You can’t quit now. This is getting you into Stanford.”
Injury Patterns in Swimmers

Medscape: Could you discuss injury patterns in swimmers?

Dr. Frey: It has been said that at some point in a swimmer’s career, if the swimmer is at a competitive level, more than 80% will have a shoulder issue. It won’t necessarily mean that the swimmer will have to stop swimming, but it is very common to have a shoulder issue. So much of the stroke is built into the stability and position of the shoulder.
The shoulder is a unique joint and has more range of motion than any other joint in the body, so it is not hard to imagine how it can get injured. It is very mobile, and in swimmers, it tends to get almost hypermobile because of the mechanics of swimming. Swimmer’s shoulder is an inflammation around the shoulder unit, and the person who is most at risk for this type of injury is a swimmer with a more relaxed or more hypermobile shoulder because his shoulder can assume more complex and varied positions.
It is not unusual for a competitive swimmer who swims up to 20,000 meters a day, 6 days a week and then does dry-land exercises, too, to do about 4000 strokes per shoulder per day. The rotator cuff and biceps tendon are commonly inflamed. The cause of swimmer’s shoulder is a combination of this hypermobile shoulder and problems with swimming technique.
The technique that leads to swimmer’s shoulder is often related to the way the swimmer’s hand enters the water. Swimmers enter the water at midline or off to the side a little bit. We call it “crossover.” He enters the water, and then his hand crosses over his body a little bit. People with swimmer’s shoulder have a little more of that crossover and may enter the water completely thumbs down. That puts a little too much torque on the shoulder.
These are some of the things you can look for that might cause some repetitive trauma, malpositioning, or mechanical problems to the shoulder. It requires an analysis of the swimming technique.

Medscape: When you come across a situation like that — let’s say you find it in an athlete who is in a competitive situation — what can you do?

Dr. Frey: The main thing to do is change the swimmer’s technique. Technique is one of the reasons that speed has increased so much. We also have kids who are just getting bigger, and that helps in swimming — big feet and big hands. Having swimming coaches who really work on the mechanics of the stroke has improved swimming tremendously in the past 20 years.
You can look at the swimmer’s mechanics and change the position of the swimmer’s hand as it enters the water, with less torque on the shoulder. The swimmer can enter just short of midline.
That is just one example, but you need to look at the mechanics first of all and change the mechanics because you can do that, much like a weightlifter can change the position of his hands on the weight bar. You want the muscles of the shoulder to work through a stable arc. You don’t want an unstable shoulder, with too much motion.

What are the key remedies?

The key remedies for swimmer’s shoulder are physical therapy, working on mechanics, and working on core strength. Why core strength? Core strength allows the swimmer to streamline well, and in swimming, streamlining is making sure you don’t wobble side to side.
Think of the midline or the lane line. You want the body to stay on that lane line. It’s like an airplane landing. Side-to-side movement, also called “body roll,” can be reduced by core strengthening. Core strengthening will also put the shoulder in a better position. The exercise ball is really good for that.

There are so many good exercises for swimmers, such as the supine back extension stretch, that can be done with a core ball. Another exercise is called “Superman.” Most swimmers know what a Superman is. You lay on the core ball face down, your opposite leg goes up from your arm, and you go back and forth doing a back extension.

Push-ups and trunk rolls can be done on the core ball. The upper and lower abdominal muscles must be kept very strong. This will stabilize the pelvis, stop the lateral trunk movement in the water and stabilize the shoulders and trunk. This will make the swimmer more powerful and less apt to get injured. Physical therapy and looking at mechanics will solve 90% of the problems with swimmer’s shoulder.

Injuries in Practice

Medscape: What if you are in a situation where somebody is injured during competition? Do Olympic swimmers develop swimmer’s shoulder during competition?

Dr. Frey: Most injuries happen during practice, when athletes are swimming 20,000 meters. They don’t swim 20,000 meters during a competition; they swim 200 meters. I can’t think of an example where an injury has happened during competition. That is how rare it is. The injuries at competition are accidents, not overuse.

Medscape: You were a Division I swimmer. Did that lead to your medical career, or were you already embarked on it?

Dr. Frey: I probably always wanted to be a doctor. I may have been brainwashed a little bit by my grandmother, who was a medical missionary. She used to say, “You would be a great doctor,” so I always had it in the back of my mind. What solidified orthopedics, and this is probably true of a lot of orthopedic surgeons, was that I had an injury in college. I was a swimmer but I also played volleyball, having grown up at the beach, and during a pick-up volleyball game right after coming out of the pool, I tore my anterior cruciate ligament. My injury didn’t hurt my swimming. I actually rehabilitated in the pool really well. Just going through that — and I was at Stanford University at the time — I got to know orthopedics and orthopedists, and I thought it was a brilliant career. The patients you see are wounded, not really sick, and they get better. If you do the right thing, they get better in 6 or 12 weeks. Very few specialties in medicine are like that. There is instant feedback that makes orthopedics a very positive career.

Medscape: You follow the Olympics swimming very closely. Do you follow the rest of the Olympics, and do you have any general observations about orthopedics in the Olympics?

Dr. Frey: My husband was one of the Olympic doctors. He is an orthopedic surgeon, as well. To be an Olympic doctor, you have to train for 2 weeks. You have to leave your practice, go to Colorado Springs, move into a dormitory, and train with the Olympic people and personnel to learn how to treat the athletes. You get to know their specific trainers. These are not random doctors. They are selected by the Olympic committee.

Developments in Training

Medscape: Are there new things in swimming that orthopedic physicians would like to hear about? Are there new developments coming down the line?

Dr. Frey: The developments have to do with training. Everybody wants to know what makes Michael Phelps or Ryan Lochte so good. Why are they so spectacular? There is a lot of talk about how big Phelps’ hands and feet are. You can’t do anything about that. That is a genetic lottery.
One of the things that has come out of the Olympics happened when the East Germans came on the scene. It was in Munich. Everybody disapproved of their methods. They looked for markers — physical traits — and funneled kids into sports really early, like at 5 years old, on the basis of these traits. This information came out when the Berlin Wall came down and the Cold War ended.

They were the ones who started the weightlifting and emphasized dry-land exercises for swimmers. When I was swimming, which was in the 1970s, we weren’t doing much dry-land work, and when we saw how big and powerful the East Germans were, that was a turning point for swimming. Maybe there was a lot more going on behind the scenes, but we started weightlifting and realizing it was important to have strong upper-body muscles, a strong trunk, and core strength. All needed to get back in the game.

The practice of doing genetic testing and picking kids on the basis of genetic traits sounds awful to the sensibilities of the Western world, and some of the books also show that the East German athletes were using steroids and strength-enhancing drugs. It wasn’t all dry-land work, as it turns out.

I have a true story about swimming against the East Germans. The first time we saw them, upon walking into the women’s dressing room with the showers in our peripheral vision, and just seeing them from behind — their backs, their shoulders — and hearing their voices, I walked out and said, “Are we in the boys’ locker room?” I was not small. I was 5′ 11″ and 165 lb. I was considered big in those days, and those girls were bigger than me.

Medscape: As I think back on that, the East Germans were notorious.

Dr. Frey: They were, but we can learn from them. We learned that we needed dry-land exercises, that we couldn’t just swim in the pool 20,000 meters. Even today, we are learning new training techniques. When you pick up a magazine, such as Triathlon or Outside, which profiles a lot of athletes, their nutrition gets as much publicity as anything.

Ryan Lochte is famous for saying that he eats French fries and hamburgers all the time, but in a recent edition of Outsidemagazine, he said that he has changed his diet. One US decathlon player spent half an article giving recipes for highly nutritious meals. Nutritional status, flexibility, and body work have become much more important in our training. It is not just how many miles you log or how many laps you swim anymore.

The Personality of an Athlete

Medscape: Any final words?

Dr. Frey: What we need to understand about athletes is that so much of their personality is being an athlete. All of their spare time has been devoted to their sport. These people essentially gave up their youth to train and watch their diets, to go to meets, and to try to prevent injuries. To help them as physicians, we have to let them know that we are part of their team and will work to keep them in the game. I know that’s a cliché. We don’t want them to play so that they injure themselves, but 99% of the time, there is a way to keep them in the game.

When athletes get injured, they need to know they are on the injury list. Most people at an elite level have had an injury at some point in time and have lost a week or more of playing time or practice. It is part of getting to that level. I can’t think of one player who hasn’t had an injury at some point that required an orthopedic surgeon, a physical therapist, or time off from play.

If you can manage it, keep them in the game even when they are injured, by seeing a physical therapist and getting them in the pool doing pool exercises, side steps, and Pilates exercises, which were actually designed for injured warriors.

Remember that mentally, this is their identity. They have given up so much, and you have to keep them positive and you want to always try to get them back in the game they love so much.

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