Where does high school football get you? In the knee.

Brian Harrison broke from the huddle, crouched in his position at defensive tackle for the Pearce High School Mustangs, and awaited the play. Brian, 16 years old and a junior, was not an imposing physical specimen, especially for a defensive lineman; at 5’9″ and 165 pounds, Brian was usually overmatched by the offensive linemen he faced. Overmatched but not outplayed; Brian was a starter because he was agile and aggressive. And he loved football; since ninth grade he had loved playing it, loved watching it, loved being a part of it. Even more than the game itself, he sometimes admitted, he loved the glory.

And there was a lot of glory to be had in this game tonight. The Mustangs were undefeated in their first five games of the 1977 season, and tonight, in Sherman, they were facing the tough and talented Sherman Bearcats. It was the first quarter, and Sherman was mounting the first significant offensive drive of the game. Brian tensed for the snap, prepared for the crunch of contact. The pitchout went to the Sherman halfback, who ran a sweep out to the right side. Brian maintained his balance off the initial block and chased the play to the outside. The ball squirted out of the halfback’s hands. Brian moved toward the loose ball. Just as he began to dive, a Sherman blocker blasted into his right knee. Brian felt only the suggestion of pain as his leg caved inward. He recovered the fumble. It was his last play of the season.

Brian tore the ligaments in his knee; he was the fourth player on the Pearce team to go down and out with a knee injury last season. (That night the team lost the game by a point.) Two games later, another of Brian’s teammates hobbled off for the rest of the season with a serious knee injury, the team’s fifth.

Brian underwent knee surgery four days later. Lying on his back in the post-op ward as he came out of sedation, his leg in a sling, his agony reached its height. His knee burned with pain, his mouth burned with thirst. A nurse gave him a wet rag to suck on, but there was no relief for his knee. Even now, nine months later, after “successful” surgery, a week in the hospital, eight weeks in a cast, and week after week of whirlpool treatment and exercise, Brian’s knee still has not entirely stopped hurting. There is a tender knot just below his kneecap and a ragged scar carved along the inside of his knee; he still winces at any pressure in either area. And football season is about to begin.

The orthopedic surgeon who operated on Brian’s knee has indicated his concern over the prospect of Brian’s playing football again. He has told Brian and his parents that if Brian returns to football, there is a 40 percent chance that he’ll re-injure his knee. He has told them that surgery the second time is generally more difficult than the first, and that any additional damage increases the likelihood that Brian’s knees will be swollen with arthritis by the time he’s 30 years old. Brian entertains no illusions of playing football in college – he knows he’s too small; there are no athletic scholarships to think about. He is now intimately familiar with the frustration of immobility, the tedium of recovery, and the pain. He knows that of his two teammates with knee injuries, one has decided to give up football entirely and one has decided to concentrate on his skills as a catcher in baseball. His parents worry about Brian’s returning to football, but say that it’s his decision; they will willingly spend the $250 for a knee brace to offer some protection if that’s what Brian wants. “If Brian decides he wants to play football again,” says his mother, “we’ll let him play football. He loves to play.”

Brian has decided he wants to play football again.

Dr. John Gunn is the orthopedic surgeon who repaired Brian’s knee. Dr. Gunn loves football almost as much as Brian Harrison does. Every Dallas Cowboys home game finds Dr. Gunn in Texas Stadium, cheering as avidly as the next fan. He enjoys watching football on television on weekends whenever his schedule allows him a chance to relax in his large University Park home. He appreciates football’s drama, its strategic subtleties, its force. Dr. Gunn likes football. He doesn’t like what it does to football players.

Growing up in a small town near Houston, with two older brothers who were high school football stars and local heroes, John Gunn was inevitably a football fan. When his time came, he too played on the high school team. But he wasn’t as talented as his brothers and when career decisions arose, John Gunn left the gridiron in favor of the operating room. When he graduated from Southwestern Medical School in 1961 with credentials in orthopedics, Dr. Gunn joined a medical group headed by Dr. Marvin Knight, who had just been appointed team physician for the fledgling Dallas Cowboys. Over the last 17 years, Dr. Gunn has seen a lot of football injuries, mostly injured knees. Many of those knees have been high-school-age knees.

Dr. Gunn knows as much about football knees as anyone. And what he knows distresses him. Football and football injuries have done a lot toward keeping Dr. Gunn’s operating table busy and his banker happy. But football, Dr. Gunn thinks, needs some reevaluation. Particularly on the pre-college playing fields, before the game has become professionally and financially rewarding. “The pros risk their bodies for money, a lot of money,” says Dr. Gunn. “But high school kids tear themselves up for nothing.”

The knee is made for running – running forward. It is not made to cut sharply and suddenly from side to side. And it is definitely not made to withstand the impact of 200 hurtling pounds of middle linebacker.

The knee is a marvelously complex contraption that manages to connect two of the largest bones in the body with an impressive degree of mobility. But because of its mobility, the knee lacks protection. Unlike many of the body’s joints, the knee is not a ball and socket arrangement, which has its own bony protection and stability. The knee instead is held together by four major sets of ligaments, tendon-ous tissue attached to the bones of the leg and binding them together, one ligament stretching vertically on either side of the knee joint, one behind the joint, and one set of two ligaments stretching in crisscross fashion through the center of the joint. Lying horizontally at the juncture of the leg bones is the meniscus, two horseshoe-shaped pieces of cartilage that act as a shock absorber between the bones. Covering the end of the femur (the upper leg bone) is the articular cartilage, a lubricated tissue which allows the joint to move with minimal friction.

Serious knee injury almost always involves a tearing or severing of ligament or cartilage. Such terms as “pulled ligaments” and “torn cartilage” have become so common in football phraseology that on the medical shock-value scale they register little more impact than “stubbed toe.” But the football fan who watches in despair as his starting tight end goes down knows “torn ligaments” means “out for the season.”

The knee, of course, is not the only part of the body susceptible to football injury. The ankle is more often injured, but seldom seriously; shoulder separations are not uncommon; fingers regularly dislocate; and pinched nerves are part of the game. But ask any orthopedic surgeon who deals primarily with athletic injury, and he will tell you that knee injuries form the bulk of his practice. Football, of course, is not the only sport that causes knee injury. Basketball can wrench a knee; so can soccer. But most knee injuries happen on the football field. One national survey indicates that 68 percent of all athletic knee injuries occur in football.

In the last ten years, as American sport has grown phenomenally, a new professional term has sprouted: sportsmedicine. The repair of athletes, amateur and professional, has become big business – there are sportsmedicine magazines and journals; there are sportsmedicine committees and conferences; there are sportsmedicine specialists and sportsmedicine stars. A few physicians first began specializing in the treatment of athletic injury in the late Fifties and early Sixties; it’s not happenstance that the birth of sportsmedicine coincides with the dawning of the golden age of football. “Sportsmedicine,” says one Dallas physician, “is football medicine.”

The waiting room of the Sports Medicine Clinic of North Texas on Forest Lane is not at all like the waiting rooms of most doctors’ offices. For one thing, it’s carpeted with Astroturf. For another, the room is decorated with sports memorabilia – instead of the usual bad oil paintings, the front wall displays an old pair of cross country skis. The waiting room gleams with some 30 stylish chrome chairs. Thirty chairs means a lot of waiting patients. The chairs are mostly empty on a July afternoon, but one suspects that in October they are full.

The Sports Medicine Clinic of North Texas is the domain of Dr. Pat Evans, team physician for the Dallas Cowboys. When he’s not tending the breaks and bruises of the Cowboys, he’s tending his patients here. Four years ago, as an orthopedic surgeon with a private practice, Dr. Evans found himself unable to ignore the fact that more and more of his work involved athletic injury. His interests and his instincts led him to a decision to specialize. Within a year, he was able to eliminate all other aspects of his practice and establish the Sports Medicine Clinic.

Dr. Evans is a big man, heavy set, with thick jowls framing a friendly face; he looks like a former offensive lineman. A massive Cowboy Super Bowl ring adorns his right hand. He is convivial and pleasant until he’s confronted with the sportsmedicine-is-football-medicine equation. He bristles slightly. “I think that’s overstated,” he says. “From my observation, the growth of sportsmedicine is related to the surge in youth sports, all sports. I’d say some sixty percent of my practice is high school age or younger. And it’s not just football. We’re now seeing, for example, a lot of injuries from jogging and more and more from gymnastics.”

Like most of his colleagues in sports-medicine, Dr. Evans prefers to emphasize the positive aspects of the profession. He and his clinic are widely respected for innovative work in the areas of conditioning to prevent injury and rehabilitation to prevent recurrence. There is an understandable reluctance to speak negatively on the subject of football and its risks. It’s not surprising; for a sportsmedicine specialist to denigrate the game of football would be like a veterinarian berating dogs. “I don’t think football is nearly as bad a phenomenon in America as television,” he says. “I do agree that at certain levels football has an elevated value. There’s a kind of limelight-to-obscurity risk that can be sad. But as for physical risk – well, in my mind football is less dangerous than getting in a car.”

Eddie Lane, head trainer for the Dallas Independent School District, has made a career of treating high school football injuries. His headquarters are in the concrete bowels of the old Cobb Stadium on Harry Hines, in the thick air permeated with the smells of liniment and rubbing alcohol. Eddie Lane has seen countless athletes hobble in and out of his training rooms. He’s a busy man, one of only four trainers serving the 12,000 student athletes of the DISD. Everyone will tell you that Eddie Lane does a remarkable job considering the burden of those numbers. (“This town,” says Dr. Gunn, “is very lucky to have Eddie Lane.”) But even Eddie Lane will tell you that he could use some help. “At a minimum,” he says, “we should have one certified trainer at every high school. Ideally we should have two trainers, one male and one female, at every high school. Most suburban schools here are able to provide a trainer per high school. But we simply don’t have the funds to do that.” Without on-the-spot trainers, the burden of injury protection and care falls on the coaches. Eddie Lane, with gratification, has watched the coaching mentality change from “Spit on it, kid, and get back in there,” to a much higher degree of concern. Lane and his staff have educated coaches in conditioning exercise, in safety precautions, in recognizing injury, and in emergency on-field treatment.

But regardless of such efforts, football, by the nature of the game, will continue to injure. In the last five years, two Dallas high school football players have died from neck fractures; three additional neck fractures have been suffered in that time, one resulting in quadriplegia. Eddie Lane’s log book for the past year shows some 6,000 treatments for some 4,000 athletic injuries; beside each entry is a notation for the sport being played when the injury was incurred; about two thirds of the entries are marked “f.b.” Since only 32 percent of the students engaged in high school athletics are playing football, one third of the athletes incur two thirds of the injuries. Last year 28 DISD high school athletes required major knee surgery; 24 of them were football players. In the state of Texas during the 1975 season (the most recent for which statistics have been compiled) there were approximately 9,000 reported high school football injuries; of these, almost 1,000 required hospitalization; and of those, 450 required surgery. And 22 percent of the 9,000 were knee injuries – by far the largest category.

It should be an encouraging sign that the state’s high school football injury rate appears to be in moderate decline, according to Dr. Bailey Marshall, director of the University Interscholastic League of Texas. But orthopedists suggest that the trend might be misleading. “In spite of all the valuable efforts that have been made to make the game safer,” says Dr. John Gunn, “football, even on the high school level, has gotten bigger, faster, and more violent. We may be seeing fewer sheer numbers of injuries from football, but we’re seeing more of the severe injuries.”

The various official governing bodies of football at all levels (the NFL, the NCAA, the UIL, etc.) are aware of the risk of injury. They have made efforts to reduce football injuries through rule changes and equipment improvements. Some key rule changes have been specifically designed to protect the knee; for example, the elimination of the crack back block and the curtailing of downfield punt coverage. Equipment improvements have done little to save the knee. Despite experimentation, nothing has been developed to protect the knee and at the same time retain the mobility necessary to play the game effectively. In football, despite the pounds and pounds of protective equipment, the knee, the body’s most vulnerable joint, remains essentially unprotected.

Dr. Gunn adjusts his gold-rimmed half-moon glasses and leans back in his chair. If he weren’t still wearing his blue medical smock, he’d look more like a bookkeeper than a surgeon. A slight, mild-mannered man with thin graying hair, he doesn’t speak with vehemence about the perils of football; his attitude, emphasized by those glasses, is professorial. “A 200-pound boy in full equipment with good shoes on good turf under a full head of steam can create a terrific impact,” he says. “I recently had a patient who had been hit by a truck. His knee was all torn up,. But it was no worse than a lot of knees I’ve seen injured on the football field.”

As he talks about football, Dr. Gunn occasionally shows traces of uneasiness; from time to time, he is conscious of biting the hand that feeds him. He is anxious to explain that he is not bothered simply by the fact that football causes injuries. That’s part of the game, and everybody knows it. But knees are his business. And it’s about knees that Dr. Gunn raises his most serious question about football: What happens to football knees later in life? Orthopedic surgery, like almost everything else in medicine, is an evolving art. Orthopedic surgeons know more about knees now than they used to. And what they have been discovering in the last few years is that the effects of high school football injuries don’t necessarily end with graduation from high school.

In 1966, as a sophomore at Hillcrest High School, Steve Pardue was a tight end, and a good one. During summer practice that season, he gathered in a pass and was suddenly hit from the side, on his left knee. The pain, he remembers, was excruciating. “I was screaming like hell. I couldn’t help it. It felt like someone had stuck a torch inside my knee.” Torn ligaments. Surgery was performed four days later. Months later, the knee still retained some of the swelling, but Steve decided to play football again his junior year; he also ran track that year, high hurdles. The knee wasn’t great, but it was good enough. His senior year, in the first game of the season, Steve caught a pass, cut from a tackier, and felt his knee twist and snap. Surgery again; this time the operation achieved, surprisingly, an even better repair. But Steve had had enough and didn’t even consider college football. He figured a no-more-football policy would put an end to his knee problems. He was wrong.

Now, ten years later, at age 27, when Steve gets out of bed in the morning, his knee is stiff. He likes to play tennis and work out at Nautilus, but whenever he does, his knee swells up. Always there is a deep, dull ache. Several months ago, while deer hunting, he squatted down and tore the cartilage in his other knee, very likely because of instability resulting from football injuries. “I’ll always have trouble,” he says resignedly. “My knees will always hurt.”

Orthopedic specialists are discovering that injured knees are subject to long-term arthritic degeneration. “A lot of orthopedic surgeons are seeing the same thing that I am,” says Dr. Gunn. “A kid, Joe Smith, comes in to me with an injured knee. I perform surgery and repair it. Everything looks good. Joe Smith returns to playing football. I watch him break loose and score a touchdown, and that’s thrilling and rewarding. I’m happy, his parents are happy, Joe Smith is happy. Then eight years later Joe Smith walks into my office and says, ’Doc, every time I jog, my knee swells up.’ “

There is no perfect knee surgery. Ligament and cartilage do not regenerate; they heal with scar tissue. So no matter how masterly the surgery, the repair won’t be as strong as the original. (Unlike bone to bone repair, which often can be restored to its original strength. Says one Dallas physician, “A football player would really do better to break his leg than to tear his knee ligaments.”) Thus, almost any repair leaves the knee with a certain amount of instability, which, over time, can put undue stress and pressure on key tissues, particularly the articular cartilage, the lubricant tissue covering the end of the femur. Under pressure the lubricant tissue gradually breaks down (Dr. Gunn says it’s “like losing the mortar between bricks”), increasing friction in the joint. The result is an arthritic condition, with stiffness and swelling.

“The long-term effects of these injuries are only now coming to light,” says Dr. Gunn. “At first, we blamed these degenerative effects on poor initial surgery. While poor surgery certainly increases the likelihood of degeneration, we’re now seeing that even good surgery can, ten years down the line, end up as bad knees. It’s just something we didn’t know. The attitude of the injured athlete was not ’Am I all right?’ but ’Can I play again next season?’ Coupled with the ’wound-ed-soldier-hero’ and ’play-with-pain’ syndromes that football seems to promote, the thrust of orthopedics was how to get the injuries fixed and get the kid playing again, with little worry about what would happen in ten or fifteen years.”

For a long time, for example, with a torn meniscus (tearing of the major interior cartilage of the knee, the shock absorber, which is the most common of the serious knee injuries), it was standard procedure to remove the meniscus entirely. It is now apparent that full removal of the meniscus greatly adds to the wear and tear on the articular cartilage, stimulating degenerative changes. Alternative procedures are now being developed. “In a way,” says Dr. Gunn, “we were like the auto manufacturers – they didn’t know 20 years ago that their engines were damaging the air; we didn’t know we were creating future damage in the knee. There are no villains. No one is to blame. I’m just as guilty as everyone else. But there’s a great deal of research to be done in the area of long term degenerative changes.” There are, as yet, no reliable statistics regarding the likelihood of degeneration. But Dr. Gunn, making a very rough estimate, guesses that of 100 surgically repaired football knees, some 50 would experience varying degrees of degeneration. Fifteen to forty of those knees, he guesses, would suffer significant degeneration, resulting in the curtailment of physical activity. There is also indication that even without serious injury, without surgery, the general battering a knee takes while playing football can cause “cartilage disruption,” a kind of gradual shredding of the tissue, which can lead to degenerative changes.

“But we really don’t know anything about the odds yet,” says Dr. Gunn. “And it’s difficult to advise a kid that he shouldn’t play football on the possibility of degenerative changes. It’s not easy to tell a black kid looking at an athletic scholarship as his only way out that he might be sorry. But on the other hand, I had a patient, a black kid, who injured his knee; I repaired it; he returned to play but was unable to land a scholarship. He’s now working in a warehouse. His knee is degenerative. Every time he lifts a box, his knee gets a little worse. Before long, it’s possible he won’t even be able to do that. Football will have denied him a livelihood instead of providing one.”

Dr. Dickey Jones, chief of orthopedics at the V.A. Hospital, rolls up the pants legs on his pale blue, blood-speckled surgery garments. On his left knee is a long jagged scar, the remnant of three operations. His right knee is unscarred, but as Dr. Jones flexes his leg muscles, it jumps back and forth in a bizarre fashion, a sign of ligament instability.

Dickey Jones was a top-flight high school running back in Florida in the early Sixties. He played unscathed until his senior year, when, as he carried the ball, a tackier hit his knee from the front and he suffered a hyperextension. He decided to forgo surgery and played in the high school All-America game that summer. But during pre-season practice as a freshman at the University of Florida, he tore his cartilage. Surgery removed half of his meniscus. As a sophomore, he was rein-jured; the other half of the meniscus was removed. As a junior and senior, his speed had diminished so much that he was moved out of the backfield and into the line as a tackle.

But his excursions to the operating table stimulated an interest in medicine that overtook his interest in football. He got out of football, but not soon enough. Today, the knees of Dr. Dickey Jones are degenerative. He has reduced his weight from 240 to 170 pounds to lessen the stress on his knees. He wears a knee brace when he plays basketball; he exercises his knees routinely so that he can continue to play racquetball; he takes 16 aspirins a day to turn back the pain.

Dr. Jones finds football knees and their degenerative effects a matter of personal concern. Like Dallas’ other top orthopedic surgeons, he is pioneering techniques to lessen those effects. There are experiments, for example, in joint transplant – grafting healthy articular cartilage (taken from a cadaver) onto the prepared end of the femur where degeneration has occurred. There are experiments in ligament transfer. There are experiments with artificial ligaments (thus far unsuccessful) and with artificial joints (mostly unsatisfactory). Most important, perhaps, are the advances being made in arthroscopic surgery. The arthroscope is a surgical tool with a long hollow tube which penetrates the knee, or other joint, and through which light can be cast to illuminate the interior of the knee for viewing, first for diagnostic purposes (superior to x-ray), and then for surgery, since repair can also be performed through the tube. Because incision is eliminated, the trauma to the knee is greatly reduced and rehabilitation is greatly facilitated. Through such techniques, Dr. Jones will give injured knees a better chance than his ever had.

But Dr. Jones voices no regrets as he watches his knee jump in and out. “Football,” he says, “is just another trade-off, and there are a lot of those in life. If a kid gets his strokes from playing football, then he may have to pay a price.”

Dr. Gunn thinks the price may be too high. “I’m not saying abolish high school football,” he says. “That would be foolish. But I do think football at that level needs some perspective. People say, ’Football isn’t as dangerous as riding a motorcycle’; well, that may be true. But the community doesn’t rally around motorcycling on Friday nights. Two football deaths in five years may not seem like much, but if they’d happened in metal shop there’d be an uproar. And football is exclusive – it precludes small males and all females. I’m not questioning football, I’m questioning its institutional support, its preeminence within the structure of our public schools. There are several factors to weigh when trying to place high school football in its proper perspective. In the first place, it has been proven that football, as a conditioning sport, is one of the least valuable in terms of healthful exercise. Football is a stop-and-start sport, with a lot of stop between plays. Football develops strength and certain muscle tone, but it’s not much of an overall conditioner when compared to many other sports.”

This assertion is confirmed by Dr. Jere Mitchell, a cardio-pulmonary specialist at Southwestern Medical School, who has done a great deal of research in exercise conditioning. “It has become widely accepted,” says Dr. Mitchell, “that the best general guideline of the overall effectiveness of any exercise is the extent to which it develops the cardio-pulmonary system, the heart and lungs. The fitness of the cardio-pulmonary system is best measured in terms of maximum oxygen uptake, or consumption, during activity.” Test results, provided by Dr. Mitchell, show that of the team sports, football ranks higher only than baseball in terms of oxygen uptake, and decidedly lower than soccer or basketball. And none of the team sports ranks with such individual sports as cross-country skiing, long distance running, rowing, bicycling, and swimming. “Surprisingly,” says Dr. Mitchell, “even the goalie in soccer ranked higher than the wide receiver in football. And it seems to me that another problem with football, as it is played in schools, is that the conditioning exercise, like running laps, too often becomes the penalty, the punishment; that disturbs motivation.” (As Dr. Mitchell walks down the hall of the Medical School, he is rubbing his left shoulder. “Got a bad shoulder,” he mumbles. “Old football injury . . .”)

“All things considered,” says Dr. Gunn, “a 17-year-old would do his body a much bigger favor by joining the swimming team than by joining the football team. If the object of public education is to educate, and to educate the body as well as the mind, then the education by swimming is more valuable, and certainly safer, than education by football. But the priorities don’t work that way.

“There’s another aspect of it too, again in the educational vein. How valuable are the skills learned in football? For most football players, their career ends as a senior in high school. How often later in life are they able to use the skills learned in football? Except for an occasional game of catch, probably never. What good are offensive blocking techniques when you’re 45 years old?” Statistics again bear out his point. According to the National Federation of State High School Athletics Association, there were some 1,100,000 students playing organized high school football in the United States last year. At the same time, there were approximately 45,000 athletes playing college football in the U.S. last year; meaning that, at best, only one out of every 25 high school football players goes on to play football in college. To take it a step further, consider that there were some 1,400 players in the National Football League last year, meaning that only one out of every 785 high school football players might ever earn a living playing professional football in the NFL.

“Football,” says Dr. Gunn, “is just so shortsighted. It seems to me we need to be thinking about that, about football’s place in the community of the future. You ask me what I’ve done. Well, not much. I’ve only mentioned it. At an orthopedic conference not long ago, I made the remark that ’You know, if they stopped playing football, we wouldn’t have to hold this meeting.’ I got nothing but cold stares. Lets face it, it’s a precarious position. If football disappeared, I know a lot of orthopedic surgeons, including myself, who’d be nearly out of business.”

He smiles, almost apologetically, as ifhe’s said quite enough for now, thanks.His stance may be uneasy, but his concernis real. When he hears that Brian Harrisonhas decided he wants to play footballagain, Dr. Gunn grimaces. He knows thatBrian might possibly return to the gridiron, perform beautifully, and live withhappy knees for the rest of his life. But heknows the odds aren’t good.


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