Dr. Christopher Wahl says he’s found the perfect job at the University
of Washington. Assistant professor of orthopaedics and sports medicine
at UW Medicine, Dr. Wahl enjoys working with college athletes because
they are serious and dedicated, but at the collegiate level,
the love of the game is still strong.

In this exclusive interview with UWTV, Dr. Wahl talks about his work with Husky sports, shares his teaching philosophy and explains how he helps athletes at all levels achieve their goals. And don’t miss Dr. Wahl in “Arthroscopic Shoulder Stabilization,” airing Oct. 15 at 8 p.m. PT on UWTV.

Dr. Christopher Wahl helps athletes at all levels stay healthy and enjoy the sports they love.

Which UW sports teams do you treat? Do you treat them all?

Yes and no. I’m the primary physician for a lot of the overhead sports. I work most closely with the softball players, baseball players, gymnasts, swimmers and tennis players. I also work with volleyball, which has been particularly fun these days because they’re doing so well. But we also divvy work up in our group according to who has a specialty interest in a specific area.  While I perform minimally invasive and arthroscopic procedures in the shoulder, elbow, knee, hip and ankle, I have a particular interest in shoulder instability, complex knee ligament reconstructions and articular cartilage reconstruction techniques — so players from any sport with those injuries are frequently sent my way.

What is the biggest challenge you face as a team physician for college athletes?

All the rules are a little bit different in terms of how you treat an elite athlete who, in some cases, has a future and career riding on their injury and its treatment. You have to think not only about their general health, but also weigh pretty complex issues about when you can return them to play safely and how the injury and recovery affect their eligibility, the team and their ability to play at the next level, whether it be professional athletics or the Olympics. As team physicians, we get into situations where there’s no real right answer in terms of sending someone back to play. We would never send someone into a situation where we think their overall health is in danger, but certainly we push the envelope on return to play in terms of rehabilitating athletes quickly.

One of the best and worst things about working with collegiate athletes is that it’s almost impossible to shut them down. Being unable to participate in their sport is very painful for them because their entire persona and frequently their hopes for the future are all built around their health. In a casual or recreational athlete, it may be a nuisance to stop, but it’s usually not something that threatens their livelihood or even their sense of person. Take elite runners, for example. It’s as if they think they’ll forget how to run if you tell them to stop running for six weeks. They can’t stop. But that’s also what makes them so great to work with.  They rehabilitate quickly because they’re so motivated.  There’s a real sense of teamwork there.

Sports medicine covers a wide range of physical activity levels, from college football players to middle-aged recreational joggers. What process do you use to decide what method of treatment will work best with each patient? You’ve already touched on that with the issue of return to play for elite athletes. What approach would you take for the recreational athlete?

I try not to take too different an approach.  I try to treat my recreational athletes like they’re elite athletes. The first set of questions when I first meet with any patient is, What do you like to do? What are your hopes and aspirations for where you’d like to go with your sport or activity? Unless their goal is totally unrealistic or hazardous to their overall health, I do whatever I can to get people to the level of sport play or function they desire. Today, people spend a lot of time and effort training — the level of competition at the recreational level is pretty intense.

The difference between recreational athletes and elite athletes is that the recreational athlete is frequently not being held to strict criteria, like a season when they have to be back, so in rehab we can move a little more cautiously. But in terms of ultimate outcome, I try to find out what someone’s expectation is and see if we can’t make it happen. I feel like it isn’t my role to tell someone to stop doing what they like to do unless I think it’s dangerous to their health. The classic example is the person who absolutely loves running but is starting to experience some of the detrimental effects of overuse. We usually have a discussion about how to introduce cross-training and non-impact exercises to their routine. I tell them what things to watch for so that they don’t cause any serious injuries, but I don’t tell them not to run. In my opinion, the positive psychological and physical health benefits of exercise often outweigh some of the detrimental effects of overuse.

What do you do in the case where you’re treating someone who’s being noncompliant in their treatment? How do you handle that situation?

The typical thing is overtraining. We live in the Nike generation now, where everybody thinks that you can’t just go out and play tennis or take a bike ride. You have to run a marathon or ride a century or you crush your opponent in whatever sport you do. I tell people that through things like cross training, you actually are going to end up being a better athlete and in better overall health to play at a higher level than if you try to put millions of miles on your legs with the same activity over and over. If you look at the great athletes out there, they are good athletes in part because they can do anything well. Look at Michael Jordon. He can golf. He can play basketball. He’s a good baseball player. And in some ways, I think that overall conditioning and overall training and agility moving from sport to sport and activity to activity make you a better overall athlete for any particular sport. And you last a lot longer.

You’ve mentioned that the nature of athletics makes the types of injuries you treat incredibly varied. Having said that, what are some of the more common injuries you treat in your work with UW’s sports teams?

Again, because I do a lot of upper extremity work, I treat a whole lot of shoulder instability problems, such as shoulder dislocations and elbow problems. In the knee, I treat anterior cruciate ligament tears and multi-ligament injuries. ACL tears are rampant in cutting and jumping athletes. And as the energy and intensity of competition has increased, we see more and more multiple-ligament injuries, like ACL/PCL injuries and knee dislocations. The last thing I treat that we’re seeing more and more of because these athletes train at such a high level, is cartilage injuries — that is, arthritis in young people. We’re seeing 17, 18 and 19 year olds who have good-sized arthritic lesions and cartilage injuries in their knees. We’re now seeing the first generation of athletes who in many ways have intensely trained since they were six years old to do what they are doing. The classic example is in baseball, where we have kids who’ve been four-season athletes since the time they were 13 or 14 years old. We’re seeing kids with the kind of elbow and shoulder injuries that we used to only seeing 35- and 40-year-old professional baseball players.

How have treatments improved to allow those younger athletes to continue and have a career into their 40s or however long they want to play?

It’s a combination of treatment and prevention. In terms of treatment, we’re learning a lot more about these injuries because we’re seeing so many more of them. For instance, medial collateral ligament tears of the elbow used to be a rare injury. We’re seeing them so often now, and there’s a lot of basic science out there about it, that we understand how to treat it surgically. In terms of prevention, we’re much more cognizant about it — telling parents, coaches and trainers that they just can’t play these kids four seasons or they’ll ruin them for the next level of play. They’ve got to take at least one season off, and I’m still an advocate of at most two seasons of any sport and two seasons cross training, again to give them a generalized fitness and agility.

How has working with collegiate athletes motivated you in your work?

Working with collegiate athletes is exactly where I’d like to be. As part of my fellowship, I had the good fortune to work with the New York Giants football team. Then I went into private practice in New Haven at Yale, where I worked mostly with high school athletes. For me, collegiate athletics is the absolute perfect compromise. It’s elite enough that it’s like professional athletics. We can actually impact how kids are treated because we work closely with the trainers. But it’s not at the level that it’s all business here. There’s still that joy of play. In professional athletics, even with great organizations, it’s a business. At this level, it’s still about the kids and their education, scholarship and athleticism. That to me is the perfect mix.

How do you educate patients about preventing future injuries, and how closely are you involved with monitoring follow-up care such as physical therapy?

In terms of prevention, if we see that an injury is due to overuse, we talk to athletes about training styles and different things they can do to try to limit the overuse-type injuries. I was lucky to find an exceptional physician assistant, Suzanne Slaney, who is also an athletic trainer. Suzanne’s athletic training background has added a lot to the practice, and we have a pretty unique situation. We work closely together in every facet of patient care, from the OR to the clinic to the playing field.   

In terms of our physical therapy, Suzanne and I both monitor that. Suzanne’s experience is indispensable. She’s very familiar with exactly where people should be at each stage of their rehabilitation and their progression toward return to sport. It’s great because either one of us seeing folks can very quickly identify when problems are developing from both the surgical side and the rehabilitation side, two very different things that need to be evaluated each time you are following someone after surgery.

On July 1, you opened the Arthroscopy Research and Training Laboratory, also known as the ART-lab. Could you talk about the lab and the type of research you and our colleagues will do there?

In this state, it’s the only lab of its kind. And in the Pacific Northwest, it’s one of a very few. Both for training residents and also for training other surgeons who want to get up to speed on arthroscopic skills in terms of different procedures that we’re now doing through the scope, it’s very difficult and in many ways unethical to learn or practice these difficult skills on patients. The lab allows residents and surgeons to work on cadaver specimens donated for research. We take our residents who are in sports training through the different procedures to allow them to practice and get the majority of their experience in the lab setting. It’s a very real situation. These are real knees and shoulders.

What’s exceptional about the lab is we’re pioneering new techniques and instruments and implants. I work with companies developing and refining the instrumentation that we use for our real surgeries and also refining techniques that we are using that haven’t been performed before or haven’t been performed as well as they could be arthroscopically.

We’re doing a lot of work with shoulder and knee instability. One of the issues in shoulder stabilization is that we can easily make a shoulder stay located in the joint, but it’s frequently too stiff. And people dislike a stiff shoulder as much as they dislike a dislocated shoulder. The Holy Grail is to stabilize a shoulder so it never comes out of joint but maintain all its motion. One of the difficult obstacles to overcome is if there’s bone defect so the surface area of the joint doesn’t match. Then you have to either constrain the amount of motion that the shoulder can have or you have to accept the fact that the shoulder will dislocate again. We do a lot of work on trying to treat these bone defects arthroscopically so that, when we stabilize the shoulder, we can preserve motion.  It’s the best of both worlds.

We are also working to refine arthroscopic rotator cuff techniques. Right now, arthroscopic rotator cuff procedures have not yet proved superior to traditional open rotator cuff repairs. We’re doing a lot of work to not just get these arthroscopic techniques to be as good as the traditional open ones, but actually take advantage of the scope to develop techniques that are superior to the traditional ones.

How are new techniques in arthroscopic medicine changing the practice of sports medicine?

We are learning more and more about how and what the problems are in the different joints because we can appreciate so much more with the scope. There are always lesions or constellations of symptoms that appear, and we never completely understood why or how they came to be.

The big advantage of arthroscopy is it’s a less invasive way to get into a joint and then you’re working as if you’re standing inside the joint. In joints like the hip, which is proving to be the next frontier of arthroscopic medicine, arthroscopy can really shine. The hip is such a deep joint and is so constrained – it’s completely surrounded by muscle. An open hip surgery is inherently a much more traumatic procedure than an open knee surgery or open shoulder surgery, so it is ideal for the scope.

What’s interesting is that hip arthroscopy is relatively new, so the first question we have to answer is what’s normal and what’s abnormal. With hip arthroscopy, we now see the anatomy in an entirely different way. We can’t say with certainty what is normal and what’s not. We’re still learning what findings are actually causing pain and which are normal variants. It is a very exciting time.

Things like hip labral tears are incredibly common. They appear in unique populations – hockey players and golf players get them. So all of a sudden, we’re seeing all these patients who have this snapping hip whose problems maybe even made them unable to participate in that sport. And suddenly now we have the smoking gun. We can see what the problem is and treat it.

So there have been the same kinds of discoveries with other joints, like the shoulder and the knee?

Yes. My partner Roger Larson and I we were recently talking about this very phenomenon. Roger was one of the pioneers of knee arthroscopy, and he laughs that the early meniscus procedures in the knee, where the knee cartilage is removed, would take three hours. These are procedures that you can do now in 15 or 20 minutes. Now we know all about the meniscus, what it’s supposed to look like and how to treat the different tear types. But back when arthroscopy was in its infancy in the knee, people were still trying to figure out what tears mattered.  We went through the exact same process in the shoulder. It’s very variable in its anatomy, and we had to determine abnormal anatomy and normal anatomy. Now, we’re going though that process with the hip and to some degree the ankle, too. These two joints share a common difficulty in that they are both very constrained joints.

As a side note, unlike open surgery, what’s fun about arthroscopy is, because these joints are constrained and because our access is limited since we’re trying to be least invasive as possible, there are very specialized tools that are designed just for the purpose they’re used for. With open surgery, you basically have your knife, your spoon and your fork. With them, you can pretty much deal with everything you have on your plate. Now, with arthroscopic surgery, we have cheese forks and nutcrackers and the whole bit. It’s all gourmet now.

An important part of your work at the university is teaching residents and other surgeons. What is your teaching philosophy?

I came from a residency and fellowship training environment that allowed me to see a number of different ways to perform surgeries. In my fellowship at the Hospital for Special Surgery, there were 18 sports surgeons. It was a luxury to be able to see 18 different ways to do an ACL, and also several different ways to mess one up. 

Having come from that background, the main thing I try to teach the residents is to understand not just the actual mechanics of what it is we’re doing, but also what my operative rationale and order of steps is. We try not to do anything by accident. If residents can learn the rational approach to solving a problem that takes into consideration factors that have to do with three things — the patient, the problem the patent has and the surgeon’s own personal strengths and weaknesses — then they can always come up with a treatment plan that is absolutely appropriate.

Where you go wrong is having the right treatment for the right problem in the right patient but a surgeon who is incapable of doing it, or having the wrong treatment for the right problem in the right patient even if the surgeon is capable of doing it, or having the right treatment for the right problem but the wrong patient. If any three of those factors is off, it’s a catastrophe. So I try to teach students the rationale about what I’m thinking about as I’m working. But I don’t expect that they will do things exactly the way I do it, I just want them to mature in the way they think about and approach problems.

On a personal note, you and your wife have 22-month-old toddler triplets. When and how will you get them involved in sports in a way that would allow them a lifetime of fulfilling physical activity?

First, I would encourage my kids to do whatever they are passionate about. I tend to think when people develop problems is when they are being pushed to do a sport that they’re not going to be naturally gifted at. My boy is probably never going to be an offensive lineman. He’ll just never have that body type. He could probably be a world-class hockey player because he’s likely to have the perfect size and build for it, and he’s a little toughie.

These are three kids who’ve been treated exactly the same way since day one, and they could not be more different. There’s no nurture involved as far as I can tell. And there’s no question one of the girls is going to be a great athlete. She’s a competitive little pip. She’s small, but she’s a spitfire. She brushes dirt right off her. The other one is a little girly-girl. She hates to get dirty. She’s finicky. She loves pretty things. She already loves to dress up. Totally different person.