When to Hang It Up

The year is 1979. Twenty-two-year-old Larry Bird has spurned Red Auerbach’s initial offer of $500,000 a year, and Bird is back in Terre Haute, Indiana, counting down time until Auerbach either ups his offer or the Celtics lose their exclusive negotiating rights to the player already known as the Hick from French Lick. Bird figures regardless of what happens in Boston, he’ll end up playing somewhere.

One afternoon that summer, Bird breaks an index finger during a softball game. It’s his right index finger, which he depends on to guide a leather ball with a 29½-inch circumference into a hoop that’s 56½ inches around. Bird walks over to a teammate and asks him to snap the finger back in place so he can keep playing. He finishes the game – you can bet his team won – and with that, Larry Bird is on his way to becoming Larry Legend.

It’s a compelling cliche: the modern-day athlete as a proud and fearless warrior, always willing to sacrifice his body for a win. Like many cliches, it resonates partly because it’s true and partly because we want it to be true. Here in Boston, a medium-size city that’s a huge sports town, there’s a richly celebrated tradition of players who have put themselves at risk for glory’s sake. Remember Kevin McHale, gamely battling the Los Angeles Lakers’ James Worthy for position during the 1987 NBA finals? When he wasn’t on the court, McHale was in so much pain he was forced to use a hotel chair as an improvised walker. It turned out he was playing on a broken foot, and the Hall of Fame forward was hobbled with injuries the rest of his career. Think back to Pedro Martinez, pitching in relief in an elimination game in the 1999 playoffs just days after being unable to lift his throwing arm above his shoulder without tears welling in his eyes. Martinez used a combination of guts and guile that afternoon to blank the prodigiously powerful Cleveland Indians for six masterful innings. And without taking anything away from David Ortiz, it was Curt Schilling, who insisted that doctors suture a dislocated tendon in place to keep it from snapping back and forth across his anklebone, whose blood-soaked sock provided the single most indelible image from the Red Sox’s 2004 World Series run.

We look to athletes to transport us to a world of black and white, right and wrong, winners and losers, and we’ve been conditioned to think that the winners are the ones who leave it all on the field, consequences be damned. When we reminisce nostalgically about the heroes who risked everything for their love of the game, we remember players like Bird and McHale, Martinez and Schilling. We praise Tedy Bruschi’s dedication when he suits up for the Patriots less than nine months after suffering a stroke, and we cheer Ortiz when he’s back in the batter’s box a week after checking into Mass. General because of heart palpitations.

We don’t think of Marty Barrett, who played in 740 games for the Red Sox from 1984 to 1988 but made it on to the field for a mere 111 games after his 31st birthday because, he says, he received improper treatment and came back prematurely after he tore his ACL, the ligament that connects the tibia to the femur. (In 1995, Barrett won a $1.7 million malpractice suit against former team doctor – and part owner – Arthur Pappas.) We don’t think of Reggie Lewis, whose fatal heart attack resulted from his stubborn (or stupid) determination to continue playing basketball after he’d been diagnosed with a crippling heart defect. We don’t think of Matt Clement, who in 2005 insisted on returning to the mound just nine days after being hit in the head by a line drive traveling more than 100 miles per hour. By the end of the season, his ability to get Major League hitters out seemed to evaporate, along with his confidence. And we don’t wonder whether Ortiz should have taken a few more days to make sure he wasn’t putting himself at risk.

The field of sports medicine has experienced exponential growth in the last decade, fueled by the explosive rise in player salaries and the christening of sports doctors as celebrities in their own right; indeed, it’s not a stretch to say that today’s big-time professional athletes have at their disposal a higher quality of medical care than any other group of people in the history of the world. “There have been enormous advances in the field of sports medicine," says Dr. Thomas Gill, the Red Sox’s medical director and the Patriots’ head team physician. “So many of these have resulted from contributions that have come out of professional sports. The team physicians that care for athletes are much more advanced than in the past."

But as the country’s major professional sports leagues – and professional sports medicine – have become more lucrative, the field has been roiled by accusations of conflicts of interest and negligent care.

Over the last eight months, three stories have converged to shine a light on what might very well be the most frightening sports injury of all – the literal loss of one’s mind. The resulting attention has emboldened a growing number of physicians and medical researchers to question whether our modern-day gladiators are getting the level of treatment they deserve. It’s one thing, after all, for Schilling to knowingly risk further injury for a shot at a championship. It’s quite another for former New England Patriots linebacker Ted Johnson, now 34, to face the rest of his life saddled with debilitating depression and crippling memory loss, which doctors around the country attribute to the multiple concussions he received while a linebacker with the Patriots.

But unlike what happens on the field, in many of these cases there is no clear right and wrong, no obvious heroes and villains. Coaches get caught up in the moment; doctors are forced, out of necessity, to perform rushed on-field examinations and make snap judgments with tens of thousands of fans (millions if you factor in TV), looking on; players hide injuries to protect their roster spots; agents encourage their clients to get back out there and prove they’re worth that next big contract; and fans worship players who show durability, no matter the cost.

There are, however, clear losers – not only the Ted Johnsons but also the countless kids playing Little League and Pee Wee football, the kids who emulate their idols and force themselves to get back on the field after getting dinged up, sometimes with disastrous results. “There’s huge peer pressure, not just from friends but from society at large," says Dr. Robert Cantu, the chief of neurosurgery at Concord’s Emerson Hospital and the co-director of the neurological sports injury center at Brigham and Women’s. Cantu is one of the doctors who examined Johnson, and he and many of his colleagues would like to see an organized effort, almost on the level of the anti-smoking campaigns of the last decades, that would strive to end the deep-rooted, culturally based lionization of athletes who force themselves to play while injured – and the muted (and sometimes not so muted) disdain for those who don’t.

“We teach these kids to play hurt, to play through what’s perceived to be minor injuries. But most of the time they just don’t know – the coaches, the parents, certainly the kids," Cantu says. “So you have more 13-year-olds coming in for Tommy John surgery, more high school coaches asking kids to throw a huge number of pitches. And when it comes to head injuries, well, some of them don’t come in for surgery. Some of them die."

Last October, Chris Nowinski, a former varsity football player at Harvard and onetime World Wrestling Entertainment competitor, released Head Games, a book that details what Nowinski calls “football’s concussion crisis." For the 28-year-old Nowinski, who received two of the six concussions he’s aware of while playing college ball, this was no mere academic exercise. Before his premature retirement from wrestling, Nowinski was kicked in the back of the head with such force his opponent thought he might have broken his foot. (Even though much of the action in professional wrestling is scripted, many of the moves are real, and wrestlers experience injuries ranging from broken bones to concussions.) Nowinski blacked out in midair; his failure to complete his next “scripted" move momentarily threw the match into confusion. Two months later, Nowinski took a boot to the chin. Again, he became unaware of his surroundings. The next night, Nowinski, who felt as if he were in a “fog" for days, was on the losing end of what’s called a table match, which is exactly what it sounds like: The loser gets thrown through a table. A few weeks later, Nowinski tried to get back into the ring, but after a couple of fights, the WWE wouldn’t let him continue because of his condition. He would never get in the ring again.

As he soon discovered, the effects of his multiple concussions were not over. Twenty-four hours after his last match, Nowinski was in a hotel room in Indiana with his girlfriend. He woke up in the middle of the night, confused. “I found myself facedown on the floor, surrounded by shards of glass," he writes in Head Games. “I looked to my right. The nightstand was broken, and its glass surface was shattered. The lamp and the alarm clock that had been on the night stand were on the ground." As Nowinski tried to get his bearings, he heard his girlfriend crying out his name, and as he turned around, he saw her huddled in terror on the bed. She told him she had awoken to Nowinski’s otherworldly screams; he looked, she said, as if he were trying to climb up the hotel room’s walls. These days, he lives in fear of what his future will bring. He sometimes struggles with names. Is that normal forgetfulness? Or a harbinger of what’s to come?

Nowinski, like virtually all of the people advocating for more attention to the dangers of playing despite debilitating injuries, argues passionately about the harm faced by teenagers, whose developing bodies are especially vulnerable. At the beginning of his painstakingly researched book, Nowinski writes of 12-year-old Kyle Lippo, 16-year-old Osten Gill, and 17-year-old Edward Gomez. The three boys died within months of one another in the fall of 2003. All three deaths occurred soon after the boys played in football games, and two of the cases were clearly connected with blows to the head. Lippo, a trombone-playing Boy Scout from Round Lake, Illinois, asked his coach if he could sit out because of a headache. Five minutes later, his coach asked him if he wanted to go back in. Lippo started crying. “It hurts real bad," he said. He died after being airlifted to a local hospital. Deaths like these could be avoided, Nowinski says, if the public were better educated about the risks of playing with injuries. Cantu, who wrote the preface to Head Games, agrees.

A month after Nowinski’s book came out, Andre Waters, an NFL safety from 1984 to 1995, shot himself in the head. After reading about the suicide, Nowinski, suspecting that Waters had been suffering from a traumatic brain injury, persuaded Waters’s family to send sections of his brain to Dr. Bennet Omalu, a neuropathologist at the University of Pittsburgh. Omalu was a natural choice: He had examined the brains of Mike Webster and Terry Long, two former Pittsburgh Steelers who died young and experienced post-concussive brain dysfunction. (Webster went through periods of homelessness after retiring from football. He died of heart failure in 2002 at age 50 while suffering from dementia. Long, who doctors said had “punch-drunk syndrome," committed suicide in 2005 by drinking antifreeze. He was 45.) After studying tissue samples, Omalu said Waters’s brain resembled that of an 85-year-old with Alzheimer’s, and he believed the damage was caused or severely exacerbated by Waters’s many concussions.

Three months later, in February of this year, Ted Johnson went public with his struggles with depression and memory loss in the two years since he retired from the Patriots. Johnson attributed his difficulties to concussions he received during his playing career and spoke specifically about an incident that occurred in August 2002. According to Johnson, Patriots coach Bill Belichick went against the advice of the team’s trainer and insisted Johnson participate in full-contact practice drills just days after an exhibition game in which Johnson had been hit so hard that he blacked out. Johnson received another concussion that afternoon in practice, and, he says, his life has never been the same. He retired after the 2004 season, and the past two years have been the most brutal of his life. (Belichick has said that Johnson should have told him he wasn’t ready but also has expressed regret over how the situation unfolded.)

Because of the revelations involving Nowinski, Waters, and Johnson, football fans may soon be discussing second-impact syndrome and post-concussive syndrome as often as they talk about groin pulls or dislocated shoulders. Ironically, if not for research fueled by professional sports, the sad sagas of Johnson and Waters and Long might have been seen as tragic, isolated incidents.

Still, even now, advances in sports medicine don’t always mean that athletes are receiving the best possible care. There’s a long history of focusing solely on athletes’ playing careers when considering their medical treatment – think of the retired catchers who no longer have any cartilage in their knees or the once-proud linebackers who can’t walk on their own. And only recently has the sports world begun to collect data on major professional athletes after their playing days are over. (The research conducted today doesn’t focus as much as on smaller leagues and less popular sports because the financial stakes there are so much lower, making it less likely that players will push themselves – or be pushed – to the point at which they risk life-altering injuries.)

“For a long time, there was nothing but anecdotal evidence about the lives of athletes once they were out of sports," says Dr. Kevin Guskiewicz, the director of the University of North Carolina’s Center for the Study of Retired Athletes. Guskiewicz, who founded the center in 2001 with Dr. Julian Bailes, says he “wanted to find out what was really going on, and base that in science. And what we found was that a lot of the anecdotal evidence ended up being true." The center’s best-known studies have focused on just the type of post-concussive brain injuries that are receiving so much attention today.

“I might be able to limp through this ankle sprain and still be OK 10 years from now," Guskiewicz says. “But when we talk about brain injuries, you can’t limp through them. It’s scary. And when we talk about people dying on the playing field, it’s most often a high school athlete who still has an immature brain. With more advanced players, with National Football League players . . . there would very well be long-term depression or early-onset dementia." Among other things, he’s studying whether some people are predisposed to those conditions.

Guskiewicz is fighting an uphill battle, and often it seems as if virtually no one in professional sports is really paying attention to the type of research he’s doing. Earlier this year, NFL Players Association head Gene Upshaw said it was a player’s responsibility to decide when he could and couldn’t play. “If a coach or anyone else is saying, ‘You don’t have a concussion, you get back in there,’ you don’t have to go, and you shouldn’t go," Upshaw said. “You know how you feel. That’s what we tried to do throughout the years, is take the coach out of the decision making." That statement is so patently ridiculous it would be risible if the consequences weren’t so dire. In the moments after someone sustains an injury, he is the person least able to properly diagnose himself: The adrenaline coursing through his body serves as a natural painkiller. Concussions – which, by their very definition, leave a player disoriented – add a whole other wrinkle. And football players, who don’t have guaranteed contracts and live in fear of losing their jobs to the next guy on the depth chart, are infamous for not acknowledging injuries. Even without all of those factors, 20-something athletes who have never known life outside of sports are not famous for making decisions that realistically consider their futures.

While the NFL’s Mild Traumatic Brain Injury Committee has been disturbingly slow to adopt – or even consider – recommendations made by researchers like Cantu, Guskiewicz, and Omalu concerning mandatory time off the field following a concussion, at least the league has started to analyze data it has collected on its own. In the National Hockey League, the players union has permitted teams to gather information about concussions so long as they don’t analyze any of what they collect.

“They’re afraid we’re going to say there are situations in which players can’t be out there," says a New England-based doctor who has worked with the league and who, like many physicians actively involved with professional sports teams, asked to remain anonymous to maintain their relationships. “The union won’t allow that. They want to ‘protect’ – and I’m fully aware of the irony there – their members’ right to go out and play whenever they want. Because God forbid they should lose their place on the first line."

Jonathan Weatherdon, a spokesman for the NHL Players’ Association, says the league and union are jointly analyzing the data, “as has always been the case with the concussion program."

Thirteen years ago, Rob Huizenga published You’re Okay, It’s Just a Bruise, a chronicle of his seven years as the team internist for the then Los Angeles Raiders. Huizenga is an engaging, humorous writer, and he does a good job conveying the intensity, the camaraderie, and the commitment that comes with being part of an NFL team. But what makes his book a lasting contribution to sports literature is his illustration of the “fuzzy boundary between good medicine and good team doctoring."

“Imagine the pressure," he wrote. “The Super Bowl is a week away and your team’s star is injured. Your boss – a win-at-all-costs businessman – has doled out over $34 million in salaries and expects a return on his investment. The player, mesmerized by the pregame hype, or subconsciously realizing that refusing to play hurt may damage his reputation as a macho tough guy (and eventually impact salary and endorsements), states openly that he’s willing to take almost any risk to play. Enter you – the team doctor – perhaps also a little caught up in the pregame excitement. Remember, even medical professionals are human. They can occasionally succumb to pressure just like everyone else."

According to a number of current team doctors, this description of the job remains accurate. But these days, it’s not just about pressure or the contradictions of big-league sports medicine, in which team doctors owe their allegiance to teams, not the players they’re treating. It’s also about money and prestige for physicians and medical institutions. The benefits of being associated with professional teams are so numerous that over the past dozen years hospitals have been known to actually pay teams for the right to provide medical care. Several leagues have instituted regulations that prohibit these types of direct payoffs, but, as one local team doctor notes, “there are plenty of ways around that – buying a luxury suite, advertising, whatever." (Look around our local arenas or ballparks, and it’s clear the New England teams have found no shortage of ways to monetize their medical relationships. Four years ago, the Red Sox, who are partially owned by Globe parent The New York Times Co., took bids from local hospitals that wanted to be known as the team’s official healthcare provider. Beth Israel won out, and it’s now known as the Red Sox’ “official hospital," despite the fact that Gill and the group of doctors who actually treat the team are based at Massachusetts General Hospital.)

“Doctors and the hospitals get a lot of attention around here," Celtics team physician Brian McKeon says. “Compare it to an Orlando, where there’s a lot less interest. Here, everybody knows the Boston Celtics." Because of that, he says, it’s impossible not to be aware of the benefits of being associated with the organization.

In this case, the Celtics get access to world-class physicians for below-market prices, and McKeon and New England Baptist, which he represents, get the refracted glow that comes from an association with the most storied franchise in the NBA. Therein lies the rub. “If you’re a sports medicine physician . . . it’s human nature" to want to protect that relationship, says Cantu, who is also a consultant for the Boston Cannons lacrosse team. “Let’s talk about the extreme pressure these guys face. If Bill Belichick doesn’t like the way you smile, he can fire you. If he doesn’t like what you do, he can fire you. If he doesn’t like the fact that you talk to [a player], he can fire you. He’s in absolute control of the Patriots. That puts tremendous pressure on the medical staff. It doesn’t mean they’re not giving it their best shot, but it does mean [you’re] under extraordinary pressure when compared to the normal doctor-patient relationship, where the patient is not only employing you but you’re their advocate exclusively, and, quite frankly, they’re the ones that can fire you. When the doctors are employed by the team, that’s not the case."

Not surprisingly, those doctors who have gone against the wishes of a team have discovered just how expendable they are. During the years in which Arthur Pappas served as the Red Sox’s team doctor, he also consulted with other local teams. “One time, I saw a player who was injured," he says. “I suggested [to his coaches] that he probably needed another two weeks [before he could return to the field]. The team made it clear that he was not under any circumstances being paid to sit out. I decided to tell the player my opinion on my own. From that point on, I did not see patients from that team."

Some club officials are aware of the ethical questions involved. “Some days, I think the absolute best thing to do would be to just walk out, to quit," says one front-office employee of a Boston-area team about the health risks the organization’s players faced. He spoke off the record to prevent his views from being taken as the team’s position and because he didn’t want to imply he had firsthand knowledge of any specific examples. “Because I wonder: In 20 years, in 30 years, if these guys are all falling apart, if they can’t walk or all are getting cancer or whatever, am I going to be able to live with myself?

“On the other hand, what can I do? Speak out? The players would never say anything was wrong. They want the money. And the fans wouldn’t be too happy, either. So I’d lose my job, all of my colleagues would hate me, and I wouldn’t have accomplished a [expletive] thing."

He’s right. Take, for instance, the steroid controversy in Major League Baseball. Its players (and the players union) have been fighting against more stringent testing, testing that could, at least theoretically, both level the playing field and protect their future health. But in the short term, there’s a good argument to be made that the more steroids that are in the game, the better it is for everyone involved. The league and its owners would make more money, the players would get bigger salaries, and fans, who certainly weren’t complaining about the home-run binge of the late 1990s, would get to watch the offensive fireworks they love. “You think it’s the doctors who are covering this up because it’s what the teams want?" asks a local team doctor. “You’re out of your mind. If you so much as hint to a player that you want to talk about the risks of, say, HGH [human growth hormone], you’re risking a lawsuit. You’ll have the union up your ass. You’ll have the player’s agent saying the team is just trying to find a way to knock down his value for his next contract. Eventually you throw up your hands. If a patient fights that much against [as little] as being educated, well, fine."

Some fans don’t want to know, either. Or don’t care. And that only contributes to the pervasive mind-set that a player’s health doesn’t matter nearly as much as his statistics. “Kids and their parents both look up to professional athletes," says Guskiewicz of the Center for the Study of Retired Athletes. “They take their lead from these guys. I mean, if it’s good enough for your hero, the guy making however many millions a year, isn’t it good enough for you?

“I have three young boys, 7, 9, and 10 years old. They all play football. I love the game. I want them to be able to play as long as they’re able. And I want to know – and I want them to know – what they can safely do and what they can’t safely do. I would think everyone would want that, for themselves and their children. But it’s just not the case."