From the World Cup to the Olympics, sports medicine is racing to improve how injuries are treated

Whether they’re in a World Cup match or an Olympic race, injuries can be devastating for elite athletes — particularly when they prove difficult to treat quickly.

“Sports medicine today is still extremely primitive,” said Kentaro Onishi, an assistant professor of physical medicine and rehabilitation at the University of Pittsburgh School of Medicine and doctor on the International Olympic Committee. Using ultrasound technology to guide his procedures, Onishi has been able to adapt some common surgeries to be much less invasive.

But the treatment for many of the most common injuries he treats —  tendon problems — is still largely limited to managing symptoms. He and other researchers are trying to develop new technologies to change that, though. With funding from the Department of Defense, he is working to develop a lotion that will target the molecule that scars and destroys tissue, relieving athletes from developing tendonitis and other conditions that damage tendons. The idea, he said, is that athletes could one day “slap [it] on before you go work out, like a sunscreen.” New options like this for athletes “change the paradigm of treatment,” he added. “We can prevent a tendon from ever getting injured.”

STAT spoke with Onishi about his use of technology to help elite athletes and the state of sports medicine as a field. The conversation has been condensed and lightly edited.

How do you think the World Cup is handling injuries?

I think they’re doing a great job. In the previous World Cups, they’ve returned people with concussions on the same day and that was a little bit, you know, controversial. But this World Cup particularly, I don’t think that there was anything that stood out to me that was considered a bad call. Seemed like the doctors are doing really well.

Can you talk about your experience in the 2021 Summer Olympics in Tokyo?

Tokyo happens to be my hometown, and that was my childhood dream to be an Olympic doctor… And six years after my fellowship training in sports medicine at Mayo [Clinic], I returned to my homeland as an Olympic doctor working with the IOC research team. And so that was kind of a really nice way to make your childhood dream come true, full circle in your home city.

My work was to bring ultrasound technology, which has become extremely portable nowadays. It fits in your jacket pocket and basically allows you to see, through the skin to make a diagnosis from the sideline [of] a fracture or tendon muscle tears. So surprisingly, the Olympics never really had it as a standard offering to Olympians competing at the venue. They traditionally had an ultrasound in what we call Polyclinic, the central location where all the athletes stay, sleep, eat, where a multidisciplinary sports medicine clinic exists… But at the venue is a different story.

And what was unique about the Tokyo Olympics was the fact that it was the largest human sporting event and the first mega sports event held inside the Covid bubble. So transferring the athletes from a place to another place runs the risks of athletes getting an infection. Dr. Freddie Fu, who was the long term Chair of orthopedic department at the University of Pittsburgh, suggested ultrasound should be brought to the athletes as opposed to bringing the athletes to the imaging…

We piloted what we call the IOC venue ultrasound program at the Tokyo Olympics for the first formal offering to the athletes at seven different venues and these sports included basketball, a three-by-three basketball which was a new sport in Tokyo, rugby seven, BMX, indoor men’s and women’s volleyball, and handball.

These choices are based on another research project I worked with during the Tokyo Olympics,  the injury illness surveillance program, which surveys the injuries that occur during the Olympics so we understand which sports are high-risk that require a good medical support team… In many of these cases, having ultrasound at the venue actually allowed doctors to make a better decision by virtue of having imaging information, as opposed to the decision made without imaging [through] clinical exam.

What is special about ultrasound compared to other imaging technology?

Imagine having a simple X-ray machine; you have to have a dedicated room so that no one else that does not need imaging gets radiation, right. Same thing for MRI. MRI is an expensive device. Say the Olympics has the financial means to bring MRI to the venue. You have to have a dedicated room so that, let’s say, if there is a spectator with a pacemaker, their pacemaker will not stop with MRI running on the field. So an ultrasound machine is the only one that can fit in your pocket, but it requires a skilled physician to use. And this project really couldn’t have been done anywhere else other than Japan. Japanese doctors have a high ultrasound literacy…Of those 14 injuries evaluated using ultrasound, the diagnostic accuracy, compared to clinical gold standards such as MRI, was 100%.

How do you use ultrasound to diagnose injuries?

Clinical examination, as you know, is not 100%. Doctors grab legs and move them around. And no matter how good of an examination you do or how many years of experience you have, it’s never 100%. So you want to add things to increase the diagnostic accuracy as misdiagnosis will lead these people to wrong decisions. In the case of the Olympics, it might make a difference between this person playing at the Olympic gold medal match versus not playing at all. So timely diagnosis in sports medicine is so crucial.

Every year, athletes are pushing the needle forward in terms of what the human body can do. Do you think that sports medicine is able to keep up with these developments in sports?

Yes, we can. But I think we need to change… A lot of sports medicine doctors treat their athletes based on what they are taught. And what they are taught is what was taught to their mentors by their mentors. So you basically carry down a habit not based on scientific facts. And if we keep doing that, and if we don’t change this mindset, we will fall behind athletes trying to do crazy things.

We are playing with the idea … that maybe humans one day can soon run a sub two-hour marathon, but to do that, you will obviously have to train harder with higher intensity and likely higher mileage or distances run. And with those athletes doing this type of training, you anticipate increased numbers of, for example, tendon problems. And if you’re doing palliative care for tendinitis, … the tendons will fail to achieve their functional goals. So we have to understand how the tendon gets injured on the biological basis, maybe better yet the genetic basis, and to understand how to reverse it, instead of saying my mentor has traditionally injected steroids around the tendon to take care of tendonitis…

You have to ask the question of why you’re doing what you’re doing. And I think we just have to create independent research topics that we really have to understand the biological basis for. We have to really be diligent. The research is not elegant at all. Research takes time. It’s no one’s idea on Christmas Eve to pipette stem cells in a petri dish and wait for that to culture. But we must do that stuff so that we can come up with an innovative treatment option that would allow athletes to achieve their functional goals or performance goals.

Do you find the pressure on athletes to get back in the game can conflict with the need to treat their injuries?

Yeah, I do. That’s why I kind of stick with the basic tenet of medicine: your only obligation is the patient’s concern. So I don’t really talk to coaches. Unless I hear from the athletes, “I want to get back as soon as possible,” I won’t pull the trigger for aggressive, invasive interventions. Even though 90% of the time their goal is to go back to playing sports, … I will make sure to ask the question like, “Is your goal to go back to training as soon as possible?” And surprisingly, sometimes that answer is not “yes” [for] some athletes. I’ve treated some Olympic-level tennis players that are like, “Yeah, I’m okay with this season. I have a couple of months to get better.” So you just have to ask that because you can’t assume that. Because those aggressive interventions that likely return athletes to sports quicker might carry higher risks than less invasive options. So, you know, you just have to be on the same page with athletes.

What have been some of the most fulfilling moments in your career?

I may not be adding years to life, but I’m certainly adding quality to life… medicine has been pretty successful saving people’s lives, but I don’t really think medicine has long been focused on the quality of life that you have. It’s equally fulfilling to see those individuals affected by arthritis who are elderly, whose goal is to, you know, pull their grandchild’s hand and go for a nice hike on the beach… I think that story is as fulfilling to me as hearing like some of the top Olympic athletes competing at one of the world’s stages.

One of the top decathletes in the world has seen me for various injuries over the years, and seeing him lead the world at the World Track and Field Championships… I was in Japan presenting at a conference but watching him from Japan while he’s competing and hoping that the injury I treated wouldn’t fail, so it’s like a bad sweat. But when he comes through the finish line as the number one competitor in the world, it’s also fulfilling.  I think that you can actually tangibly see the fruits of your work in something other than just the added years of life. Doing something like that sometimes changes their entire life. If you’re talking about high school athletes getting treatment in a timely fashion to make it to the state championship and he wins that and he gets a scholarship to college… you did a small part in allowing the high school student to choose their path.