While scores of Americans have had to postpone elective surgeries, sometimes for serious conditions, at least eight professional athletes have gone ahead with procedures including elbow and knee ligament reconstruction and groin surgery.
Some names are familiar to sports fans: Major League Baseball pitchers Justin Verlander had groin surgery and Noah Syndergaard and Chris Sale had "; Major League Soccer star Josef Martinez had anterior cruciate ligament (ACL) reconstruction.
Many sports medicine providers support these athletes' surgical endeavors, citing their need to support their livelihood, as well as the absence of major restrictions at their surgery locale at surgery time (most of these occurred in mid to late March), and the potential for further harm if the athletes waited until after the pandemic.
Yet others question the safety and ethics of undergoing what they deemed non-essential surgeries when the U.S. Surgeon General, state governors, and the Centers for Medicare and Medicaid Services (CMS) have cautioned against them.
"It's this question of what's essential and what's not essential," said Lee Igel, PhD, a medical ethicist with the New York University Tisch Institute for Global Sport.
"There are tens of millions of people out of work," said Igel. "Should a professional athlete go and get Tommy John surgery or ACL surgery so they can get back onto the field that much sooner and resume their career? It is tough for most people to look at it and say, 'Oh sure, go ahead and get it.'"
Forging Ahead
Sale, of the Boston Red Sox, had his procedure in Los Angeles on March 30, after the county had released guidelines recommending against elective surgeries, and Syndergaard, of the New York Mets, had his in West Palm Beach, Florida on March 26, which was 6 days after a state executive order to conserve medical supplies for only emergency and other urgent needs. Martinez had his surgery on March 17 at the University of Pittsburgh Medical Center (UPMC).
David Altchek, MD, who performed Syndergaard's surgery, deemed it essential, sent to Sports Illustrated, and told Newsday he risked long-term nerve damage if he delayed the procedure. HSS Florida declined to comment or make Altchek available.
Sale's surgery was delayed for several days until they could secure a time and location they believe did not interfere with any resources needed to battle COVID-19, Neal ElAttrache, MD, of Cedars-Sinai's Kerlan-Jobe Institute, performed that procedure. ElAttrache was not available for this story, according to a Cedars-Sinai spokesperson.
Pitchers Tyler Beede and Reggie Lawson both had their Tommy John surgeries on March 20 with Keith Meister, MD, director of the Texas Metroplex Institute for Sports Medicine & Orthopedic Surgery. Meister told ľֱ that was 2 days before the Texas governor banned elective procedures.
Many other metro areas were already suffering greatly from the pandemic, Meister acknowledged, adding that he empathized with the plight of New Yorkers, especially as a native whose niece is working in a Bronx emergency department. He completed the surgeries because his state and HCA Healthcare, which provided the site, had sanctioned them and because he believes his patients needed them.
"You have to look at each case individually," said Meister, who has been a team physician for the MLB's Texas Rangers for 16 years. "Obviously life and death issues are far more critical than the things we are talking about, but there is a compromise."
Had all these pitchers -- in addition to Blaine Hardy and Andres Munoz who had Tommy John surgeries in March -- delayed their procedures, they would have risked missing most or all of next season, in addition to the 2020 season, should it be played.
That could have cost them a significant chunk of their careers and lowered their bargaining leverage when their contracts are up, as the average MLB career is 5 to 6 years, said Chad Carlson, MD, president of the American ľֱ Society for Sports Medicine (AMSSM). The average player has only "a somewhat narrow window to earn," he said.
Returning to play from an ACL tear takes , less than the typical year-long recovery for Tommy John. It's not clear why Martinez and his surgeons at UPMC -- Freddie Fu, MD, and Volker Musahl, MD, -- proceeded with reconstructing an ACL for the 2018 MLS Most Valuable Player in mid-March.
UPMC declined to comment for this story and a spokesman said the surgeons were not available. ľֱ could not reach Martinez, and his team Atlanta United FC did not return queries asking to be connected with Martinez.
UPMC continued permitting many elective surgeries despite the national guidelines, leading 291 of its providers to sign an citing their safety concerns. Martinez's operation occurred a few days before the letter was circulated.
Martinez and his surgeons may have been justified, Meister said, adding that he's not familiar with the specific circumstances. Waiting too long for surgery can lead to further knee damage and "not all ACLs are the same. There are a lot of other confounding variables" informing surgical decisions, he said.
Also in March, Verlander, the Houston Astros star pitcher, underwent groin surgery sidelining him for 6 weeks. It is not clear who performed the procedure or where.
The "where" is important context to consider, said Del Bolin, MD, PhD, a family medicine doctor and fellow with the American College of Sports Medicine. Bolin lives in the Roanoke, Virginia metro area, which had only 40 reported coronavirus cases as of Tuesday, "so the risk [there] would be no greater than it would be if we were not in the middle of a pandemic," he said.
He noted that patient outcomes depend partly on how soon surgeries can safely be conducted. "If the environment is not virus-dense and surgeries can be performed safely, it would absolutely be in the patient's interest" to operate as soon as patients are ready, he said.
Discussing elective surgeries in general, Meister said: "This is not cosmetic surgery. This is patients with debilitating problems. ... There is potentially some risk if you do not do these things in a prompt fashion, just because it's not necessarily urgent."
"This comes down to a balance between lives and livelihoods," Igel said. "For athletes, their agents, their teams -- anyone who's involved in or directly interested in that athlete's career -- that surgery is a big deal. It's perceived as essential because there's a sense the athlete can't go on" without it.
Special Treatment
Critics were quick to point out that these surgeries require scarce resources such as personal protective equipment that, even if not needed in that moment and region, could be needed elsewhere and at other times to fight the pandemic.
"It's a little tone deaf for a player from [a team in] the city of New York to be doing this when the one city that's been hit harder than any other is New York," said AMSSM president Carlson, who practices with Stadia Sports Medicine in West Des Moines, Iowa.
Conducting the surgeries could also have jeopardized the health of the healthcare workers assigned to them, not to mention the athletes themselves, providers said. In the off chance they suffered serious complications, they could need space in an intensive care unit, which is already in demand for COVID-19 patients, experts said.
In addition, "people are sick and they're dying and there aren't enough supplies to go around," Igel said, "and your athlete's going to get surgery to get back out there sooner to get a contract for several million dollars. It's not the right time, it's just not right."
Hollyanne Fricke, MPH, an Omaha, Nebraska public health researcher, for instance, had to postpone a hip arthroscopy scheduled for March 26. Fricke had been training after qualifying for the prestigious Boston Marathon, which has been rescheduled for September.
She was hoping to sign up until her surgery was postponed indefinitely. "As bummed as I was, I definitely understood," she said. "I've tried to come to some level of peace with it."
Fricke experiences pain daily. "It's not awful, but definitely noticeable," she said. She sometimes rides a bike for low-impact exercise, which she did not do before the injury. "I was very much a runner and only a runner before," she said. She will need to wait at least 3 months after the surgery until she can run outside at all, making running in the marathon a long shot.
It's "unfair" for professional athletes to have their surgeries if most other injured Americans cannot, she said. "I would have a hard time saying no if they called me up today and said I can come in tomorrow" for surgery, she said.
Then there is the pipeline of athletes feeding the professional leagues. Many college juniors annually express their concern that injury rehab would force them to miss parts or all of their senior seasons, when they audition for professional leagues, said Bolin, who has worked with teams at Virginia Tech and Radford University.
Any such athletes who had been scheduled for surgery in March or April will now likely re-examine that decision, depending upon when elective surgeries are cleared.
Many younger athletes also have had surgeries delayed, said Carlson. They are also eager to return to play and "it's important to their psyche that they be made whole again."
With CMS and a few states loosening restrictions around elective surgeries this week, insiders said athletes of all ages and status will become strong candidates. Providers question whether professional athletes should be first in line to flood into backlogged hospitals and surgery centers. They say decision-makers will need to weigh several criteria, including who is presenting, and when and where they would have the surgery.
Meanwhile most of the country is still advising against conducting Tommy John, ACL reconstruction, and other elective sports medicine procedures. "This is the kind of stuff that ought to be deferred," Carlson said.
Long-time shoulder surgeon Gerald Williams, Jr., MD, of the Rothman Institute in Philadelphia, is not so sure. "I could make an ethical argument on both sides," said Williams, who has operated on several pro athletes. "At what point does society think that it's not better to make them wait any longer? ... Everybody's getting antsy, patients and surgeons alike."