PART
A
Fundamental Principles
CHAPTER
Sports Medicine: The Team Approach
M
illions o people throughout the world perorm physical exercise and play sport. Tese people have speci�c medical needs. o cater or these people a branch o medicine known as ‘sports medicine’ has evolved.1, 2 Sports medicine includes: injury prevention, diagnosis, treatment and rehabilitation; perormance enhancement through training, nutrition and psychology; management o medical problems; exercise prescription in health and in chronic disease states;3 the speci�c needs o exercising in children, emales, older people and those with permanent disabilities; the medical care o sporting teams and events; medical care in situations o altered physiology, such as at altitude or at depth; and ethical issues, such as the problem o drug abuse in sport. Because o the breadth o content, sports medicine lends itsel to being practiced by a multidisciplinary team o proessionals with specialized skills who provide optimal care or the athlete and improve each other’s knowledge and skills. 4 A sporting adage is that a ‘champion team’ would always beat a ‘team o champions’ and this also applies to sports medicine. Individuals who provide specialized skills and who utilize the skills offered by other members o the team provide the best athlete care. Tis team approach can be implemented in a multidisciplinary sports medicine clinic or by individual practitioners o different disciplines collaborating by cross-reerral.
The sports medicine team Te most appropriate sports medicine team depends on the setting. In an isolated rural community, the sports medicine team may consist o a amily physician or a physiotherapist/physical therapist alone. In a airly populous city, the team may consist o:
1 • • • • • • • • • • •
amily physician physiotherapist/physical therapist sports physician massage therapist orthopedic surgeon radiologist podiatrist dietitian/nutritionist psychologist sports trainer/athletic trainer other proessionals such as osteopaths, chiropractors, exercise physiologists, biomechanists, nurses, occupational therapists, orthotists, optometrists • coach • �tness adviser.
In the Olympic polyclinic, an institution that aims to serve all 10 000 athletes at the games, the sports medicine team includes 160 practitioners (able 1.1). Multiskilling Te practitioners in the team have each developed skills in a particular area o sports medicine. Tere may also be a considerable amount o overlap between the different practitioners. Practitioners should be encouraged to increase their knowledge and skills in areas other than the one in which they received their basic training. Tis ‘multiskilling’ is particularly important i the practitioner is geographically isolated or is travelling with sporting teams. Te concept o multiskilling is best illustrated by a number o examples. When an athlete presents with an overuse injury o the lower limb, it is the podiatrist or biomechanist who has the best knowledge
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, McGRAW-HILL PROFESSIONAL
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PART A FUNDAMENTAL PRINCIPLES
Table 1.1 Staff who provide medical coverage at an Olympic and Paralympic polyclinic Administration/organization
Chief Medical Officer Deputy Chief Medical Offi cer, and Chief, Athlete Services (sports physician) Director of Clinical Services—Polyclinic (sports physician) Director of Nursing Director of Physiotherapy/Physical therapy Director of Remedial Massage Director of Podiatric Services Director of Dental Services Director of Emergency Services Consulting
Medical practitioners: sports physicians; orthopedic surgeons; general practitioners; rehabilitation specialists; emergency medicine specialists; ear, nose and throat specialists; gynecologists; dermatologists; ophthalmologists; ophthalmic surgeons; radiologists; amputee clinic physician; spinal clinic physician Physiotherapists/Physical therapists Massage therapists Podiatrists Optometrists Pharmacists Dentists Interpreters
o the relationship between abnormal biomechanics and the development o the injury, in clinical biomechanical assessment and in possible correction o any biomechanical cause. However, it is essential that other practitioners, such as a sports physician, orthopedic surgeon, physiotherapist/physical therapist and sports/athletic trainer, all have a basic understanding o lower limb biomechanics and are able to perorm a clinical assessment. Similarly, in the athlete who presents complaining o excessive atigue and poor perormance, the dietitian is best able to assess the nutritional state o the athlete and determine i a nutritional de�ciency is responsible or the patient’s symptoms. However, other practitioners such as a sports physician, physiotherapist/physical therapist or trainer must also be aware o the possibility o nutritional de�ciency as a cause o tiredness and be able to perorm a brie nutritional assessment.
The sports medicine model Te traditional medical model (Fig. 1.1) has the physician as the primary contact practitioner with subsequent reerral to other medical and paramedical practitioners. Te sports medicine model (Fig. 1.2) is different. Te athlete’s primary medical contact may be with a physician, however, it is just as likely to be a trainer, physiotherapist/physical therapist or massage 4
Patient
Physician
Physiotherapist/ Physical therapist
Others
Podiatrist
Massage therapist
Dietitian
Figure 1.1 The traditional medical model
therapist. Athletes usually present to the practitioner with whom they have the best relationship or are most accustomed to seeing. Tereore, it is essential that all practitioners in the sports medicine team understand their own strengths and limitations and are aware o which other practitioners can offer the required skills or the best management o the patient. I a patient is not responding to a particular treatment regimen, it is necessary to reassess the situation, reconsider the diagnosis and consider alternative methods o treatment. Tis may require reerral to another member o the sports medicine team.
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, McGRAW-HILL PROFESSIONAL
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CHAPTER 1 SPORTS MEDICINE: THE TEAM APPROACH
Trainer Physician
Dietitian
Physiotherapist/Physical therapist
Massage therapist
Athlete—Coach
Psychologist
Podiatrist Others
Figure 1.2 The sports medicine model. In professional sport the player’s agent also features prominently in athlete–coach interaction
The challenges of management Te secret o success in sports medicine is to take a broad view o the patient and his or her problem. Te narrow view may provide short-term amelioration o symptoms but will ultimately lead to ailure. Examples o the narrow view may include a runner who presents with shin pain, is diagnosed as having a stress racture o the tibia and is treated with rest until ree o pain; a baseball pitcher who presents with shoulder pain, is diagnosed as having rotator cuff tendinitis and is treated with anti-in�ammatory medication and rest rom aggravating activities; or a triathlete who presents with excessive atigue and poor perormance and is treated with rest. In all these examples, it is likely that in the short term each o these athletes will improve and return to activity. However, in each case there is a high likelihood o recurrence o the problem on resumption o activity. It is not adequate simply to diagnose the athlete’s presenting problem and treat accordingly. Te clinician must always ask ‘Why has this injury/illness occurred?’. Te cause may be obvious, or example, recent sudden doubling o training load, or it may be subtle and, in many cases, multiactorial. Te greatest challenge o sports medicine is to identiy and correct the cause o the injury/illness. In the cases mentioned above, the runner with shin pain arising rom a stress racture will continue to have problems unless the cause is corrected. Te cause may be one or more actors, such as abnormal biomechanics, inappropriate ootwear, change o
training surace or change in quantity or quality o training. Te baseball pitcher may have shoulder tendinopathy because o poor throwing technique, excessive pitching or the presence o mild instability o the shoulder joint. Te triathlete may have atigue and impaired perormance because o overtraining and/or inadequate recovery, poor nutrition, accompanying viral illness or a medical condition such as exercise-induced asthma. In each o these cases, it is essential to take a broad rather than narrow view o the problem. In medicine, there are two main challenges—diagnosis and treatment. As mentioned, in sports medicine, it is necessary to diagnose both the problem and the cause. reatment then needs to be ocused on both these areas. Diagnosis Every attempt should be made to diagnose the precise anatomical and pathological cause o the presenting problem. With adequate knowledge o anatomy (especially surace anatomy) and an understanding o the pathological processes likely to occur in athletes, a precise diagnosis can usually be made. Tus, instead o using a purely descriptive term such as ‘shin splints’, the practitioner should attempt to diagnose which o the three underlying causes it could be—stress racture, chronic compartment syndrome or periostitis—and use the speci�c term. Accurate diagnosis permits precise treatment. Tere are, however, some clinical situations in which a precise anatomical and pathological diagnosis is not possible. For example, in many cases o low
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, McGRAW-HILL PROFESSIONAL
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PART A FUNDAMENTAL PRINCIPLES
back pain, it is clinically impossible to differentiate between potential sites o pathology. In situations such as these, it is necessary to monitor symptoms and signs through careul clinical assessment and correct any abnormalities present (e.g. hypomobility o an intervertebral segment) using appropriate treatment techniques. As mentioned, sports medicine ofen requires not only the diagnosis o the presenting problem but also the diagnosis o the cause o the problem. Te US orthopedic surgeon, Ben Kibler, has coined the term ‘victim’ or the presenting problem and ‘culprit’ or the cause.5 Diagnosis o the presenting problem requires a good knowledge o anatomy and possible pathology, while diagnosis o the cause ofen requires a good understanding o biomechanics, technique, training, nutrition and psychology. Just as there may be more than one pathological process contributing to the patient’s symptoms, there may also be a combination o actors causing the problem. As with any branch o medicine, diagnosis depends on careul clinical assessment, which consists o obtaining a history, physical examination and investigations. Te most important o these is undoubtedly the history but, unortunately, this is ofen neglected. It is essential that the sports clinician be a good listener and develop skills that enable him or her to elicit the appropriate inormation rom the athlete. Once the history has been taken, an examination can be perormed. It is essential to develop examination routines or each joint or region and to include in the examination an assessment o any potential causes. Investigations should be regarded as an adjunct to, rather than a substitute or, adequate history and examination.6 Te investigation must be appropriate to the athlete’s problem, provide additional inormation and should only be perormed i it will affect the diagnosis and/or treatment.
Treatment Ideally, treatment has two components—treatment o the presenting injury/illness and treatment to correct the cause. It is important to understand that no single orm o treatment will correct all or even the majority o sports medicine problems. A combination o different orms o treatment will usually give the best results. Tereore, it is important or the clinician to be aware o the variety o treatments and to appreciate when their use may be appropriate. It is also important to develop as many treatment skills as 6
possible or, alternatively, ensure access to others with particular skills. It is essential to evaluate the effectiveness o treatment constantly. I a particular treatment is not proving to be effective, it is important �rstly to reconsider the diagnosis. I the diagnosis appears to be correct, other treatments should be considered (Chapter 36). Meeting individual needs Every patient is a unique individual with speci�c needs. Without an understanding o this, it is not possible to manage the athlete appropriately. Te patient may be an Olympic athlete whose selection depends on a peak perormance at orthcoming trials. Te patient may be a non-competitive business executive whose jogging is an important means o coping with everyday lie. Te patient may be a club tennis player whose weekly competitive game is as important as a Wimbledon �nal is to a proessional. Alternatively, the patient may be someone to whom sport is not at all important but whose low back pain causes discomort at work. Te cost o treatment should also be considered. Does the athlete merely require a diagnosis and reassurance that he or she has no major injury? Or does the athlete want twice-daily treatment in order to be able to play in an important game. Obviously, the latter approach is more costly but may be what the patient wants. reatment depends on the patient’s situation, not purely on the diagnosis.
The coach, the athlete and the clinician Te relationship between the coach, the athlete and the clinician is shown in Figure 1.3. Te clinician obviously needs to develop a good relationship with the athlete. A eeling o mutual trust and con�dence would lead to the athlete eeling that he or she can con�de in the clinician and the clinician eeling that the athlete will comply with advice. As the coach is directly responsible or the athlete’s training and perormance, it is essential to involve
Athlete + Agent
Coach
Clinician
Figure 1.3 The coach, the athlete and the clinician
BRUKNER AND KHAN, CLINICAL SPORTS MEDICINE 3E, McGRAW-HILL PROFESSIONAL
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CHAPTER 1 SPORTS MEDICINE: THE TEAM APPROACH
the coach in medical decision making. Unortunately, some coaches have a distrust o clinicians, eeling, rightly or wrongly, that the main role o the practitioner is to prevent the athlete rom training or competing. It is essential or the coach to understand that the practitioner is also aiming to maximize the perormance and health o the athlete. When major injuries occur, proessional athletes’ agents will be involved in discussions. Involving the coach in the decision-making process and explaining the rationale behind any recommendations will increase athlete compliance. Te coach will also be a valuable aid in supervising the recommended treatment or rehabilitation program. Discussion with the coach may help to establish a possible cause or the injury as a result o aulty technique or equipment. A good practitioner–coach relationship is a win–win situation. Te coach will develop a better understanding o what the clinician has to offer and is more likely to seek help or minor problems which, i managed appropriately, may prevent subsequent major problems. Te clinician will bene�t rom an increased understanding o the demands o the sport and may have an opportunity to institute various preventive measures.
‘Love thy sport’ o be a successul sports clinician it is essential to know and love sport and to be an advocate or physical activity. Te sports clinician needs to understand the importance o sport to the athlete and the demands o the sport. Tese demands may be physical, such as training and technique, or psychological. As well as understanding the general philosophy o sport and the athlete, it is important to have a thorough understanding o particular sports.
A good understanding o a sport and exercise coners two advantages. Firstly, i the clinician understands the physical demands and technical aspects o a particular sport, then this will improve his or her understanding o possible causes o injury and also acilitate development o sport-speci�c rehabilitation programs. Secondly, it will result in the athlete having increased con�dence in the clinician. Te best way to understand the sport is to attend both training and competition or to actually participate in the sport. Tus, it is essential to be on site, not only to be available when injuries occur, but also to develop a thorough understanding o the sport.
References 1. Matheson GO, Pipe AL. wenty-�ve years o sport medicine in Canada: thoughts on the road ahead. Clin J Sport Med 1996; 6: 148–51. 2. Blair SN, Franklin BA, Jakicic JM, Kibler WB. New vision or health promotion within sports medicine. Am J Health Promot 2003; 18(2): 182–5. 3. Chakravarthy MV, Booth FW. Eating, exercise, and ‘thrify’ genotypes: connecting the dots toward an evolutionary understanding o modern chronic diseases. J Appl Physiol 2004; 96(1): 3–10. 4. Hahn A. Sports medicine, sports science: the multidisciplinary road to sports success. J Sci Med Sport 2004; 7: 275–7. 5. Kibler WB, Sciascia A. Kinetic chain contributions to elbow unction and dysunction in sports. Clin Sports Med 2004; 23(4): 545–52. 6. Khan KM, ress BW, Hare WSC, et al. ‘reat the patient, not the X-ray’: advances in diagnostic imaging do not replace the need or clinical interpretation. Clin J Sport Med 1998; 8: 1–4.
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