An NFL game is a complicated beast.
Every Sunday, two head coaches and their staffs engage in a 60-minute chess match. In total, 106 players carry out each move with jaw-dropping athletic prowess, incredible strength and superhuman speed and agility.
All the while, medical professionals such as Dr. Matthew Matava—president of the NFL Physicians Society (NFLPS), Professor of Orthopedic Surgery and Sports Medicine at Washington University in St. Louis and head team physician for the Rams—are watching, ready to act.
After all, as an inherently dangerous sport, injuries, for better or for worse, are a part of the game of football.
Depending on the events following an injury, a player's season could continue without issue, or it could end on the spot. The actions of medical personnel go a long way toward determining the outcome, and as such, Dr. Matava and his colleagues are in the thick of it—from beginning to end.
According to Matava, medical care begins well before kickoff. For an early game, he typically arrives at Edward Jones Dome at around 9:30 a.m. ET and gets to work.
"During pregame time, we are evaluating any players that may be questionable for the game," he offered. "The team has up to an hour and a half before game time to list their roster, so we might take some players out on the field early on—to stretch them out, run them and have them go through various maneuvers they would do at their position—and then make a decision on whether or not they are ready to play that game."
He and his staff have various tools at their disposal. However, the oft-discussed anti-inflammatory drug Toradol is not frequently one of them. It is a powerful non-narcotic pain-reliever, but it does not come without risks—although neither does any medication.
"(It) is something we are asked quite frequently. It used to be that players were given shots of Toradol before the game. We’ve eliminated that practice altogether," Matava explained.
Hydration is also key. Though sometimes overlooked, adequate fluid intake is crucial for a player to maximize his time on the field.
As game time gets closer, introductions start. Matava continued:
"We will go out about 40 minutes before the game to meet the opposing team physicians, who are typically our friends. We'll introduce everybody to everybody else.
"A new policy in the NFL is that the head doctor for each team has to introduce themselves to the head referee. (That way), in the event that there is a significant injury or head injury, they will know who to turn to on each sideline to describe what (they) saw."
Matava and his team also meet with the "eye in the sky"—an independent athletic trainer that remains near the press box to oversee the game as a whole.
Believe it or not, the introductions are not a trivial task.
"We have so many medical specialists there. It takes about five minutes to make all the introductions," Matava joked.
The final steps involve last-minute taping or bracing and answering any questions that players or trainers may have about a particular injury or condition. By that time, the unscientific designations of "probable," "questionable" or "doubtul" are more clear.
"(The designations are) a relatively crude (classification) in terms of chance to play. I can't give any scientific basis. It's based on experience, the nature of their injury and how they've responded to rehabilitation," Matava clarified. "It's a way we can communicate amongst each other to tell where a guy is in terms of his ability to be able to play in that game."
On-Field Injury Response and Immediate Care
Once the game starts, the medical staff shifts into an entirely different gear. The height of the team's responsibilities? Responding to an acute injury on the field.
"(If a player) is tackled and doesn't get up, Reggie Scott and myself will immediately run out to the player," he explained.
Scott is the Rams' head athletic trainer.
"The first thing is to establish what was injured," Matava went on. "If they are not saying anything (due to shock) and they are writhing around, we will try to keep them still so whatever is injured is not disturbed further.
"If a player does announce that it's his knee, for example, and he is lying face down, I'll grab the part that is injured. Reggie will man the head and calm him down, and we'll try to roll him over on his back. If he is lying on his back already, it's a little bit simpler.
"(We'll) try to let the player calm down and know that everything is under control—to try to relax. That's Reggie's job. Meanwhile, I will palpate to make sure the knee is reduced. A lot of times with these injuries you can go out there [...] thinking maybe an ACL tear, and it's a knee dislocation."
Palpation involves systematically feeling each bony prominence, ligament and joint line to assess for pain, swelling or deformities suggesting a dislocation or fracture.
"The first thing I'm doing is a general assessment of the limb in terms of its overall alignment to make sure there's no open fractures, femur fracture or tibia fracture—things like that. Once it's established that there are no gross deformities, I will go through a brief general examination of the knee to get an idea if there is good range of motion."
Specialized physical exam techniques for the knee—such as the Lachman, posterior drawer and valgus or varus laxity tests—can yield immediate information about what possibly happened. The ability to move the foot and toes also provides the medical team with basic information on the status of the nerves and blood vessels within the leg.
Getting the athlete off the field for further evaluation comes next.
"Let's say (the player) has an ACL tear. If he can get up and walk on his own, we'll have him sit up first, and then we'll go ahead and prop him up on his good foot and have him walk out if he is able."
If an injury precludes walking—such as a tibia fracture—the process proceeds differently.
"(In that case), we will immediately call for the head athletic trainers to come out. They will bring an inflatable splint. Then, the transportation team—the cart you see on TV—comes down the field."
Sometimes, dislocated joints require immediate reduction, even before additional help or the cart arrive.
"Despite the fact that it sounds brutal, the best time to reduce (a joint) is right then and there," Matava pointed out. "There is no spasm of the muscles yet and no significant swelling. Typically it goes right back in very quickly, and you hear a big sigh because the pain that was so unbearable is now relieved."
Emergent Situations on the Field
The staff and stadium are fully equipped to deal with medical emergencies. Matava and his colleagues also follow a strict protocol to assure a seriously injured player's safety—especially when an injury causes a player to lose consciousness.
"The first thing you want to do is protect the neck and establish the airway. We immobilize the neck and immediately remove the facemask," he emphasized. "We never, ever, ever transport a player by cart without removing the facemask."
The concern stems from the fact that if an unconscious or injured player cannot keep his airway open—an immediately life-threatening situation—he needs intervention without any delay whatsoever.
"That's rule number one."
Furthermore, the shoulder pads and helmet either come off or stay on as one. They never separate, as doing so could worsen an unstable neck injury.
"If you take off the shoulder pads but leave the helmet on, the neck and cervical spine go into flexion. If you leave the shoulder pads on and take off the helmet, the neck goes into hyperextension. Both can disturb the vertebral structures, which, if there is a significant neck injury, can do further damage."
The nightmare scenario? A player stops breathing.
"We have a physician on the sidelines who is available for emergency airway management," Matava reassured. "Typically, these are anesthesiologists or emergency medicine physicians. You will know them because they have a red hat on and typically stand on the 30- or 40-yard line."
The airway physician can intubate—and even perform a surgical procedure called a cricothyrotomy if needed—to access a player's trachea. Fortunately, it has not proven necessary yet.
"(The airway physicians) are a great insurance policy, but no one has had to be intubated during an NFL game so far. But again, it's one of those things you want to be better prepared than not."
On-Site Diagnosis and Treatment
According to Dr. Matava, the NFL mandates all stadiums have X-rays on site to diagnose fractures or dislocations. MRIs can come later.
"We aren't going to emergently take (an athlete) to the hospital for an MRI. You aren't going to fix an ACL that night, for example. In that situation, the player will go back to the locker room. He'll remove his equipment, and he will apply ice to the area."
Braces, crutches and pain control are next. Suture kits, braces, casts and splints are also at the ready when needed.
"It's basically a small emergency room on the sidelines and in the locker room," Matava said, adding that he and his team can treat any non-urgent fracture on site.
That said, some situations call for prompt action.
"If it's a life- or limb-threatening problem—let's say the player is unconscious—he is going straight to the hospital," Matava made clear. There, players can receive urgent CAT scans to look for bleeds within the brain, for instance.
Returning to the Field Following an Injury
Often, a player will leave an NFL game only to return to the field later that day. The nature and severity of the injury determine if such a return is possible, and Matava and his team work together to make the decision.
"I can’t remember a situation where I thought a player could play (with an orthopedic injury) and our head trainer didn’t, or vice versa," he reflected, "But I am the ultimate say."
Internists and primary care physicians manage and clear returns from non-orthopedic issues, such as dehydration or complications from an illness.
As for concussions, Matava explained that every team carries a designated specialist.
"In our team’s case, it’s a primary care physician who has an interest, both clinical as well as research, in concussions."
The specialist evaluates suspected concussions and makes the call as to when a player must leave the game. He or she can consult with an unaffiliated neurotrauma specialist, also present on the sidelines.
Strength in Numbers, Strength in Care
There might not be a better place to have a medical issue than on an NFL sideline. After all, at times, up to 27 medical professionals are manning the field.
"You know how many people are on your sideline," Matava explained, "but you have the EMT people there. You have X-ray technicians."
That's not it.
"We have an ophthalmologist [an eye specialist]. We have a dentist in the stands. There is no other situation in life that I can think of where so many medical eyes (can watch) a catastrophe happen right before them."
And make no mistake. They are the best of the best.
"A good number of the about 177 NFL team physicians are (in academia). They teach. They do research," he continued. "They aren't just clinicians. They are leaders in their respective fields of medicine, and their first, second and third priorities are the medical care of the team."
Furthermore, the care doesn't change based on the score.
"Physician jobs are not dependent on wins and losses. [...] I've survived 1-15, 2-14 and 3-13 seasons with the Rams," Matava recalled. "We can go 0-16, and my job does not change one iota. [...] Obviously, we know that we want to have the guys back on the field as quickly as they can be in a safe fashion—and we can be creative in the ways we do so—but there are no competitive issues involved in our decision to (allow) return to play."
Can Medical Staffs Win or Lose Games?
All told, there is no way to easily determine the degree of a medical staff's influence on the final score.
That said, at the suggestion that Matava and his crew's excellent care allowed the then-3-6 Rams to upset the 6-2 Indianapolis Colts in Week 10, he chuckled and played along.
"We like to say that we out-doctored them."
Dr. Dave Siebert is a resident physician at the University of Washington. Find more of his written work at the Under the Knife blog.
All quotes were obtained by the author during an exclusive phone interview with Dr. Matava on the evening of Thursday, Nov. 14.