Brian Cushing of the Houston Texans is tended too after suffering an injury against the Jets last season. (Jim McIsaac/Getty Images)

When Washington Redskins quarterback Robert Griffin III gimped onto FedEx Field in the fourth quarter of a January playoff game against the Seattle Seahawks, he was under the gaze of no fewer than six physicians and assorted medical personnel. There was an internist, two orthopedists, an emergency medicine specialist, a neurologist and a renowned knee surgeon. There were five certified athletic trainers on the sideline, and another stationed in a booth high above, an “eye in the sky” tasked with spotting injuries.

It was visible to all of them, as it was to the audience, that Griffin was so compromised by a strained right knee ligament that he could barely run. Yet the experts did not intervene. In the next moment, something became plain: There is medicine, and then there is National Football League medicine, and the practice of the two isn’t always the same.

Griffin tried to field a bad snap, and his leg collapsed at a weird angle, his knee so unstable that even a cumbersome brace could not keep him upright. He fell to the ground like a doll with a broken spring, injured with torn anterior cruciate and lateral collateral ligaments. With that, a central tenet of the Hippocratic oath — “Do no harm” — instantly seemed turned on its head. Asked later how Griffin could have been permitted to retake the field, NFL Commissioner Roger Goodell called it “a medical decision.” Yet in the aftermath, even longtime NFL loyalists questioned why doctors allowed a brilliant rookie quarterback to play hurt and jeopardize his future.

“That was a horror show, letting him do that,” said agent-attorney Ralph Cindrich, who played in the league from 1972-75.

RGIII was primed to be the great young face of the NFL — and still may be — but in one January afternoon, he became an example of something else: a medical culture with conflicts of interest and competing pressures, in which players feel they must play through pain and team doctors often utilize short-term cures to help them do it. These doctors must decide whether their duty is to get the player back in the action or to get him healthy — a choice that often involves difficult judgments about drugs, procedures and treatment that can dramatically depart from what the average patient might receive.

“A lot of doctors would say we’re much more aggressive with the players, getting them back out there with their team, than we would’ve been with the guy who had any other job,” said Kurt Warner, a Super Bowl-winning quarterback who is now an analyst for the NFL Network.

Interviews with more than 50 doctors, players, agents, owners and medical ethicists suggest that what the NFL Physicians Society calls the game’s “unique clinical challenges” can result in inconsistent standards in treating players and cause some doctors to depart from best medical practices and safety norms.

Example: An ordinary citizen would receive a shot of the powerful painkiller Toradol for acute pain only after undergoing surgery, and typically for no more than five days. But in the NFL, doctors administer it weekly despite dangerous side effects that include renal failure, and its ability to mask pain to such a degree that a player injured during a game may not even be aware of the extent of his injury.

In a 2002 academic paper, 28 NFL physicians reported administering Toradol every game day, injecting up to 35 players per club. Though NFL doctors say use has declined in recent years, several current and recently retired players said the drug continues to be administered freely — and the NFL Physicians Society felt compelled to issue guidelines on its usage last season. “It is not a legitimate thing to offer a player on a weekly basis without a proper indication,” said Andrew Bishop, an orthopedist who for 11 years was the Atlanta Falcons’ team physician.

Oversight and quality of care can also vary widely from city to city. In San Diego, for example, team physician David Chao has become a subject of controversy for an extensive history of complaints and malpractice suits — including four by former Chargers players. The California State Medical Board has initiated proceedings to revoke or suspend his license, citing “gross negligence” and “repeated acts of negligence.”

Even as league officials say they’re taking seriously the risks posed by head trauma, the NFL Players Association charges that some teams have been careless or lax in administering concussion tests. The union’s consulting physician, Thom Mayer, counted at least seven occasions last season in which players took heavy blows to the head yet were returned to play almost immediately. “When we know, for example, the sideline concussion exam takes seven minutes to administer, and a player who looks like he had a concussion goes to the sideline and he’s back in less than a minute, we simply know the protocols weren’t employed,” said DeMaurice Smith, the NFLPA’s executive director.

More than 4,000 former NFL players are suing the NFL, contending team doctors did not properly inform them of the risks of playing with concussions. Given that there are approximately 18,000 living NFL alumni, that means nearly one quarter of them take issue with the care they received and feel team doctors have compromised their health.

Goodell says that improving player safety is his “top priority,” and many players and agents agree that the league has taken several positive steps in that direction. In the past two years the league has responded energetically to studies linking head trauma with a variety of brain diseases. It has established a half-dozen committees on health and safety. A dozen more subcommittees are devoted to specific body parts, head, neck and spine, cardiovascular, foot and ankle. In addition, the league has developed elaborate protocols for the sideline diagnosing of concussions.

“If you think about it, every NFL game will have anywhere from 10 to 14 pairs of medical eyes evaluating every play,” said Matt Matava, team physician for the St. Louis Rams and president-elect of the NFL Physicians Society. “Football players liken a collision on the field to a car wreck. But there’s no situation I know of where you have a car wreck happen and you have so many medical experts there waiting for it to occur.”

None of the Redskins doctors would address Griffin’s injury specifically. But according to confused and contradictory public accounts from Coach Mike Shanahan and orthopedic surgeon James Andrews, the determination of whether Griffin should keep playing was made not by doctors on Jan. 6. The call was made by Griffin himself, an overeager 22-year-old rookie. And no one stopped him.

“Robert said to me, he said, ‘Coach, there’s a difference between injured and being hurt. I can guarantee I’m hurting right now — give me a chance to win this football game, because I can guarantee I’m not injured,’ ” Shanahan said. “That was enough for me.”

The doctor-patient dynamic

The biggest difference between the NFL’s medicine and yours might lie in the triangulated relationship between patient, physician and club management, combined with the urgency of decisions made on the sideline.

Some health care organizations pay seven figures for the right to call themselves official medical care providers for NFL teams, a status that can increase business exponentially, and over which doctors have been known to be bitterly competitive. “There is an ego to it. . . . Especially in big cities, it gets pretty testy,” said David Geier, an orthopedist who briefly worked for the Rams.

Such deals can create the perception that NFL medicine is for sale, and team doctors are compromised, according to several people with current or past associations with the league. “The perception is, if a bunch of money is changing hands from the medical side to the team then that individual will do anything it takes to keep that job and keep that team happy,” Bishop said. “Even if he is practicing good medicine, there is that perception.”

The NFL tried to address the issue in 2004 by forbidding marketing deals that required teams to use doctors exclusively from a medical sponsor, a ruling reiterated by Goodell last year. The result is that teams have multiple relationships. The Redskins use Virginia-based Commonwealth Orthopedics as their official team health care provider, but they also retain Andrews, one of the country’s most prominent orthopedists, as a consultant. Their head physician is Anthony Casolaro, an internist with subspecialities in pulmonary and critical care who has been with the club for 14 years.

NFL physicians say such arrangements don’t affect their Hippocratic Oath. “ There is the misperception that the team physicians are working under the thumb of ownership or coaching, in terms of medical decision-making,” said Tim McAdams, a Stanford Hospital orthopedic surgeon and a team physician for the San Francisco 49ers “That couldn’t be farther from the truth of what my practice is like with the 49ers.”

San Francisco team owner John York, a retired cancer pathologist and chair of the owner’s Health and Safety committee said, “I’ve never heard or seen an owner, a head coach or a general manager ever do anything to suggest they wanted to overrule what the physicians were doing.”

But independent ethicists and others linked to the sport say that no matter how excellent a doctor, the third-party dynamic can create subtle pressures — especially in the game-day swirl of hectic circumstances on the sideline. “The coach is looking to the doctor, and the doctor is feeling the coach and his anxiety,” Cindrich said. Fidelity to the team might make a problematic medical call even more difficult.

“We knew — their job is to get us on the field by any means necessary,” said former wide receiver Joe Horn, a 12-year veteran who is among the retired players suing the league.

Therein lies the dilemma facing NFL physicians. “To say there’s no conflict there, from an ethical point of view, is to have your head in the sand,” said Lawrence Gostin, a professor of global health law at Georgetown University.

Mark Schlereth, who played 12 years in the NFL and today serves as an on-air analyst for ESPN, said he always trusted his physicians — but also knew who was signing their paychecks. “What we’re asked to do as players — they would never in a million years ask one of their patients to ever do what they allow us to do,” he said. “They would be on bed rest for something they tell us to practice with on Thursday.”

Asked to identify a classic case in which an NFL doctor might feel conflicted, Geier and Bishop named meniscus surgery. The meniscus is the shock absorbing cartilage in the knee. When a player tears a meniscus it can often be fixed in two ways: part of it can be trimmed out, or it can be sewn back together. The sewn method is preferable for preventing degenerative changes 10 or 15 years down the road — but the recovery period is three to six months. A trim takes just three to six weeks.

Both surgeon and player are faced with the question: Cut away the damaged cartilage and get the player back on the field in the short term — or sew it and cost him his season?

Most NFL contracts aren’t guaranteed beyond a single season. The average NFL career lasts just 31 / 2 years, so a borderline player could fear losing his roster spot and never suiting up again. The alternative, though, could result in a lifetime of problems. An NFL-financed study at the University of Michigan in 2009 found that one in four NFL retirees over the age of 50 has had a joint replacement.

“These players may or may not have something to fall back on,” Matava said. “Their goals are different. They’re not better. They’re not worse. They’re different than the average citizen.”

Seeking a second opinion

League executives say there are built-in checks and balances to ease the pressures of such decisions. Under the collective bargaining agreement between the players’ union and management, all players have rights to second opinions from the doctor of their choice. “Players have the ability to second guess, if you will, their team physicians, and get quality care they are comfortable and confident in,” said NFL Executive Vice President Jeff Pash.

But players face certain ugly realities. Some teams are not welcoming of second opinions, or happy about their obligation to pay for them under the CBA, or at the prospect of yielding control, according to several player agents. Certain team doctors “get their noses out of joint,” said Rick Smith, whose Chicago-based agency Priority Sports & Entertainment represents more than 70 NFL players. Smith demands his clients receive an MRI and second opinion for every injury. He estimates they diverge from the club physician’s opinion “four to five times out of every 25.”

All concussions will be subject to second opinions next season. In response to union concerns, the league has agreed to station unaffiliated neurologists on the sidelines to ensure protocols are followed. But there is some apprehension among teams even about this. Players have “highly individualized” reactions to pain and injury, said Pittsburgh Steelers trainer John Norwig, and team medical staff know — and are therefore best equipped to make evaluations.

“I don’t have a problem with someone being part of our team,” he said, “But we don’t want someone looking over our shoulders. We want someone to be part of our group.”

Not all players feel secure enough to challenge club authority by requesting outside advice, much less following it. Former defensive back Fred Smoot, who retired in 2009 after nine seasons, said he never sought a second opinion and that players can feel self-conscious on the subject. “It’s an uncomfortable position to be in because it looks like you might not have a lot of faith in the training and medical staff,” he said. “It was one of those unspoken things, never really talked about. People just knew not to do it.”

One reason players may not exercise their medical rights is because they simply are not accustomed to having any. Prior to 1986, NFL players were not even entitled to a copy of their medical records, nor could they choose their own surgeon. Today, they are allowed to obtain copies of their records twice a year, though their personal physician can request to view them at any time.

A 2008 Congressional report on NFL players and disability quoted an internal memo from an NFL Players Association staff counsel who handles injury grievances, reminding players to obtain their medical records — and read them closely. “Players who review their club’s medical records for the first time while preparing their arbitrations are often surprised to read what has been written about their injuries by the club doctors and trainers,” the NFLPA counsel advised. “The level of detail in the records far exceeds what is told to them by the club.”

Many current players are reluctant to speak openly about their medical care while they are still under the supervision of NFL doctors. From the time they are rookies, players don’t have much say over their bodies. In the NFL’s pre-draft evaluation process, they submit to a battery of fitness and medical tests that are shared with team executives — the details of which are frequently leaked to the media.

“It becomes even worse because you’re talking very often about very young men who, No. 1, want to succeed very badly, they want to please very badly, they want to show that they’re tough to their peers, and they’re trusting,” Gostin said. “All of that leads to intense vulnerability.”

Gostin’s words describe Chris Cooley’s mind-set in 2005, when the Redskins’ tight end tore the meniscus cartilage in his knee and also sprained his hip. Three days later, Joe Gibbs asked him if he could practice, and he said yes. “I was slow,” the nine-year veteran said. “I was young, too.” Cooley said he did not resent his coach for asking him if he “could go.” He simply wanted to prove he could.

A safety-first message

The NFL has advertised its commitment to health and safety by strictly policing on-the-field violence. Goodell has levied hefty fines against players who lead with their helmets. Most famously, the commissioner suspendedCoach Sean Payton and six members of the New Orleans Saints for a “bounty” incentive system that exchanged cash for big hits. Goodell has vowed to be “incredibly relentless” in imposing discipline over safety issues.

Goodell has not, however, disciplined the Saints for their prescription drug violations, though the team is facing civil fines from the local U.S. attorney after an assistant coach was caught on camera in 2010 stealing painkillers from the training room. Nor has the commissioner acted against Chao, the Chargers’ controversial team doctor.

According to court documents, DEA agent Brenda Catano discovered in 2010 that Chao had written 108 prescriptions to himself, as well as assorted others in the name of his clinic, or simply in the name of “San Diego Chargers,” a violation of federal law. The DEA confirms Chao was cited for five infractions, all of them related to “failure to maintain accurate dispensing records of all controlled substances.”

Abuse of painkillers in NFL locker rooms is an undeniable problem. In 2010, clinical researchers at the Washington University School of Medicine in St. Louis produced a study of former players showing that 52 percent of them reported using narcotic painkillers during their career, with 71 percent of those misusing them.

Court records and interviews reflect that until recently some clubs either ignored or were ignorant of DEA regulations. The DEA investigation of Chao resulted in the shutdown of a local dispensary, and, according to records, investigators found 82 team doctors in 27 states who wrote prescriptions to themselves in violation of the law. The records did not show how many of those were NFL physicians.

The NFL acknowledges it has spoken with DEA agents about the control and distribution of prescription drugs. “We have met with the DEA on multiple occasions to talk about issues, not so much involving a specific club, but on compliance in general,” Pash said. Asked if all teams were now in compliance with the law, he said: “I think you have very substantial compliance across the board. I can’t say I know every prescription every doctor’s written conforms with every aspect of the governing regulations.”

Chao’s record is replete with other instances of alleged misconduct. In addition to facing four lawsuits by former Chargers players, he has been ordered by the state medical board to undergo “ethics” training for failing to disclose two drunk driving convictions. According to its complaint, the state board is currently seeking to revoke or suspend his license for “repeated acts of negligence” in three cases between 2007-10.

The NFLPA has demanded Chao be fired; the Chargers refuse. Goodell has declined to intervene, despite broad powers to discipline anyone associated with a franchise for “conduct detrimental” to the league, defined as behavior that harms the public’s confidence in it.

Chao’s qualifications and care were reviewed by a panel of NFL doctors in 2012 at the request of the players’ union. Although the panel’s deliberations are confidential, the Chargers have said Chao was “exonerated,” an assertion Pash repeated.

The state’s complaint against Chao will probably not be heard until 2014. San Diego Chargers President and CEO Dean Spanos declined to be interviewed for this story. Chao and his attorney did not respond to phone calls.

The NFLPA’s DeMaurice Smith called Chao’s record: “An embarrassing fact for the Chargers organization, and for the NFL as a whole. You would think that the league could do better than this.”

Goodell has said that overall, “athletes in the NFL are getting extraordinary care,” and many teams can point to doctors with world-class reputations — the 49ers receive their care from Stanford Hospital, for example, and the New York Giants are treated by the Hospital for Special Surgery in Manhattan. Casolaro, the Redskins’ head physician, was singled out for praise in interviews with players and agents.

Many players, agents and union officials, though, take issue with the consistency of the league’s message. NFL numbers show that 60 percent of injuries occur during games, yet Goodell wants to increase the number of regular season games from 16 to 18. To do so, he proposes eliminating two preseason games, which feature only limited action by a team’s starters.

“The league, their No. 1 focus — at least they say their No. 1 focus — is health and safety,” NFLPA president Domonique Foxworth said. “And we say our No. 1 focus is health and safety. How come we have such a hard time moving the ball on some health and safety issues?”

Advising players on risks

While there have been many questions about the medical treatment and advice that Griffin, now 23, received on the Redskins’ sideline in January, one thing is clear: The quarterback wanted to re-enter the game. It’s a scenario that plays out every Sunday in NFL stadiums across the nation — an injured player eagerly returns to the field.

“Trust me, Robert wanted to be on the field more than anyone,” Cooley said.

Griffin’s decision — which might have been labeled gutsy with a different outcome — was both naïve and perilous, say many in the game. But few call it surprising. “We’ve all done it,” said Warner, the former quarterback. “That’s our mentality. . . . We all think we’re invincible.”

Pro football players don’t make for easy or obedient patients. A team physician’s responsibility is complicated by the fact that his patients are often willing to assume unwise risks that other people wouldn’t.

“Most people, when they’re injured, they stop,” said Stanley Herring, a team physician with the Seahawks who was on the opposing sideline the game Griffin was injured. “You have a highly motivated patient who is willing to compete when it’s not best for them. They don’t act like you or me.”

Certainly, no one pushed Griffin to keep playing. Casolaro, who started with the Redskins in 1999 and has been the primary team doctor the past six years, would not talk specifically about Griffin, but he did say this: He’s never felt any pressure from a coach or owner to roll the dice with a player’s health.

Potential conflicts come with all ambitious or driven patients, he said. Casolaro gave the example of a patient he recently admitted to a hospital, a 50-year-old with a heart attack. The man had no insurance or sick leave and was desperate to return to his job as a carpenter as soon as possible. “If he didn’t work, then his family might end up on the street,” he explained. “While it would be best for him to rest for a few weeks, I recognize that won’t happen so we tried to compromise and let him go back in two weeks.”

The most difficult injury for an NFL doctor to treat is the invisible one, when a player appears to be well enough to play and insists he’s fine, but he’s not. Interviews with players and agents illuminate a code in which it’s routine to hide injuries from team physicians, or understate them for fear of losing a starting job or letting down a team. One agent even said some players have already figured out how to pass the league’s concussion tests to return to action.

“You can’t make the club in the tub,” Smoot said. “That’s what they say. There are so many [injuries] the doctors don’t even know we have. Why? You gonna play through it. You don’t want it to be part of your list, you don’t want to be one of those people who is ‘injury prone.’ ”

According to the league’s most recent numbers, there were 4,473 injuries in the 2011 season, a 29 percent spike from the previous season. Every player interviewed for this story said he signed up to play knowing he would be harmed. “When you step on that field, you know it’s violent game,” said Marshall Faulk, a Hall of Fame running back who retired in 2007. “What do they need to have you do? Sign a waiver? It’s like, you get on a roller coaster; ‘This ride could make you sick.’ ”

The question facing doctors is not whether there is risk in football, but whether players are properly advised of it and treated — whether they have informed consent. This is the point being argued in the massive concussion litigation, and in which NFL doctors are becoming key figures in questions of liability as retired players experience remorse and recrimination for their symptoms.

“We hear all the time that players know what they signed up for, know the risk,” said Smith, the players’ union chief. “And with respect to those players and their beliefs, that’s fine. We are not challenging what they believe. Nonetheless, the employers still have an obligation to provide a workplace as safe as possible.”

Some observers suggest the best way to ensure the league’s goal of a “culture of player safety” is to go to an entirely neutral, standardized medical system. Bishop, the former Falcons’ team doctor, would like to see the league mandate an appropriate salary range, to take the money out of the equation. Others would like to see a neutral physician on site at all NFL facilities, at all times.

There is no perfect answer, as long as players are willing to disobey a doctor’s orders. But ethicists say the important thing is that those orders be clear, and not muddied by conflict or open to interpretation. “That person can still ignore them,” Gostin said, “but the doctor would have no hesitation saying, ‘No, this is not good for your health. I don’t care if you like Quarter Pounders with cheese or that you want to get on your bike and ski, that’s not what’s in the best interest of your health.’ That’s what doctors are trained to do, to tell people something they don’t want to hear.”

The shooting-star brevity of NFL careers means that some medical dilemmas are inevitable — whether the long-term remedy versus the quicker procedure, an abbreviated rehabilitation, or medicine that masks pain. No amount of padding, no number of doctors, no quantity of committees, no rule changes can make those issues go away. What all parties agree on is that they can do a better job of addressing them.

“At the end of the day,” said the NFLPA’s Smith, “without health and safety, there is no game.”

Julie Tate contributed to this report.