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Christopher Ahmad: I grew up in Long Island and I had a love, and that love was playing soccer.
Catherine: This is Chris Ahmad. A young Long Islander with big soccer dreams.
Christopher Ahmad: I practiced every day. I got coaching and very early on I knew I wanted to play soccer at one of the best soccer programs in the country, Columbia University.
Catherine: Chris was good. By the time he was 15, recruiters began taking notice. And in time, his childhood dream was fulfilled. He went to Columbia to play soccer. And he had a successful college career... until his senior year.
Christopher Ahmad: My, uh, senior year in college, I was in the best shape of my life and I was at the best soccer performance, uh, skill level of my life and I was looking forward to an amazing season. Our first match was against Harvard, and at about 20 minutes into the game, I received
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a hard tackle. A player hit me on the outside of my knee and I had a high-grade grade three MCL injury. I got injured in a, um, a very, uh, I would say a way that was, um, unsettling. That's the way it is. You get hurt and you had a, um, aspiring career in sports. Then you realize, uh, I'm not gonna have a long-term career and, uh, life goes on.
Catherine: The injury itself was devastating. But it came with a silver lining that changed the course of his life.
Christopher Ahmad: Taking care of my own knee allowed me to meet a orthopedic surgeon for the very first time. His name is Michael Kelly. And, uh, at the time that he was taking care of me, he was the doctor for the Knicks. But uh, during that time, I developed a relationship.
Catherine: When Chris met Dr. Michael Kelly, he was instantly drawn to him. Dr. Kelly was a charismatic orthopedic surgeon -- who took care of professional athletes
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-- putting broken players back together. Chris thought to himself, I want to be like him.
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Christopher Ahmad: To meet the person who you wanted to be, it would be the equivalent of a kid who wants to play a professional soccer and meets, uh, Lionel Messi. That orthopedic surgeon that invited me into the operating room, and I observed knee surgery with him and said, uh, no question about it, I wanted to fix people's shoulders, elbows, and knees. I love the idea of somebody breaks something and you put it back together and you get them back to what they love doing.
Catherine: I'm Catherine Price, and this is Advances in Care. Today, we're joined by Dr. Chris Ahmad -- he's the Chief of Sports Medicine at NewYork-Presbyterian/Columbia, a renowned Orthopedic Surgeon, and the team physician for the New York Yankees. I had the opportunity to talk with him about his innovative work
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on one of sports medicine's most infamous operations – Tommy John surgery.
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Christopher Ahmad: I love being overly honest about this. When I grew up, I did not like baseball for a couple of reasons. My brother played baseball and who wants to do what their older brother does? I needed to be my own person and I did not like waiting around. You're sitting in the outfield waiting for a ball to hit to you, and then you gotta wait your turn to get at bat. I did not understand that. I'm like, I want to, I wanna play. I want the ball and I want to go get it.
Catherine: Yes. Soccer and baseball. Very different.
Christopher Ahmad: Yeah. Even though I was a soccer player and never played baseball growing up, a big part of my career right now is taking care of baseball players.
Catherine: Chris may not have been interested in the game of baseball growing up, but he eventually became very interested in one of the most common injuries in the sport.
Christopher Ahmad: There is nothing more fascinating than the very small ligament – it's about the thickness of a shoelace – that lives inside everybody's elbow,
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and that is the ligament that baseball pitchers tear. That ligament is under so much stress and when it tears, we are able to rebuild it and get baseball pitchers throwing upwards of a hundred miles per hour after a procedure that we call the Tommy John Surgery.
Catherine: Quick history on Tommy John surgery: Tommy John was a lefty pitcher for the LA Dodgers -- and in 1974, he was at the height of his career.
Christopher Ahmad: He was in a game against the Montreal Expos and he threw a pitch and felt some pain in his elbow, and he didn't know what to make of it. He threw another pitch and the pitch went way wild. And then he had incredible pain in his elbow and he knew something was wrong.
Catherine: His team doctor, Frank Jobe, examined him. Tommy John had torn his ulnar collateral ligament. It was a career-ending diagnosis.
Christopher Ahmad: At the time, there was no surgery to correct it. He put 'em in a cast,
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rested them, rehabbed them, and he could not get back to playing. And Dr. Jobe said, I am sorry your career is over. And Tommy John said, I am not ready for my career to be over. I need you to operate on me. And Jobe said, but there's no operation. And Tommy John said something that changed the world of baseball science. He said, make an operation up. I trust you.
Catherine: Tasked with inventing a brand new surgery, Dr. Jobe and his colleagues came up with a solution -- borrowing some inspiration from techniques being used in hand surgery. They'd take a piece of the palmaris longus in the forearm and graft it -- to reconstruct the ulnar collateral ligament.
Christopher Ahmad: Anatomically it looked just like a ulnar collateral ligament.
Catherine: Dr. Jobe gave Tommy John a one in one hundred chance that the operation would work. But as far as Tommy John was concerned, he had nothing to lose. A 1% chance of getting back on the field
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was better than nothing.
Christopher Ahmad: He performed the surgery on Tommy John in 1974. And history now has been made.
Catherine: Tommy John eventually healed, and went back to the Dodgers pitching mound. A couple of years later, the Dodgers made it to the World Series.
Christopher Ahmad: He had more wins after his Tommy John's surgery than he had before.
Catherine: It wasn't long before Tommy John surgery was standard in the world of professional baseball. Now, injuries that would have been career-enders had an effective surgical treatment. Dr. Jobe had changed the game of baseball. A few decades later, Dr. Chris Ahmad was a young orthopedic surgeon. And he knew that if he wanted to become the best surgeon he could be, he needed to learn from the best. Which is how he found himself learning how to do Tommy John surgery from the man who invented it.
Christopher Ahmad: I still recall the very first time as a fellow
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I was assisting him in a Tommy John surgery. I couldn't be more excited to see this operation that he invented that is saving the careers of pitchers. And, uh, when he took the scalpel, he said to me, you know what? I've done so many of these, I think I'm gonna try this one lefty.
Catherine: No!
Christopher Ahmad: And he started operating left-handed
Catherine: [laughs] I’m not sure how I feel about that!
Christopher Ahmad: Well, the ruse is on me because, uh, I did not know in actuality he was left-handed.
Catherine: Oh! Okay, Dr. Jobe….
Christopher Ahmad: So he was enjoying the moment with me, but, uh, yes, he was left-handed.
Catherine: You must have been like, ‘this guy is good!’ [laughs]
Christopher Ahmad: Yeah. For me, seeing Dr. Jobe perform the operation the same way he did on Tommy John was of course fascinating and thrilling. I could not be more amazed at how a small ligament can be rebuilt with surgical expertise. But as an engineer and as somebody
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who likes to build things and likes to improve, I was thinking in my mind very early on, on how we could make this operation better.
Catherine: Now -- Soccer may have been Chris Ahmad's first love, but growing up, he'd had another passion. Engineering.
Christopher Ahmad: There was something about creating and building that was fascinating to me. And I had this love of understanding how things work.
Catherine: Even when he was a child, Chris would spend hours with his grandfather in his woodworking shop, looking over his shoulder as he built clocks. Chris himself loved building his own model airplanes… and he flew them around Long Island in the winters when it was too cold to play soccer. At Columbia, he studied mechanical engineering. He learned how materials respond to force -- and how they break under load.
Christopher Ahmad: And so the foundation of studying mechanical engineering, uh, gave me a great opportunity to become, uh, uh, an orthopedic surgeon
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who understands how the mechanics of the body works.
Catherine: So, watching in awe as Dr. Jobe performed the surgery, Dr. Chris Ahmad couldn't help but look at it through engineer-tinted glasses. In Dr. Jobe's design of the surgery, the grafted ligament was sutured in place. It was strong, but Dr. Ahmad wondered -- was there a way to make it stronger? If he could make it stronger, it might prevent the ligament from re-tearing during rehab, and potentially speed rehab up. At the time, that recovery process was 12 months, which is a very long time for a professional baseball player to be sidelined.
Christopher Ahmad: I contacted a engineer. His name is Ty Lee at UC Irvine who I did not know personally, but knew of his reputation in LA and asked if I could do some research and use some of his equipment in his lab. And after speaking with him and him knowing my work at Columbia University,
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he offered to let me use his lab. And I took ligaments, uh, elbows, cadaver elbows. Took 'em in and broke 'em just like I would was doing as a mechanical engineering undergraduate student, but with metals and plastics. I did it on an elbow, came up with a strategy on how to position it in the machine and how to have a experimental design that was reproducible. And after breaking the ligaments, then I would reconstruct and do the Tommy John surgery with a major modification to it, fixing it in a different way. And then I would rebreak the ligament. And when rebreaking the ligament, I could keep doing variations on the surgical technique to continuously improve the strength of the reconstruction. And so one of the ways that we improved upon it was, um, simplifying how we made the tunnels. Instead of
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having multiple tunnels, uh, we had one tunnel on the epicondyle, one tunnel on the sublime tubercle, and we fixed the graft with interference screws. And interference screws is a way of securing a graft within a tunnel. It's basically- put a screw in and make it as tight as possible. Where in the past, Dr. Jobe was just suturing ligament together and stitching things together is strong, but screws could potentially make it stronger. And studying it in the lab, it was definitely stronger than, uh, say the traditional Tommy John surgery.
Catherine: This reconception of the Tommy John surgery -- fixing the graft with screws instead of sutures did make the surgery stronger. But in some cases, it also brought a new set of problems.
Christopher Ahmad: When you have a screw inside the tunnel, the graft wasn't healing as perfectly as we would like, and there had been a couple of failures, so we then modified it again. Currently do what's called a docking technique
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for, uh, Tommy John surgery most commonly. And that, uh, minimizes the tunnel configuration complexity. It makes tensioning the graft even better than the original, uh, Dr. Jobe style of doing it. It makes the surgery more reproducible.
Catherine: Unfortunately, it’s essential for the surgery to be reproducible. Between 25 and 30% of all pitchers will have the Tommy John surgery at some point. In fact, many players have it more than once. Dr. Ahmad says, this is because the game of baseball has changed. Pitchers are throwing faster than they ever have. Which means, on the whole, modern players are putting more strain on their elbows than ever before.
Christopher Ahmad: Traditionally, if you had Tommy John surgery and re-tore your graft, which is devastating, you got hurt, you had surgery, you went through the recovery, maybe you played for a couple years and then you got re-injured and tore your Tommy John's surgery graft. The outcomes of redoing the surgery was very poor. It was about a 20% success rate.
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Catherine: But Dr. Ahmad says when there’s a poor prognosis, it can actually end up providing momentum for surgical innovation.
Christopher Ahmad: Just like when Tommy John himself said, make up a surgery for me, because right now I'm not gonna play baseball. I'm willing to let you try. For patients who have had failed surgery, that have a, um, poor prognosis for return, there's so much incentive to get back to playing. It's your career, it's your love. It allows you to say, let's try something different. Let's experiment. Let's try to do it differently.
Catherine: Tommy John surgery outcomes were improving, but Dr. Chris Ahmad wanted them to be even better, so he kept thinking about how to increase the strength of that ligament. Which leads us to one of the latest surgical innovations…the UCL seatbelt.
Christopher Ahmad: The latest is we can augment the strength of Tommy John's surgery by putting in what we call an internal brace, which is essentially analogous to a seatbelt,
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and it will protect the graft while it's healing. And that could be done by primarily repairing the native ligament and without doing a graft, which is called the repair operation with internal brace. Or now we're doing a reconstruction and putting in the internal brace to help protect the graft so now with the newer techniques that we have, redoing Tommy John's surgery is extremely common.
Catherine: Dr. Ahmad is now the team physician for the New York Yankees. He has contributed to the development of new techniques for the improvement of Tommy John surgery and has performed it on nearly 1000 athletes.
Christopher Ahmad: I would say the first 10 years was just focused on being the best surgeon possible. Making sure that if there was an injury that needed to somehow get fixed, I could fix it as, as best I can. The next 10 years of my life have been about how to scale that work,
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how to teach other surgeons how to do it so it can be more, um, impact to the community, the global community as a whole.
Catherine: Dr. Ahmad is still developing new techniques to improve the Tommy Johns surgery – and teaching these techniques to other surgeons to expand his impact further. But he also realizes that the biggest opportunity for impact is in prevention. And he can make a huge difference by working not just with professional athletes, but with kids.
Christopher Ahmad: The population that has this injury more than most, more than any professional athlete is kids. The 17 and 18-year-old is the most common patient that I operate on for Tommy John's surgery, and their numbers of injuries increase every year. There's lots of opportunities for us to help prevent what's a devastating injury in a 17 and 18-year-old who's aspiring to perhaps get a college scholarship or play in college
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or even get drafted.
Catherine: In one of Dr. Ahmad's research studies, he learned that one major contributing factor to injury in young athletes is that they specialize in a single sport too early in their careers.
Christopher Ahmad: Derek Jeter, CC Sabathia as examples. They played multiple sports in high school. They both played basketball. And when you play another sport, you give your body that's used to say throwing as a pitcher, a period of rest, and you develop other muscle groups. You develop agility. There's been some research that says your injury rates are higher if you grow up in warm weather. And that's not because the sun makes your ligaments weaker, it's because you play year-round. So if you're forced to take a break in cold weather locations and or play other sports, your body will be rested and remain healthy.
Catherine: And Dr. Ahmad says this is definitely one piece of a larger cultural issue surrounding sports. The level of the game has been elevated, so
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players and their parents and their coaches are pushing performance further.
Christopher Ahmad: These young kids, they're having strength and conditioning coaches, nutritionists, hitting coaches, throwing coaches. So they are performing with extremely high demands. The velocity of 17-year-olds is much higher today than it was 20 years ago. So they are getting better at their craft, but it's putting more stress on their bodies. And the perhaps ugly part of it is, there's a culture that kids should throw with some level of pain.
Catherine: Dr. Ahmad and his colleagues at Columbia wanted to quantify this, so they surveyed young baseball players. And what they found was shocking. Eighty percent said that they had played with elbow pain. And of the kids who said this? Half of them said they were encouraged to play through elbow pain by their coach or another adult in their life.
Christopher Ahmad: A kid will say, uh, my elbow's hurting.
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And the coach will say, well, I need two more outs from you. You know, go get me two more outs. Or, you know, suck it up. You know, the, everybody plays through pain. As we all know, pain is an indicator of a problem. And if you have a problem, it's gonna be something that you just can't get through. So we're trying to make that change in culture and baseball
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Christopher Ahmad: During the playoffs in around 2016 or 2015, and, um, Jeter made a play that was routine at shortstop where he received a ground ball and fired it to first. And uh, uh, with that pivoting motion, firing it to first, that he does so frequently throughout his entire career, he fell to the ground and could not get up.
Catherine: Wow.
Christopher Ahmad: He needed assistance to get back into the clubhouse and then into the training room. I examined him with everyone. It was just a large group.
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I looked at his x-ray and he had a displaced fracture of his ankle. And so while I sat there, I had to process that I'm gonna now gonna go out and tell our team captain that he's no longer able to play and his season is over and we gotta think about next year for him. And, uh, I kind of rehearsed in my mind how I was gonna break the news to him. And knowing the warrior, his instinct is, I can play through it, tape it up, do something to get me back out there. So the first words I said to him was, you cannot play through this one. You know, that's a hard moment. So whenever we deliver bad news, it's not an easy moment, uh, for delivering it, or of course, uh, for the patient who's receiving it. The good news is, uh, we wanna preserve your next season and your career.
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So after saying you're injured, you're hurt, you need a procedure, what follows is, now let me talk to you about how we're gonna get you back. How are you gonna be back and how are you gonna be better than ever? And for many athletes, of course, that's, uh, reassuring, but they still have to go through a somewhat of a grieving process, you know, because, uh, it can be devastating.
Catherine: Dr. Ahmad is no stranger to the devastation caused by sports injury. He had his own soccer injury of course, but he’s also witnessed a massive psychological effect on his patients – whose injuries take them out of the game. In some cases, Dr. Ahmad noticed that even when players had physically recovered, they did not “return to play.” And he wanted to find out why.
Christopher Ahmad: We've identified through research that we've done that when a kid who identifies very strongly with this sport gets hurt and is no longer able to play a sport, even if it's a temporary period of time, they have a psychological impact that is equivalent to post-traumatic stress syndrome.
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Those same type of emotional feelings, anxieties, fears, intrusive thoughts… that happens to kids who get hurt. And once they're hurt, that psychological impact is not immediately reversed just because we've physically corrected their injury. So the psychological impact can linger. In fact, the number one reason for kids not to come back from Tommy John's surgery or for ACL injuries where they've had their injury corrected, is related to a psychological component, not the physical component. And as orthopedic surgeons we're trained in how to fix things, we're not as well trained on how to psychologically manage injury, but there's an opportunity there, an opportunity for us to take better care of our patients.
Catherine: Dr. Ahmad says that he's begun engaging sports psychologists to work with his patients, especially if he can tell that they're struggling.
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Unfortunately, there is still a stigma attached to getting help with mental health, even in 2023, and especially in sports communities. But his research proves that the anxiety associated with injury is real, and worthy of attention.
Christopher Ahmad: I have a, um, special relationship with a patient. And this patient when I first met them, was having a knee condition. And at the time he had somewhat of a rebellious attitude. When I met with him, he would not look me in the eye. He would not communicate his symptoms. And as I, uh, diagnosed him, uh, he had a injury in his knee that required surgery, was an OCD lesion of his medial femoral condyle, something we see in different parts of the body. And he required surgery. And throughout the process of me getting to know him, uh, and go through the rehab, he changed. The day of surgery. I met him, I talked to him and I sat with him and I marked his leg with initials, which is hospital protocol to avoid wrong site surgery.
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And as he went through the rehab process at his final visit, at about six or seven months after the surgery – this was the green light clearance visit – He was a different person. He was happy, he was smiling, and he was engaging with his family and his parents. And when I went to examine his knee, I noticed that he had the initials from the magic marker that I used on his knee. And of course, this is six months later, it had no business being there anymore. And he told me that he went and got a tattoo because of how much the surgery and my ability to help him affected his life and his outlook on life.
Catherine: Wow. What was your reaction?
Christopher Ahmad: Well, I was, um, uh, just, uh, I, I guess I was, uh, reflective of it because, uh, every now and then I needed to step back and say our impact on the lives
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of anyone that we have the opportunity to take care of is often enormous. So, for me it was just a reminder of how special a opportunity I have to affect, uh, affect the lives of people and in a positive way. And I'm very fortunate to be in a position to do that. So, gives me a sense of gratitude.
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Christopher Ahmad: When you have the ability as a surgeon to have someone trust you, undergo anesthesia, be asleep, and then you get to correct them internally that is an incredible honor and privilege and I get to do that every week. And yes, it started when I first observed surgery as a 19 year old. And to this day, where I do my surgery is in the same operating room where I first observed an operation at the age of 19.
Catherine: That’s really amazing.
Christopher Ahmad: Last Tuesday I did 14 operations, and as I, uh, head to the operating room,
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I stop and I take a look at the soccer field and I usually take a photo and I remind myself that it's an honor and privilege to do what we do. And that every day we have an opportunity to impact people in a positive way. And that's my pep talk, that you better do a good job today.
Catherine: Dr. Ahmad, thank you so much for making the time to join us today.
Christopher Ahmad: Thank you so much. It was a pleasure to be here.
Catherine: I’m Catherine Price; Advances in Care is a production of NewYork-Presbyterian hospital. The views shared on this podcast solely reflect the expertise and experience of our guests. To find more amazing stories about the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.
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