Keeping Them on the Field

Musculoskeletal injuries are an integral part of many sports. Contact sports seem to produce the most, with football, hockey, soccer, and basketball leading the way. As athletes compete and push themselves to improve, sprains, strains, contusions, and other injuries become part of the daily routine. Those often attending to these athletes with regular aches and pains are athletic trainers, physical therapists, and physicians. Such sports medicine teams are there to emphasize prevention, treat injuries, and keep athletes on the field or court. This last objective produces the following dilemma: Where is the line between allowing injured athletes to play and restraining them to prevent further injury? Who draws the line? When is further competition harmful? How much can athletes withstand, and at what point does the sports medicine team say, “It’s time to rest”? Up to the high school level, the medical team can rely on parents in the decision-making process, for it is they who—above all the hype, hoopla, and excitement—can keep the best interests of their sons and daughters in mind. When the future health of athletes is jeopardized or when there is a real chance of further injury, most parents can and do make the right decision with the help and guidance of the sports medicine team. Parents occasionally lose sight of the big picture and become blinded by their offspring’s athletic stardom. Coaches can also become irrational and shortsighted. This situation can make the life of a team physician very challenging. Thankfully, at the high school level, this usually does not happen, often making the job of the medical team straightforward. When athletes are good enough to advance to the collegiate level, the complexity of these situations expands as expectations and demands increase. In big-time revenue sports, such as football, hockey, and basketball, the pressures mount for the athletes to play through pain and injuries. The success or failure of college coaches who are commanding million-dollar salaries is often determined by a bunch of teenagers who were promised an education in exchange for subjecting themselves to the rigors of college sports. The bounty for the successful teams is impressive: stadiums and arenas full of grateful, adoring alumni willing to support the institution. Bowl games, successful recruiting, and bonuses are the spoils for those who are victorious and maintain an edge over traditional rivals. However, for those coaching regimes that do not make the grade, all too often the writing is on the wall: Too few wins and you are gone! This pressure-to-perform system places a high premium on keeping athletes on the field. They cannot win ball games in the training room. This is where the lives of team physicians get interesting and challenging. Can they help the athletes perform, by helping them overcome pain and dysfunction with safe medical care and treatment, yet detect when more serious injuries are present that demand time to heal and restricted participation? These decisions are difficult and unrelenting. For example, when is a partial ligament injury ready for a return to play and not at risk for further injury? In the energized world of college sports, the pressure can mount as the big games approach, with national rankings, television appearances, and all the rewards of college athletics possibly hanging in the balance. Can physicians protect the best interests of athletes even when everyone around seems to be caught up in these emotionally supercharged moments? In college, this may be where physicians play the most important role, as the presence of parents diminishes but the athlete is not yet a mature adult. At the next level of competition, that of professional sports, decisions appear to get a little easier for the medical team. For the most part, the athletes are adults capable of making rational decisions. Although the pressures may be greater because of million-dollar contracts and high-powered agents, dealing with those capable of making their own health care decisions, once they are adequately apprised of the risks and benefits, appears to be an easier task. Recognizing the environment that many of these situations bring should be considered. Many athletes believe that they are bulletproof and will not be adversely affected by the complications and side effects that challenge mere mortals. An American public addicted to sports competition can make stars larger than life, and it can reward them with salaries not attainable in any other field. It is easy to see how athletes can be taken in by fame and fortune and so find it difficult to make the best decisions for their medical care. To meet these decision-making challenges in all of these scenarios, at the high school, college, and professional levels, team physicians must be adequately prepared, fully educated, and proficiently trained to use all the tools at their disposal to the benefit of the athlete-patient. The side effects (short-term and long-term) and complications of medications, treatments, and devices must be fully understood to make sound medical decisions. This is part of the value of the article by Dr Matthew Matava in this edition of Sports Health. It is an excellent compilation of the risks, benefits, and problems of commonly used pain killers and anti-inflammatories in sports medicine. This article addresses many questions that sports medicine physicians will face in this challenging, demanding world—but not all. It is pretty clear that we need more research, basic and clinical, in these areas. Even though these are hot topics among physicians, trainers, and physical therapists, they are rarely discussed in forums and symposia at national meetings. The lack of openness on these topics suggests a dark side to this area of sports medicine that many athletic directors, coaches, administrators, and physicians do not readily admit as part of their program. If these practices are legitimate and part of the standard of care for athletes, why not bring them out in the open for public discussion? It may be time for a good look in the mirror and an examination of conscience. Have we crossed the line while getting too involved with the hysteria of sports competition? Are we still primarily addressing the needs of the patient-athlete? Do we spend enough time examining the risks and side effects on what we do and recommend? What will the long-term outcome studies say about these efforts? There is much to think about these days, after practice and during halftime.