More often than he would like, Thomas Bottiglieri, DO, chief of sports medicine physicians at Columbia University, has to break the news to a young athlete: For the sake of your brain health, you need to retire from your sport.
Each time, Bottiglieri knows all too well exactly what's going through their minds. He's been there. And he knows what comes next is the hard part.
Thinking back on his football days, Bottiglieri refers to himself as an undersized linebacker. He was two years into his college career when injuries caught up with him.
"I got hit a lot," he says. "So does everyone playing football, but because of my size, the collisions had greater impact." In a word: brutal. But Bottiglieri loved the game, loved being on the field, loved being part of a team.
It was the 1990s, a time when there was little broad acknowledgment or understanding of the dangers from head and brain injuries in football. Bottiglieri played through severe headaches and dizziness.
Then there was the hit that left him barely conscious and motionless on the field. It occured during a drill most football programs have now eliminated from practice. As soon as Bottiglieri made contact with the runner he needed to tackle, he recalls "something flashed in my head, my body went limp, and I fell backwards."
Diagnosis: Football is over for you
This was Bottiglieri's third injury in as many weeks. The team's athletic trainer sent Bottiglieri to a neurologist who would later determine he had lasting neurological signs of brain injury.
"The doctor said 'I think football is over for you.' I said 'why is that?' He said 'There are signs of brain damage that may or may not heal. If you continue, your brain may be permanently damaged or you can die.' And that was that," says Bottiglieri. "You know the moment you see in the movies when somebody gets life and death news? It just shook me to the core."
This was the prescription no athlete wants, but Bottiglieri knew it was correct. It was taking longer and longer to heal and recover. Playing football did not feel the way it used to. He could feel the protective lining in his head was no longer there.
But athletes aren't programmed to give up. Retiring from football-Bottiglieri does not use the term quitting-felt like the equivalent of permanently losing.
He recalls the challenge of facing his college coach, his teammates, his dad, and even his old high school coach to break the news to them. He felt like he let them down, like injuries were his fault, like retiring was an insult to them.
He was 19 years old and unprepared for what would follow: loss of identity, social network, routine, everything.
"He was 19 years old and unprepared for what would follow: loss of identity, social network, routine, everything."
"Add the stress of not being able to pursue your dreams with the loss of teammates, exercise, meetings-all the things that go along with being happy-it really creates significant chaos for student-athletes," he says.
Bottiglieri became depressed. He thought about leaving school. He self-isolated. He figured he needed to tough it out. He did not reach out to anyone. No one reached out to him because mechanisms to address the mental health of a retired athlete didn't exist. "It was miserable," Bottiglieri says. "The depression lasted for months and months. Maybe years."
Mental health guidance in sports medicine
Despite his depression, Bottiglieri kept working toward his goal of becoming a physician, eventually deciding to become a sports medicine doctor.
When he started seeing patients facing retirement in his practice, he explained the physical issues, treatments, and how the body heals. He also realized he was intuitively supporting their mental health.
"When we take the sport away, we're actually challenging your identity as a person."
"Here's something that maybe defined you a human being. When we take the sport away, we're actually challenging your identity as a person," he says.
Today, doctors screen for depression, evaluate the mental health of their patients, and refer them to mental health professionals if necessary.
Bottiglieri also helps other physicians broach the difficult discussion of retirement and its aftermath with their patients.
With Columbia neurologist James Noble, MD, and other like-minded physicians, he published guidance on the topic-"Medical retirement from sport after concussions: A practical guide for a difficult discussion." It's become a popular standard for sports medicine doctors and others working with student-athletes.
Health and well-being in retirement
Bottiglieri has treated thousands of athletes, many with career-ending injuries. The majority who need to retire from their sport are college aged. Some are in high school. A few, gymnasts who compete nationally, are as young as 13 or 14.
The question every patient facing retirement asks is: What now?
His answer is the same he found for himself: "Find another sport. It may not speak to you the way your first love did," he says, "but it will return you to exercise, social life, and happiness."
Bottiglieri laughs when he says he found martial arts. "It's a combat sport! But you can control the hits in a way you cannot in other sports, like football, which is pure chaos. I do not have to spar. I can limit contact to my head."
Most people will never be professional athletes, but everyone can-and should-use sports as a vehicle for health in later life, Bottiglieri says. "You play sports so that as you age, you have developed healthy habits that will continue to take care of your physical and mental well-being."
In that sense, there is no retirement.
References
Thomas Bottiglieri, DO, is chief of sports medicine physicians in the Department of Orthopedic Surgery at Columbia University Vagelos College of Physicians and Surgeons and assistant professor of sports medicine in the Center for Family and Community Medicine at Columbia University Irving Medical Center. He sees patients of all ages.
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