How To Develop A Thriving Sports Medicine Practice

When it comes to being recognized as a true sports medicine physician, Lisa Schoene, DPM, ATC, says in order to “talk the talk, you better walk the walk.” Dr. Schoene says the best sports medicine practitioners are the ones who cover the events and are out there covering races even when it is cold and rainy or starting very early in the morning.

“Hands-on experience is imperative in my mind,” emphasizes Dr. Schoene, who has covered many marathons, triathlons and other races. “I question the physician who says he or she is a ‘sports medicine specialist’ but never volunteers to cover an event or race.”

Amol Saxena, DPM, emphasizes the importance of getting good training from qualified practitioners as he says there “is little formal coursework or rotations” in podiatric sports medicine. He suggests students take advantage of activities such as the “Sports Medicine Days” put on by the American Academy of Podiatric Sports Medicine (AAPSM).

Richard Bouche, DPM, states there are a small amount of podiatric sports medicine fellowships available. He says one should consider these six- to 12-month fellowships if he or she is truly interested in pursuing further training in podiatric sports medicine.

“Students who are interested in podiatric sports medicine will have to go beyond the regular training to get exposure and experience,” maintains Dr. Saxena, who practices within the Department of Sports Medicine at the Palo Alto Medical Foundation in Palo Alto, Ca.

Recalling his last years of podiatric school and residency, Dr. Saxena says he actively sought out working with sports medicine gurus in other disciplines as well as podiatry. He notes that he spent time with Mark Pfeile, PT/ATC, a trainer for the Chicago Bulls; Jim Hill, MD, an orthopedist for the U.S. Olympic Men’s Basketball Team; John Durkin, Jr., DPM, who was treating all the top runners in the U.S. at that time; and Rick Cullen, DPM, who was the team podiatrist for the Boston Celtics. During this time, Dr. Saxena also volunteered for a local high school’s athletic department.

He also cites sports medicine orthopedists Fred Behling, MD and Gordy Campbell, MD, with whom he spent some time during his fourth year in podiatry school, as well as his mentor and residency director John Grady, DPM, with his development in the sports medicine arena.

“It is easy to say you want something but when it is not part of the standard path, you have to go out of your way to get it,” notes Dr. Saxena, a Fellow of the American College of Foot and Ankle Surgeons (ACFAS) and the American Academy of Podiatric Sports Medicine.

Doug Richie Jr., DPM, says “a lot of self-directed study” and working with other clinicians who are skilled in this area are keys to developing a comprehensive knowledge of your specialty as it relates to athletic injuries.

Dr. Bouche encourages sports medicine podiatrists to keep up with CME activities in order to stay sharp and on top of all that is new in the field. Dr. Saxena encourages practicing podiatrists and students to read sports medicine/orthopedic journals such as the

American Journal of Sports Medicine and the Journal of Orthopedics and Sports Physical Therapy in addition to peer-reviewed journals dealing with the foot and ankle such as the Journal of Foot and Ankle Surgery, Foot and Ankle International and the Journal of the American Podiatric Medical Association.

Building A Reputation
When he first started out in practice Dr. Richie recalls giving community lectures at running and cycling clubs as well as specialty running shoe stores on topics related to the prevention of sports-related injuries. Dr. Bouche and Brian Fullem, DPM, have also lectured to local running groups. Dr. Fullem speaks at a couple of high school running camps in the summer and now helps run such a camp (www.therunningacademy.com) in Connecticut. In addition to lecturing to running groups, Dr. Schoene lectures to dance and physical therapy groups.

In addition to working World Cup soccer games, lacrosse tournaments, semi-professional football games and the Atlanta Olympics in 1996, Dr. Schoene volunteers her time at professional ballet/dance companies and has done so for many years.

Developing A Network Of Referring Providers
All of the doctors emphasize the importance of developing a network of local physicians who specialize in sports medicine when you are first starting out and maintaining that network as a key source of referrals. Dr. Schoene notes that she gives marketing packets to physical therapy groups and physicians. These packets include her business cards, which can be given by these healthcare providers to prospective patients who may need podiatric care. She adds it is also important to keep referring providers updated on the status of their patients.

“I continue to call and write letters regarding patients to chiropractors, physical therapists, etc., to update them on patient progress and to allow them to see what I do as a sports medicine podiatrist,” explains Dr. Schoene, a Fellow of ACFAS and AAPSM.

While Dr. Schoene receives many referrals from current and previous patients, she notes that her clinician referrals tend to come more from physical therapists and chiropractors as opposed to orthopedists.

“I feel these other clinicians understand biomechanics and value orthotics, shoe gear and postural alignment more so than orthopedists,” explains Dr. Schoene, who says these groups are accordingly more of her referral focus.

Dr. Bouche says appropriate referrals to like-minded orthopedists, primary care physicians, pediatricians, neurologists, etc., ensures that “all aspects of sports medicine care can be dealt with efficiently.”

He notes that he practices at a dedicated, multidisciplinary sports medicine clinic in Seattle. At his facility, there are ten doctors, a pedorthist, a physical therapy department, in-house X-ray and a dedicated extremity MRI. Dr. Bouche says the facility also offers video gait analysis and bike fitting analysis.

“This helps us be the best we can be and deliver care as a ‘one stop shopping’ type of sports medicine clinic,” notes Dr. Bouche, a Past President of AAPSM.

Making The Rounds At Local High Schools And Colleges
In addition to developing a network of local sports medicine physicians, Drs. Richie, Saxena and Fullem say it is also important to introduce yourself to trainers and coaches at local high schools and colleges.

“In sports medicine, coaches, athletic trainers and athletes are the mainstay of referrals,” says Dr. Richie, an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College in Oakland, California.

While there is a popular perception that sports medicine physicians are routinely involved with professional sports teams, Dr. Saxena estimates that “less than five percent of the true sports medicine physicians are officially associated with pro sports teams.”

Emphasizing Empathy And Availability For The Athlete
All the physicians emphasize having a passion for treating athletes and having a strong empathy for their needs. Drs. Bouche and Fullem say having personal experience as an athlete can go a long way in this regard.

“You do not always have to be or have been an athlete yourself but it certainly helps in building your credibility,” claims Dr. Fullem, a Fellow of ACFAS and AAPSM.

Dr. Schoene says many athletes are heavily invested in the consequences of their injury and are thoroughly knowledgeable about the injury before meeting with a health care provider. They have most likely tried their best to treat the injury themselves. Athletes are looking to the sports medicine practitioner not just for treatment of the injury but for the practitioner’s help in facilitating a quicker return to the sport or activity, and the ability to continue performing with minimal or no future recurrence of the injury.

“Most athletes do not want surgery,” maintains Dr. Schoene. “Having many conservative treatment options available for these patients is paramount.”

When athletes have a positive treatment experience, they may give a favorable report back to the referring physician and also have a tendency to discuss their results with other athletes. Dr. Richie says generating positive word of mouth is another key to building a successful practice.

“Athletes are a tight group who share information readily. When they have a good experience, they are anxious to share this with others,” notes Dr. Richie, the Immediate Past President of AAPSM.

Dr. Bouche estimates that 70 to 80 percent of his practice is referrals from other podiatrists and sports medicine physicians and says these referrals are a goldmine.

“If you do a great job, your patients will go back to the referring doc and sing your praises,” notes Dr. Bouche, a Fellow of ACFAS and a Diplomate of the American Board of Podiatric Surgery. “This is the best marketing tool there is in my opinion.”

Dr. Saxena stresses the three A’s of availability, affability and ability. He adds that half of his referrals come from patients. Dr. Saxena says it is important to keep the same positive work ethic as when you started.

“We do same day appointments, particularly for athletes. We will stay late, come in early or work through lunch. We put rushes on our patients’ orthoses so they can get them in four days. We will even see them on the weekends or at their event if needed,” maintains Dr. Saxena.

Dr. Bouche agrees that timely scheduling of appointments is pivotal in a sports medicine practice.

“The key is to always try and accommodate new patients, and see them in a timely manner as they do not like to wait more than a few days to be seen,” notes Dr. Bouche. “If you cannot accommodate them, they are likely to go elsewhere.”

Addressing The Key Challenges
Of course, scheduling patients is just one of the challenges in maintaining a thriving sports medicine practice. Knowing how to handle demanding patients who are anxious to get back to the field or court or other athletic activity requires a deft approach.

“(Athletes) can be fussy, neurotic, demanding and time-consuming people,” points out Dr. Richie. “Coaches and overbearing parents can also be a challenge. Over time, you can develop an insight into how to take control of difficult situations and minimize the frustrations. It takes time and experience to learn how to communicate and treat the athlete effectively and efficiently.”

Dr. Fullem says the biggest challenge is giving each patient the best possible treatment and avoiding assumptions “such as thinking that all heel pain is plantar fasciitis right off the bat.” He emphasizes the fundamentals of carefully listening to the patient’s chief complaint and his or her injury history, and tailoring the treatment plan to each patient’s needs.

He agrees with Dr. Richie though that communication can be a delicate dance with the athletic patient. Dr. Fullem says some cases require pushing the envelope and being aggressive with your treatment plan whereas other cases may require you to pull back the reins and let the patient know that he or she needs to back off from their sport or activity. However, Dr. Fullem says it is “paramount” to not instinctively tell an athlete that he or she cannot compete because of an injury.

“Only tell the athlete to rest completely if the treatment plan and injury dictates complete rest,” advises Dr. Fullem. “For example, a stress fracture requires cessation of weightbearing but a neuroma or medial tibial stress syndrome does not always mean you have to completely rest.”

Staying On Top Of New Technology
Another challenge for busy sports medicine podiatrists is keeping current with emerging technological advances.

“It is key for the sports medicine doctor to stay on top of all new technologies and to incorporate that technology into your practice as studies come out to validate that technology,” counsels Dr. Bouche.

While there are many new advances, Dr. Bouche says many of them have not been tested as of yet and physicians should accordingly be cautious when it comes to using these modalities.

For example, Dr. Bouche says extracorporeal shockwave therapy is a relatively new technology that is showing “significant promise for plantar fasciitis and tennis elbow and other off-label uses.” Drs. Fullem and Schoene have found shockwave therapy beneficial as well.

“Shockwave therapy is one of the better new technologies out there that helps with athletic patients,” notes Dr. Fullem. “I have seen especially great results when I have used it for chronic Achilles insertional problems.”

Dr. Schoene has found success in utilizing radiofrequency treatments (Topaz, Arthrocare) for some surgical interventions and says diagnostic ultrasound can be helpful in evaluating certain injuries. In his practice, Dr. Richie recently implemented a high tech pressure mapping gait analysis system that he calls a “new technology, which gives even more insight into foot function.” He says incorporating new technologies into your practice can be extremely helpful in stimulating referrals.

“Sports medicine requires cutting edge technologies … even in the private practice setting,” emphasizes Dr. Richie.