Saturday, January 26, 2013

Victoria Azarenka’s Timeout Jeered Round the World -

MELBOURNE, Australia — When the world's top-ranked female tennis player was examined on the court and then granted a medical timeout Thursday during her semifinal match at the Australian Open, the howling commenced immediately. Skeptical fans at Rod Laver Arena and those watching on television worldwide were convinced that the player, Victoria Azarenka of Belarus, was suffering from nothing more than an attack of nerves and perhaps faked an injury to collect herself after losing several crucial points.

After her 10-minute reprieve — six minutes of it off the court — Azarenka closed out a 6-1, 6-4 victory. A sport that in recent years has dealt with loudly grunting players and accusations of match fixing is now facing another vexation: determining what constitutes a real injury.

Azarenka's opponent, Sloane Stephens of the United States, called injury timeouts — legitimate or not — "the in thing," noting that Azarenka was one of many recent opponents to use a medical timeout. "It's trendy," Stephens said.

Others were more critical. "I thought it was a little unfair play," said David Nainkin, Stephens's coach. "I thought she bent the rules. I don't think she broke the rules, but she bent them, and I think those rules need to be looked at because I think there's a gray area there."

The TV analyst Patrick McEnroe called the timeout an "absolute travesty" in a post on his Twitter page. (McEnroe also heads the United States Tennis Association's player development program, which has supported Stephens.) "I mean, everybody's appalled by it," said Pam Shriver, an analyst and a former player.

The controversy arose when Azarenka, serving for the match against the 29th-seeded Stephens at 5-3 in the second set, failed to convert on five match points and was eventually broken. When she took her seat during the changeover, she wrapped a towel stuffed with ice around her neck and was examined by the primary health care provider for the women's tour, Victoria Simpson, and by a tournament doctor, Tim Wood. She then left the court for further treatment, leaving Stephens, in her first Grand Slam semifinal, waiting nearly 10 minutes for the next game.

Stephens, who had upset the tournament favorite, Serena Williams, in the quarterfinals, proceeded to lose her serve and the match. She did not blame Azarenka's timeout for her loss.

Azarenka did not mention an injury during her on-court interview after the match, but she did refer to a feeling of crisis at the 5-4 changeover. "I almost did the choke of the year," she said. "I just felt a little bit overwhelmed. I realized I'm one step away from the final, and nerves got into me, for sure." Azarenka added: "I love to play here and I just couldn't lose. That's why I was so upset."

Later, in a news conference, she said that she left the court for treatment of a rib injury and that she had not mentioned the injury in her on-court interview because she had misunderstood the question.

Shriver, who noted that Azarenka had also not mentioned the injury in an ESPN interview while coming off the court, was skeptical. "I think her response at the time was very honest and truthful, that she was stretching the rules," Shriver said. "That was my reaction coming off the interview, and so that's why I think all of us, many of us, jumped on it. Because we've seen the rule abused for years. I abused the rule when I played."

If Azarenka was not legitimately injured, was calling a medical timeout cheating? Playing at the edge of the rules? Good old win-at-any-cost strategy?

To Michael F. Bergeron, executive director of the National Youth Sports Health & Safety Institute, it is part of a disturbing trend extending to youth sports: emphasizing winning over sportsmanship and developing character.

"I'm not saying everyone does that, and I'd like to think there are still players who would never do it," Bergeron said. "It shows a lack of character, a lack of respect for her opponent and the game. You'd like to think sports would be developing those traits. But in the bigger picture, this emphasis on winning and losing over everything else is doing athletes a disservice. It's not making them better people. It's not making them better athletes."

Bergeron, a clinical and scientific consultant to the Women's Tennis Association, acknowledged that tennis was harder on athletes' bodies than ever before. But he suspected that Azarenka had used the timeout as a strategy to stop Stephens's momentum.

Other sports have had similar issues. In football, there have been debates over timeouts taken just before field goals. During a college game between Cincinnati and Duke this season, Cincinnati took a too-many-men-on-the-field penalty to negate a 53-yard field goal, leaving Duke Coach David Cutcliffe irate. And after an N.F.L. game last season in which the Giants appeared to fake injuries to slow the Rams' offense, Seahawks Coach Pete Carroll said the phenomenon was nothing new or alarming.

In tennis, though, the injury timeout is tricky because medical personnel have to treat all calls for treatment seriously, no matter when they happen. The Grand Slam rule book does include some restrictions: all medical timeouts must take place during a changeover or a set break except in the case of an "acute medical condition."

The Grand Slam supervisor Donna Kelso confirmed that Azarenka had been given two consecutive medical timeouts of three minutes each to be treated for two separate injuries: one to a rib and one to her left knee. Azarenka explained that she was having trouble breathing on court because of a rib problem that was causing her back to seize up.

"I had to unlock my rib, which was causing my back problem," she said. "The trainer said, 'We have to go off court to treat that.' I just didn't really want to take off my dress on the court."

Nainkin, Stephens's coach, said he had "never heard of two medical timeouts back to back."

"In all my years, that's a first," he said. "Two different injuries? I think it's unprofessional. Saying that, she did win the match and played a great game at 5-4, but tennis is a game of momentum and Sloane had the momentum, and obviously the little break definitely changed things."

Azarenka agreed that the timing of her timeout was unfortunate. "The timing, yeah, it was my bad," she said. "The game before that, when I lost my service game, it kept getting worse. I thought I would have to play through it and keep calm. But it just got worse. You know, I had to do it."

Several coaches and analysts expressed hope that the incident Thursday would lead to a re-examination of the medical timeout rule at Grand Slam events and on the WTA Tour. "I think if you can continue to play in any way, it's bad luck but you've got to wait until the person is finished serving," Shriver said.

But ultimately, the decision lies with the medical personnel on court. According to the Grand Slam rule book, if they determine that a player needs a medical timeout, their word is final.

Friday, January 25, 2013

Worst NFL Injuries - Tom Junod on Injury Issue in the NFL - Esquire

This NFL season has been defined by people talking about "the injury issue" — pundits, columnists, league officials. The one voice you haven't heard — until now — belongs to the players.

By Tom Junod
Crushed Skull
Phil Toledano

Published in the February 2013 issue, on sale any day now

My left knee has been aching this entire week. I don't know why. I didn't get hit directly on it in the last game. My right knee has started the week so sore the side where the nerve got hit. When I wear the brace, my knees feel like total crap. When I start moving around, the muscles and tendons in my leg feel so stressed, sometimes I feel they might rupture. My lower back is so sore, painful and stiff; my right shoulder has lost some mobility for some reason. My right ankle is constantly being twisted; my left feels very weak. It's hard for me to react to movement, or even drive off of it. I used the word "hard" but the real word is "next to impossible." I don't sleep much, I feel super stressed, and on game day I take tons of drugs...

—An entry from a journal kept by an NFL player for the purpose of preserving, for his children, a record of his pain

In 2009, Willis McGahee, then a running back for the Baltimore Ravens, caught a pass in a playoff game — a championship game — against the Pittsburgh Steelers. The pass, from his quarterback Joe Flacco, was perfect. McGahee, known since his days at the University of Miami for his ability to catch the ball, had come out of the backfield and was heading straight upfield, ten yards beyond the line of scrimmage. He did not have to slow down. He caught the ball over his inside shoulder at full tilt. Ryan Clark, a safety for the Steelers, was waiting for him.

It was a big play in a big game, and it turned out to be decisive. The Steelers had just gone ahead, 23 — 14, on a Troy Polamalu interception return. Now the Ravens had the ball on their own twenty-six-yard line, second and six, late in the fourth quarter. McGahee caught the pass just beyond the thirty-five; with two steps, he was just short of the forty. He never got there. Clark gathered himself, then uncoiled. He simultaneously turned and lowered his shoulder, and from a kinetic crouch he extended himself into McGahee, straightening out while leaning forward, leaving his feet after discharging all his energy, his legs helicoptering off to the side. It was a high but legal hit, and the thunderclap it released was definitive, high and low at the same time, a deep pneumatic clang, the sound of a cymbal turned by force into a gong. Clark fell to his side, holding his helmet in his hands as if to stop the ringing in his ears. McGahee fell loosely on his back, where he stayed, his cleats in Boot Hill position, toes to the sky.

"Oh, what a hit! Ball's out, recovered by Timmons. Ryan Clark is still down, so too is Willis McGahee. And they say fumble recovery, Pittsburgh..."

It was not a posture to which McGahee was unaccustomed. Six years earlier, in his last game at the U., he blew up his knee, an injury that was routinely called "gruesome" and "grotesque" and that still enjoys an Internet afterlife as one of the "Top Ten Worst Sports Injuries of All Time." Now he was on the receiving end of one of the signature collisions of the NFL's head-injury era — an era ushered in by a combination of athleticism unfolding at the edge of human capability, the expanding authority of neuroscience, and the horror stories of middle-aged football heroes descending into depression, dementia, and derangement. "When there's a savage hit, you try to get out there quickly," says Dr. Anthony Yates, who for the last thirty years has been the Steelers' team doctor and who currently serves as president of the NFL Physicians Society. "You presume it's a concussion and hope it's not more than that. And when there's two men down, you wonder about the logistics. Are we going to need two trucks, two evacuations...?"

He needed only one. After the familiar spectacle — the familiar American ritual — of two teams heretofore locked in violent struggle crowding the field in solidarity; of solitary players bent in desperate prayer; of television announcers peering through the wicket of medical personnel in order to parse the fallen for "encouraging" signs of movement; of Creedence's "Down on the Corner" playing on stadium loudspeakers for the rowdy and restive crowd: After all this, Ryan Clark walked off the field with a concussion. Only Willis McGahee was immobilized, strapped to a board, and evacuated from the stadium, after which the Pittsburgh Steelers took possession of the ball and the game, on their way to an eventual win in Super Bowl XLIII.

I called McGahee recently. He now plays for the Denver Broncos and was recovering from a torn medial collateral ligament. With the playoffs approaching, and with NFL injuries becoming ever more of "an issue" — the global warming of American sports fans, something to be fretted over and put aside — I wanted to talk to someone whose career has been defined by very public injuries and whose very public injuries have defined the state of football over the last ten years. But he didn't see it that way. "Injury has not been part of my career," he said. "I've only gotten hurt twice. I got hurt once in college and once in the pros."

Right, but that second injury, against the Steelers...

"No. I mean now. The MCL."

"So you don't consider the concussion an injury?"

"That's what they consider it. But getting a concussion and hurting your knee are two different things. You get back up from a concussion."

Willis McGahee was knocked out cold against the Steelers. He went out on the board. He didn't consider himself injured, though, because like all NFL players he considers himself an expert in what qualifies as an injury and what doesn't. The loss of consciousness he suffered in Pittsburgh didn't qualify because it didn't require rehabilitation. It didn't put his career in jeopardy. It didn't exile him from his teammates.

And most of all, it didn't hurt.

"Fans basically knownothing," Ryan Clark says when asked to talk about his experience of injury. "They know what they see on the field and that's about it. They don't know the work, the rehab, the getting out of bed on Monday morning. A lot of injuries are the ones that don't get reported, the ones that don't take you off the field. People always ask me, 'Are you feeling good?' No. You never feel good. Once the season starts, you never feel good. But it becomes your way of life. It becomes the norm. It's different from a guy going to work at a bank. If he felt like I did, he wouldn't get out of bed. He'd call in."

"Our perspective is our own pain," says the veteran who keeps the pain journal, who we'll call PJ from now on. "What other perspective do we have? We've been beaten down since we were kids that you're never too injured to play. And so when normal people — people who are not associated with football — ask 'How do you feel?' for many years it was hard for me to answer that question. It was hard for me to say exactly how I feel, because it would show a sign of weakness or softness. And at the professional level, you better not say how you feel, or the next man will get your job."

The perspective of pain is what this story is about. For fans, injuries are like commercials, the price of watching the game as well as harrowing advertisements for the humanity of the armored giants who play it. For gamblers and fantasy-football enthusiasts, they are data, a reason to vet the arcane shorthand (knee, doubtful) of the injury report the NFL issues every week; for sportswriters they are kernels of reliable narrative. For players, though, injuries are a day-to-day reality, indeed both the central reality of their lives and an alternate reality that turns life into a theater of pain. Experienced in public and endured almost entirely in private, injuries are what players think about and try to put out of their minds; what they talk about to one another and what they make a point to suffer without complaint; what they're proud of and what they're ashamed by; what they are never able to count and always able to remember.

I was surprised that the players I talked to for this story spoke as openly as they did about their injuries and their private world of pain. They spoke without complaint; indeed, they all were at pains to make sure they didn't sound as though they were complaining. They all knew what they signed up for, they said, and they all know that when they get older "we're going to be messed up," as Ryan Clark says. "We have some former players as coaches, and not one of them looks normal." But they want people to understand that the fabric of their lives is a torn one and that it's been woven for them since they started playing the game. They want people to know that, in PJ's words, "It's a crazy, crazy, crazy game, man," not least because when pain is your perspective, then your perspective becomes skewed. The first cardinal rule of the NFL is what Baltimore Ravens safety Ed Reed says it is: "There is a difference between being hurt and having an injury. You go from there."According to a study conducted by the National Football League, the approximately two thousand players active on the thirty-two NFL teams suffered about forty-five hundred injuries in 2011, for an injury rate of 225 percent. These were injuries that caused not simply pain and discomfort but also cost players at least two weeks of playing time; these were not simply bruises and scratches and abrasions but also concussions, torn ACLs, ruptured Achilles tendons, high ankle sprains, hyperextended elbows, broken metatarsals, turf toes, stretched or compressed spines, pulled hamstrings, and torn muscles, along with assorted strains, contusions, and herniations. These constitute, for the players who experience them, at least the first paragraph of the writing on the wall — because in the NFL the writing on the wall is always written directly on the body.

But when you're always hurting, how do you know when you're hurt?

Or else you do — and then you don't, because in the NFL there are always other considerations. Take Ed Reed. He has not only returned interceptions for more yards than anyone else in the history of the game; he is also a player known for an acute awareness of his own body. "I always tell the younger guys to take care of their company," he says. "That's what I call the body, because that's what it is — it's your asset." He uses his own doctor instead of the team doctor and counsels other players to do the same. He studies neurology the way he studies quarterbacks. He says he sometimes gets premonitions about injuries before games — "I've had feelings. You know, just like, This day just don't feel good. It feels like one of those days. Man, I gotta be careful today." And when he goes down, he, like Jim Brown, takes his time getting up. "Some people say, 'Every time Ed's involved in a play, Ed's on the ground.' Well, somethinghappened. And I'm down there checking on myself."You don't. Not always, anyway. "A lot of times you don't know exactly when the injury happens, because you're taking drugs like Toradol or another kind of anti-inflam, so you're feeling good," says Tennessee Titans quarterback Matt Hasselbeck. "Or maybe you're dealing with a previous injury, like an ankle, and you're taking Toradol, so you're feeling a little bit better, but now all of a sudden everything is feeling a little bit better. Plus, you have the rush of adrenaline — so the injury might hurt a little, but you don't really realize it. You might not feel it till the next day, or you may feel it that night. Because your mind-set is to play through everything you can, unless you cannot. And usually, it's been my experience that when you come off the field after an injury, the trainer or the team doctor is meeting you. They're like, 'You haven't moved your arm in thirty seconds. What happened?' And you're like, 'I'm fine, I'm fine, I'm fine — leave me alone.' "

And yet he has spent his career groping in the dark around the line that separates being hurt from having an injury. He's had a high ankle sprain that turned out to be a fracture. He hurt his ribs a few years ago, and "they hurt me to this day." He's played "the last four or five years" with a pinched nerve. Two years ago, against Pittsburgh, he had what he calls "a stinger" in his hip — "and on the next play I wound up hurting it." How was the injury different from the stinger? "I knew something was bad with it. I never felt anything like that before. It was different. It was like a beesting out of nowhere but ten times that, a hundred times that."

It was an injury, then. It qualified by the only measure that counts: He couldn't play. He had to choose between surgery and rehab. He chose rehab. He was out a "few weeks," then tried to come back against Green Bay. "It was too early. My play was affected." He had to sit back down another week. He came back, but not without the crippling awareness that he was crippled. "And, of course," he says, almost as an afterthought, "I had to get reconstructive surgery when the season was over."

He is playing now with a torn labrum, a shoulder injury that caused the Ravens to incur a fine earlier this season when they failed to report it. "It hurts a good bit," he says. But he's playing, because he's better hurt than his replacement is healthy, and he's helping his team more by playing than he would help his team by sitting down and trying to heal. He's playing because he can, and because — no matter how much attention the issue of injury receives and no matter how many changes the NFL faces — the second cardinal rule of the NFL is that you play unless you can't.

And if you change that, it's not the NFL anymore.

"It goes back to pee-wee ball," Ryan Clark says. "When I was six, I was a punt returner on my dad's team. I got hurt. I went up and told him, 'Dad, I can't straighten my neck.' But I made sure I told him that after I returned a punt for a touchdown."

You remember those if you're an NFL player. You remember the injuries you gutted out and triumphed over — what you were able to do with them. But then you remember the injuries that triumphed over you and were so decisive, as irrevocable to your soul as they were to your body.

"The worst injury I ever got, in terms of pain, was breaking my collarbone," says Atlanta Falcons defensive tackle Jonathan Babineaux. "That was in high school. I remember exactly what caused it. I had some new shoulder pads and they didn't fit right. So I went to make a tackle on a big guy, and I broke my collarbone in two places. And it was excruciating pain. I've gotten injured on every level I've played at. In college, I broke my ankle. I mean, it was hanging. And three or four years ago, I tore my biceps. My ankle hurt when I broke it. But it didn't have no comparison to the collarbone. I was lying there, and my first thought was Can I do this? Can I handle this kind of pain?"

And then, at almost the same moment, in almost the same breath, came his second thought: "How long am I going to be out, and will it jeopardize me playing football again?"

It wasn't the injury that was decisive then, or even the pain. It was Jonathan Babineaux's thought, that arousal of instinct pitched halfway between survival and suicide. Like every other player in the NFL, he's been selected at every level along the way for his size, strength, speed, skill, and level of aggression. But like every other player in the NFL he's also been selected for something else: that first desperate thought when he suffered his first injury at the outer limits of his endurance. Somewhere in every football player's career, pain offers a way out. The football player who makes it to the NFL is the one who understands from the start that what pain is really offering is a way in.

"The worst injury I've ever had on the field — for my wife and kids, at least, and my mom and dad — was an injury I got against the 49ers," says Matt Hasselbeck. "Patrick Willis hit me as I was diving for the goal line. He hit me, and twenty minutes later I'm in an ambulance on my way to Stanford Medical. I'd broken a rib on the left and I'd broken a rib on the right. The rib on the right was right next to my aorta, and it was really dangerous for my health. I couldn't breathe. It was like there was a weight on top of me. It's a scary thing, because it feels like you're drowning. I couldn't breathe at all, and I got up off the field because it was a two-minute situation — I didn't want the team to have to take a time-out. I tried to run off the field, and when the trainers met me they saw I was, like, purple in the face. And they immediately put me on the ground. Sometimes they'll put you on the ground to evaluate you and sometimes to give the backup quarterback a chance to get loose. They put me on the ground because I was purple."

That instinct — the instinct to run when you can't breathe in order to save your team a time-out — is not one often encountered in civilian life. Indeed, it is one encountered almost exclusively in war, in which people's lives, rather than simply their livelihoods, are at stake. Now, the NFL is replete with military symbolism, not to mention military pretensions. But the reality of injury is what makes it more than fantasy football, more than professional wrestling, more than an action movie, more than a video game played with moving parts who happen to be human. The reality of injury — and the phantasmagoric world of pain — is what makes it, legitimately, a blood sport. And it is what makes Dr. Yates, the Steelers' team doctor, define his job simply and bluntly: "My job is to protect players from themselves."

Dr. Yates is often the first to see a player after a player has been injured, and he always has to remind himself that he is dealing with men who, when they go down, want to get up. "After the expletives are deleted, they'll tell you where they're hurting, or they'll look at you glassy-eyed. Then they quickly say, 'I'm all right. I'm all right. Pick me up, I'm fine.' I'll usually say, 'I'm glad you feel that way. Let's get you over to the sideline and see what the real story is. Let's see if you're all right.' As you might imagine, that's easier said than done."

It is, because the players know what happens on the sideline. Yes, they are treated; they are iced and taped and sprayed and given Advil. But they are also replaced. The doctor talks to the trainer, the trainer talks to the position coach, the position coach talks to the head coach. The head coach doesn't talk to the injured player; the only thing he wants to know is "Can he go?" There are a lot of questions asked of players who are hurt or injured, and all of them are designed to decide which it is: hurt or injured. But "Can you go?" is the one that ultimately matters because everything depends on it. Players know that if they can't, someone else can — and they know that depending on their status with the team, they might never get a chance to go again.

"There are head coaches who, if you're not playing or practicing, won't talk to you," Hasselbeck says. "That's an old-school technique, but, to be honest, I kind of like it." There are also head coaches who'll visit players in the training room on Mondays. There are also head coaches who'll push trainers to get players back on the field no matter what. There are also head coaches who'll say, "If you're hurt, you're hurt," and treat you like a man. But no matter what kind of coach you think you have, you know one thing about him: If you go down at a practice, he will be the kind of coach who orders his team to "move it over ten" or "move it over twenty" so that practice can continue while you're lying on the ground. That is every coach, at every level. They move on if you can't.

This is not a complaint. This is simply an acknowledgment of the third cardinal rule of the NFL: Everybody who works for the team works for the team. The head coach works for the team. The assistant coach works for the team. The team doctor works for the team and so does the trainer. They are paid to get you on the field — or, as Dr. Yates says, "to help you fulfill your career" — and you are paid to play. They are not paid to protect you. You have to protect yourself. This is why the players' union has fought for the right to get a second medical opinion and the right to see your medical records. And this is why the players try to protect one another when it comes to injury and pain — why Ed Reed takes a locker among the special-team players and free agents, who are the team's most vulnerable players; why Jonathan Babineaux says that after every game he tries to seek out as many of his teammates as he can to ask, "Are you all right? Did you make it through?"

There is, however, one condition placed on the fellow feeling players extend to teammates who are working through injury or pain: They have to be injured or in pain. "The quickest way to earn the respect of your teammates and coaches is to play through injuries," Hasselbeck says. "The quickest way to lose respect is to say 'Hey, I can't go.' "

"You keep playing because you get so close to the guy next to you that you don't want to leave his side," says the veteran player we're calling PJ. "You're like soldiers that way, and you think like soldiers. I've never had a fear for my own health. I have had a fear of looking bad, a fear of getting beat, a fear of showing weakness. If you get hurt, you feel like you've done something wrong, especially if you go on injured reserve. Then you're in no man's land. You're in purgatory. You get forgotten easily on IR. Or people get pissed off. You feel it. People are pissed off that you got hurt. They're fucking pissed off that you got hurt. Your pain threshold is used to decide what quality of football player you are, and what quality of person. Injuries are used as a gauge. And I've done it, too. Many times, I've been battling through injuries, soreness, or pain, and I've seen a young guy come off the field for something minute.And I'm thinking, What a pussy — let's get a guy in there who's tougher."

Or, as Ryan Clark says: "I don't mention every injury. I don't complain. And I don't want the person next to me doing it either."

Whether they are soldiers on a field of battle or actors in a theater of pain, one thing is for sure: They see some shit. They see guys writhing in pain. They see guys crying, and they hear guys screaming. They see guys knocked out, guys go limp as a suit sliding from a hanger, guys stay horribly still, guys strapped to the board — "and that's what every player fears," says Green Bay Packers center Jeff Saturday. "The board. Getting strapped to the board."

They see pain, but worse than that they see fear. And no matter what they see, they know they have to keep going without succumbing to fear themselves. They know that play will resume. So they drop to a knee (always one, never two) to pray. They go to the guy who's down and do the only thing they can do — "You just tell them to stay strong," Reed says. "He's going to get through this. Battle through. You just encourage him, man. That's all you can do."

"How you act when people get hurt depends on the severity, depends on how it looks," Clark says. "Sean Spence, one of our rookies, got hurt this preseason, and I cried. A young kid, a promising young kid, hurt his knee real bad, was in a situation where he couldn't move his foot. He couldn't control where his foot was going, and that's sad. A guy sprains his ankle? We won't even talk about it."

"We had a really bad one this year," says Hasselbeck. "Our kick returner Marc Mariani had a compound fracture of his leg. The bone came through the skin and it was pretty gruesome. It's hard — it's hard when it's your buddy or your teammate. But you try to let the people whose job it is to worry about that worry about that. You try to concentrate on what you can do. You have to refocus. That's what I try to do — I get the guys in the huddle and say, 'We can't do anything for Marc right now. He's our friend, he's our teammate, he's our brother — but we can't do anything for him right now.' "

What they never do, so long as the damaging hit is legal: blame or worry about the player who dished it out. "I've stood on the sidelines, waiting to go back in, watching a guy's tibia and fibula coming out of his sock," says PJ. "I've felt bad for that guy, but never for the guy that hit him. It's always 'Hey, that sucks, you broke your leg.' It's never 'Hey, that sucks, you broke his leg.' "

What they hardly ever do: "I'm going to tell you something," says PJ. "Anybody who tells you that they feel bad causing an injury is probably lying. How can you feel bad? You're going up against a guy who is just as big and strong as you are. Your coach tells you to go kick his fucking ass. Your teammates tell you to go kick his fucking ass. Your father and your brother tell you to go kick his fucking ass. The media tells you to go kick his fucking ass. Before the game, your wife tells you to go kick his fucking ass. So you go and you kick his fucking ass. And if he gets hurt, how can you go back and say, 'I didn't mean for you to get hurt like that.' You're taught to hurt people. How can you say you didn't mean to?"

Ed Reed says he didn't mean to. "This year, I took out an offensive lineman against Philly. It was bad technique on my part, and I took out the center's knee. Our coach talks to [Philadelphia coach] Andy Reid all the time, so I told Coach to send my respects for the center and let him know I didn't mean to hurt him, man. It was just the second game of the year, so he lost his whole season. That one preyed on me, man. I didn't know him personally, but I wanted to let him know that I had the utmost respect for him."

Ryan Clark is a feared man in the NFL. He is also a frequently fined one. Last season, he was fined $55,000 for high hits not too different from the hit that knocked him and Willis McGahee out simultaneously in 2009. This season, after being called for a personal foul in a game against the Giants, he complained that NFL referees were targeting him on account of the notoriety he's won as a headhunter. He also suffered two concussions in three games and had to change the kind of helmet he wears.

He does not mean to hurt anyone, he says, even when he punishes them for catching the ball. "It's something you never want to do. You don't set out to hurt people, and knowing that makes it easier to deal with. Listen, I'm the first one to get to my knees and say a prayer."

But neither does he have any pity for those he's laid out. He doesn't have any pity for anyone in the league, least of all himself. "I have a different situation. I almost died playing football. I had a sickle-cell crisis in Denver. I have a sickle-cell trait, and the altitude affected it. I lost my spleen and my gallbladder and almost died. It wasn't an injury, but it conformed to my philosophy about injuries. Basically, I don't care about them until I have to. It's like going to the bathroom on your own when you're a little kid. It seems so hard at first. Then you get used to it. It becomes part of your life, and you don't have to think about it anymore. Well, injuries are part of your life if you're a football player. You don't think about them until you can't walk — until you stand up to walk and you can't walk. Until you try to run and you can't run. And then you have to deal with them.

"So I knew something was wrong in Denver. The training staff didn't understand. They thought it was just the altitude. They thought it was just exertion. 'You'll feel better next week. Start running.' I kept telling them I couldn't. The doctor was telling me I should be okay, but I wasn't. I demanded a second opinion, and they took me to the hospital. Because of my philosophy, I'm alive. If I could go, I could go. If I can't go, something has to be wrong with me. It saved my life."

He will never change the way he plays the game. He will try to adjust to the rules that have been put in place to check the violent capabilities of players like, well, him. But he's fused by pain and blood to a way of playing the game that fuses the cardinal rules of the NFL — that indeed sees them as inextricable:

"If you can go, you go.

"Play hard, play tough, and hit anything that moves."

In the fourth quarter of the 2003 Fiesta Bowl — the national championship game between Ohio State and Miami — Willis McGahee drifted out of the Hurricanes' backfield and caught a pass from Ken Dorsey. It was a screen pass, so he had blockers in front of him, but an Ohio State defensive back penetrated the screen like a spear and lowered his shoulder into McGahee's knee. McGahee flipped over his tackler and landed on his back. There was no report, no sound except the animal roar of the game itself and the voice of Keith Jackson: "They bust up the screen — I mean, they bust up everything. Will Allen, coming like a truck, takes on McGahee and takes him down..."

Will Allen got up and began pounding his chest with both fists, elbows akimbo. Willis McGahee stayed on his back, having sustained one of the indelible injuries of sport. His knee, Jackson said upon viewing the replay, was "gone." The kind of V-shaped angle a healthy knee forms when you flex your leg, McGahee's knee formed backward. Three ligaments connecting his thigh to his shin no longer connected his thigh to his shin. When the trainers came out, they held his hands, but McGahee, who went into what he describes as "shock," does not remember them. When I asked him over the phone who was the first person he remembers talking to, he said, "The team pastor." And when I asked if he remembers what he thought as he lay stricken, he said, "My mind was all over the place," but "I was wondering if I could ever play football again."

He could. He had a $2.5 million insurance policy that he was eligible to collect if he never played again. He decided not to collect it and entered the NFL draft. He was picked by Buffalo and spent the entirety of the next season in surgery and rehabilitation. He became a thousand-yard rusher for Buffalo and then for Baltimore, until he was replaced by Ray Rice and eventually released. He went to Denver, and this year was part of the resurgence led by Peyton Manning until he tore his MCL and suffered a compression fracture against the San Diego Chargers. He told me that he didn't know the extent of his injury during the game — "I was walking around on the sidelines" — and that he'd be back in two weeks.

But he is not telling the truth, or the full extent of the truth. In fact, when he injured his knee against San Diego, he was attended on the field by a host of medical personnel. In fact, he has not suffered just two injuries in his career, as he told me, but injuries to every part of the body that can be injured. He suffered an injury to his rib. He suffered an injury to his shoulder. He suffered an injury to his ankle. He suffered an injury to his eye. He suffered an injury to his brain. And yet he wasn't misleading me; he had no reason to. He was just speaking from the perspective of pain, and from the perspective of pain only one truth mattered:

"I can't wait to get back out there....

"Can't wait."

Sunday, January 20, 2013

How Morphine Can Increase Pain - Medical News Today

For individuals with agonizing pain, it is a cruel blow when the gold-standard medication actually causes more pain. Adults and children whose pain gets worse when treated with morphine may be closer to a solution, based on research published in the on-line edition of Nature Neuroscience. 

"Our research identifies a molecular pathway by which morphine can increase pain, and suggests potential new ways to make morphine effective for more patients," says senior author Dr. Yves De Koninck, Professor at Université Laval in Quebec City. The team included researchers from The Hospital for Sick Children (SickKids) in Toronto, the Institut universitaire en santé mentale de Québec, the US and Italy. 

New pathway in pain management 

The research not only identifies a target pathway to suppress morphine-induced pain but teases apart the pain hypersensitivity caused by morphine from tolerance to morphine, two phenomena previously considered to be caused by the same mechanisms. 

"When morphine doesn't reduce pain adequately the tendency is to increase the dosage. If a higher dosage produces pain relief, this is the classic picture of morphine tolerance, which is very well known. But sometimes increasing the morphine can, paradoxically, makes the pain worse," explains co-author Dr. Michael Salter. Dr. Salter is Senior Scientist and Head of Neurosciences & Mental Health at SickKids, Professor of Physiology at University of Toronto, and Canada Research Chair in Neuroplasticity and Pain. 

"Pain experts have thought tolerance and hypersensitivity (or hyperalgesia) are simply different reflections of the same response," says Dr. De Koninck, "but we discovered that cellular and signalling processes for morphine tolerance are very different from those of morphine-induced pain." 

Dr. Salter adds, "We identified specialized cells - known as microglia - in the spinal cord as the culprit behind morphine-induced pain hypersensitivity. When morphine acts on certain receptors in microglia, it triggers the cascade of events that ultimately increase, rather than decrease, activity of the pain-transmitting nerve cells." 

The researchers also identified the molecule responsible for this side effect of morphine. "It's a protein called KCC2, which regulates the transport of chloride ions and the proper control of sensory signals to the brain," explains Dr. De Koninck. "Morphine inhibits the activity of this protein, causing abnormal pain perception. By restoring normal KCC2 activity we could potentially prevent pain hypersensitivity." Dr. De Koninck and researchers at Université Laval are testing new molecules capable of preserving KCC2 functions and thus preventing hyperalgesia. 

The KCC2 pathway appears to apply to short-term as well as to long-term morphine administration, says Dr. De Koninck. "Thus, we have the foundation for new strategies to improve the treatment of post-operative as well as chronic pain." 

Dr. Salter adds, "Our discovery could have a major impact on individuals with various types of intractable pain, such as that associated with cancer or nerve damage, who have stopped morphine or other opiate medications because of pain hypersensitivity." 

Cost of pain 

Pain has been labelled the silent health crisis, afflicting tens of millions of people worldwide. Pain has a profound negative effect on the quality of human life. Pain affects nearly all aspects of human existence, with untreated or under-treated pain being the most common cause of disability. The Canadian Pain Society estimates that chronic pain affects at least one in five Canadians and costs Canada $55-60 billion per year, including health care expenses and lost productivity. 

"People with incapacitating pain may be left with no alternatives when our most powerful medications intensify their suffering," says Dr. De Koninck, who is also Director of Cellular and Molecular Neuroscience at Institut universitaire en santé mentale de Québec. 

Dr. Salter adds, "Pain interferes with many aspects of an individual's life. Too often, patients with chronic pain feel abandoned and stigmatized. Among the many burdens on individuals and their families, chronic pain is linked to increased risk of suicide. The burden of chronic pain affects children and teens as well as adults." These risks affect individuals with many types of pain, ranging from migraine and carpel-tunnel syndrome to cancer, AIDSdiabetes, traumatic injuries, Parkinson's disease and dozens of other conditions.

Wednesday, January 16, 2013

Standardizing Pain Management - Penn Nursing Science

Based on the compelling need to provide a "Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families," a 22-member task force commissioned by the Office of The Army Surgeon General generated a comprehensive report to address pain among military service members and Veterans.
This report underscored the importance of a consistent way to measure pain across transitions of care within military and Veterans Administration Healthcare (VHA) systems. The Army Pain Management Task Force developed a new integrated pain rating scale – the Defense and Veterans Pain Rating Scale (DVPRS).

Rosemary Polomano, PhD, RN, FAAN, associate professor of pain practice at the University of Pennsylvania School of Nursing, collaborated with Army Pain Management Task Force leaders, COL Chester C. Buckenmaier III, MD (Director of the Defense and Veterans Center for Integrative Pain Management), COL Kevin T. Galloway, BSN, MHA (Office of the Army Surgeon General) and Rollin M. Gallagher, MD, MPH (Philadelphia Veterans Administration Medical Center) to conduct initial psychometric testing of the DVPRS in 350 inpatient and outpatient active duty or retired military service members at the former Walter Reed Army Medical Center, Washington, DC. The sample included patients who were hospitalized across seven units, two medical and five surgical. The study was recently published ahead of print in Pain Medicine, the official journal of the American Academy of Pain Medicine.  

"Preliminary data from the first phase of testing for the DVPRS demonstrated acceptable reliability and validity," said Dr. Polomano. " This scale has important implications for standardizing pain assessment practices throughout military and veteran healthcare settings, improving screening practices to identify risk for pain-related issues and, providing a minimum set of patient-reported outcomes for communication and documentation across transitions of care."

Researchers utilized the standard numeric rating scale (NRS), an 11-point, 0-10 rating system and enhanced it with visual cues and word descriptors. "Traffic light" color coding was added to signify mild (1-4, coded in green), moderate (5-6, coded in yellow), and severe (7-10, coded in red) pain. Word descriptions, such as no pain (0), interrupts some activity (5), and as bad as it could be, nothing else matters (10) were added to promote a standard meaning for each numeric rating of pain. These additions allow more consistent interpretations by healthcare providers and patients. 
Supplemental questions were also added to the DVPRS to gauge the impact of acute and chronic pain on daily life such as: general activity, sleep, mood, and stress levels. The supplemental questions along with the numeric DVPRS scale encourage clinician-patient discussions about pain, its different dimensions and comorbidities, and help guide further evaluation and personalized treatment plans with the patient, researchers noted.  
"Perhaps the most important aspect of the DVPRS and its proposed general adoption by the DoD and VHA in the future is the consistency of data that standardization of "pain questions" brings to integrated electronic health records. A uniform minimum pain data set would allow comparisons and outcomes tracking currently not possible with existing clinical pain assessment practices," said Dr. Polomano. " Additionally, the DVPRS scale as designed contains essential information that is applicable to all patients and healthcare providers across all settings throughout the military and VHA systems, from point of injury or disease throughout rehabilitation and recovery, and into primary and specialty routine care."

Pain Management - Army Medicine

In August 2009, The Army Surgeon General chartered the Army Pain Management Task Force to make recommendations for a U.S. Army Medical Command (MEDCOM) comprehensive pain management strategy that was holistic, multidisciplinary, and multimodal in approach; utilizes state of the art/science modalities and technologies; and provides optimal quality of life for Soldiers and other patients with acute and chronic pain.

The Task Force conducted 28 site visits at U.S. Army, Navy, and Air Force Medical Centers, Hospitals, and Health Clinics, as well as Veterans Health Administration (VHA) and civilian hospitals. During the site visits, leadership and staff were asked to assess pain management capabilities, strengths, weaknesses, and best practices at their respective facilities. Task Force findings were compiled into the Pain Management Task Force Report.

The Pain Management Task Force Report contains 109 recommendations that support the Pain Management Task Force vision statement of "Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families."

Pain Management Task Force Report

News Release 

Pain Management Initiative 


U.S. Army Pain Management Campaign

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