The professional practice of sports medicine has increased dramatically since the early 1980s, mostly in response to the demand for high quality healthcare for ath- letes. The number of sport-related injuries has increased, and many factors have contributed to this increase (41). Figures 5.1 and 5.2 provide the prevalence rates for injuries in high school and intercollegiate sports. Table 5.7 provides some sug- gested reasons for the increased number of sport-related injuries. Sports medicine physicians contribute to total athlete care by being an integral component of the primary athletic medicine team and working with other healthcare providers from orthopedics, physical medicine and rehabilitation, athletic training, biomechanics, cardiology, nutrition, optometry, pharmacology, physical therapy, exercise physi- ology, psychology, and podiatry (41).
Guidelines for Sports Medicine Physicians
Often the sports medicine physician serves as the leader of the primary athletic medicine team through his or her role as the team physician. The importance of this role has resulted in several organizations working together to provide several Team Physician Consensus Statements. These statements are used to guide the activities and responsibilities of the team physician (22–29). A list of the current Team Physician Consensus Statements written in collaboration through numer- ous professional organizations is provided in Table 5.8.
The fi rst Team Physician Consensus Statement published in 2000 provides physicians, school administrators, team owners, the general public, and indi- viduals who are responsible for making decisions regarding the medical care of
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Thinking CriticallyWhat personal qualities and profes- sional characteristics do you believe are important for athletic trainers to possess to fulfill their primary responsibilities?
FIGURE 5.8 ▼ A team physician interviewing an athlete about an injury.
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athletes and teams with guidelines for choosing a qualifi ed team physician and an outline of the duties expected of a team physician (26). This consensus state- ment provides clear and concise information about the defi nition, qualifi cations, and duties of a team physician. Each of the subsequent consensus statements has identifi ed important topics relevant to providing the best medical care for athletes at all levels of participation. Table 5.9 provides a summary of the responsibilities of the sports medicine team physician.
Advances in the Treatment of Sport-related Injuries
The primary responsibility of sports medicine professionals is to provide the best care possible to physically active individuals and athletes. There are several
Table 5.8 Team Physician Consensus Statements
TOPIC YEAR PUBLISHED
Team Physician Consensus Statement 2000
Sideline Preparedness for the Team Physician: A Consensus Statement 2001 The Team Physician and Conditioning of Athletes for Sports: A Consensus
Statement
2001
The Team Physician and Return-To-Play Issues: A Consensus Statement 2002 Female Athlete Issues for the Team Physician: A Consensus Statement 2003 Mass Participation Event Management for the Team Physician: A Consensus
Statement
2004
Psychological Issues Related to Injury in Athletes and the Team Physician:
A Consensus Statement
2006
Concussion (Mild Traumatic Brain Injury) and the Team Physician:
A Consensus Statement
2006
Table 5.7 Reasons for Increased Sports-related Injuries (41)
Increased participation in sports
Increased numbers of previously sedentary individuals becoming active Increased variety of sports available
Increased opportunities for participation Increased sophistication of participants in sports
Increased participation intensity which often leads to increased risk of injury Athlete specialization at a young age leading to overuse injury
Poor coaching and training methods leading to increased sport injuries
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advances in the medical treatment of orthopedic injuries that have accomplished that aim. In most cases, these advancements have resulted in the development of minimally invasive procedures and a shorter recovery time for the athlete. In some instances, the careers of athletes have been saved or extended as a result of these advancements. Examples of these procedures include arthroscopy, ACL reconstruction, ulnar collateral ligament reconstruction, and chondrocyte implan- tation. Each is discussed in the following sections. The examples provided are not meant to be an inclusive list of signifi cant developments in athlete care, but a sampling of advancements made over the years.
Arthroscopy
Arthroscopy or arthroscopic surgery is a minimally invasive procedure used to examine and treat damage to the interior of a joint. The procedure is performed by a sports medicine physician using an arthroscope and is shown in Figure 5.9.
Arthroscopic surgery is used to evaluate and treat many orthopedic conditions such as torn fl oating cartilage, torn surface cartilage, and the ACL of the knee
Table 5.9 Responsibilities of the Team Physician (26,51)
RESPONSIBILITY PHYSICIAN ACTIONS
Work with the athletic trainer Supervise and advise athletic training staff; share philosophy regarding injury management and rehabilitation
Work with other sports medicine personnel
Provide the best possible care using the expertise of the primary sports medicine team
Compiling medical history Oversee medical history; conduct physical examinations for each athlete
Diagnosing injury Assume responsibility for diagnosing an injury; make recommendations for treatment to the athletic trainer and other sports medicine personnel
Deciding on disqualification and return to play
Determine when an athlete should be disqualified from competition and when that injured athlete may return to play Attending practice and
games
Attend as many practices, scrimmages, and competitions as possible; be available to other sports medicine personnel for consultation or advice
Commitment to sports and athletes
Demonstrate a strong affection and dedication to the athlete and sports
Academic Program Medical Director
Be responsible for the coordination and guidance of the medical aspects of an accredited athletic training education program
Arthroscopy A minimally invasive surgical procedure used to repair damaged tissue.
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joint. Arthroscopic surgery does not require the treated joint to be surgically opened. Only two small incisions are made, one for the arthroscope and one for the surgical instruments. The physician views the joint area on a video monitor and can diagnose and repair torn joint tissue including ligaments and cartilage.
The postoperative recovery time is reduced and the surgery success rate is usually increased because there is reduced trauma to the connective tissue of the joint.
This procedure is especially useful for athletes who require a rapid recovery time following surgery. Arthroscopic surgery is commonly used for joints of the knee, shoulder, elbow, wrist, ankle, and hip (10).
Anterior Cruciate Ligament Reconstruction
Anterior cruciate ligament reconstruction (ACL reconstruction) is a surgical procedure that uses a graft replacement of a torn ACL in the knee (Figure 5.10).
A torn ACL dramatically decreases the stability and functional ability of the knee
Arthroscope
Cannula for fluid
Meniscus cutter
Medial condyle of femur
Medial tibial plateau
Meniscus cutter
Medial meniscus tear Arthroscopy
The arthroscope, attached to a video camera, is inserted into the fluid-filled knee. Next, the surgeon inserts small instruments through a second incision. Guided by the image on the TV monitor, the surgeon explores the menisci, and, if needed, removes or trims damaged tissue.
FIGURE 5.9 ▼ Arthroscopic surgery of the knee joint. (Asset provided by Anatomical Chart Co.)
Anterior cruciate ligament reconstruction A surgical procedure that uses a graft to replace a torn anterior cruciate ligament in the knee
Ulnar collateral ligament reconstruction A surgical procedure in which a ligament in the medial elbow is replaced with a tendon from elsewhere in the body.
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joint and is usually treated medically. Torn ligaments do not heal, so surgery is often required to medically treat the injury. An ACL reconstruction requires a tissue graft from another part of the body. The torn ligament is removed from the knee before the graft is inserted, and attachment is made to the tibia and the femur. The types of surgery differ mainly in the type of graft that is used. Part or all of the ACL reconstruction is performed using arthroscopic surgery (10).
Ulnar Collateral Ligament Reconstruction
Ulnar collateral ligament reconstruction is a surgical procedure in which a ligament in the medial elbow is replaced with a tendon from elsewhere in the body, usually from the forearm, hamstring, knee, or foot. Damage to the ulnar collateral ligament usually occurs in response to the stress of the throw- ing motion. In the procedure, the replacement tendon is woven in a fi gure- eight pattern through tunnels that have been drilled in the ulna and humerus bones that are part of the elbow joint. Ulnar collateral ligament reconstruction is also known as Tommy John surgery. John was a pitcher for the Los Angeles Dodgers who was the fi rst professional athlete to undergo the surgery, which was performed by Dr Jobe. Following surgery, an extensive rehabilitation pro- cess is undertaken by the athlete. ROM and resistance training exercises are performed for about 6 months. Thereafter, the athlete can begin a throwing program.
Patellar surface of femur
Posterior cruciate ligament Medial meniscus
Tibial collateral ligament Tibial tuberosity Tibia
Femur
Anterior cruciate ligament
Lateral meniscus Fibular collateral ligament Fibula
Normal knee anatomy (Patella removed)
Anterior cruciate ligament tear
FIGURE 5.10 ▼ Anterior cruciate ligament tear. (Asset provided by Anatomical Chart Co.)
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Autologous Chondrocyte Implantation
Articular cartilage covers the ends of the long bones of the body, is essentially frictionless, and provides a smooth surface for the contact and movement of bones. Articular cartilage is formed by cells called chondrocytes. Autologous chondrocyte implantation (ACI) is used to repair defects in the articular car- tilage, usually in the knee. Patients eligible for treatment with ACI usually have joint pain, swelling, catching, or grinding. ACI is generally applied to patients between the ages of 15 and 55 years, with little or no additional damage to the knee joint. These are patients who do not have enough knee damage to need a total knee replacement, but who are experiencing considerable pain that may be impairing their sport performance or quality of life. Clinically appropriate patients are identifi ed through traditional diagnostic methods, such as magnetic resonance imaging, X-ray evaluation, and an arthroscopic examination (8).
Once a patient is determined to be eligible for ACI, a biopsy sample of between 200 and 300 mg of the patient’s articular cartilage is collected. The tissue sample is then sent to a laboratory, where the chondrocytes are separated from their surrounding cartilage and cultured for 4 to 5 weeks, generating between 5 and 10 million cells. The implantation of the cells is a surgical procedure in which the patient’s joint is exposed by the orthope- dic surgeon. The defect area is prepared by removing dead cartilage and smoothing the surrounding liv- ing cartilage. A piece of periosteum, the membrane that covers bone, is taken from the patient’s tibia and attached over the prepared area. The cultured cells are injected by the surgeon under the periosteum, where they will grow and mature over time. In about 10 and 12 weeks, the patient can put full weight on the knee but complete recov- ery may take up to 1 year (8).