Keywords

Sports medicine is a dynamic and far-reaching field that continues to broaden. It incorporates many specialties and encompasses diverse medical topics. Sports medicine physicians provide comprehensive care of a diverse population, including high-level athletes, weekend warriors, and the less active population with musculoskeletal complaints that impede activities of daily living. Based on the care setting, the responsibilities of a sports medicine physician may include prevention, diagnosis, treatment, and rehabilitation of musculoskeletal pathologies and medical illnesses that would otherwise interfere with participation in physical activity. A multidisciplinary team is ideal to thoroughly address this broad spectrum of pathologies and duties. The sports medicine physician is responsible for the coordination of the multidisciplinary team and, in many cases, will be the primary provider for the athlete and will direct return to play.

Traditionally, the field of sports medicine has been regarded as largely musculoskeletal medicine. However, in practice, sports medicine involves any condition that limits an athlete’s participation and possibly with activities of daily living. While the presenting athlete may complain of pain, the true deficiency is how the pain or dysfunction affects athletic performance.

The two main settings of sports medicine are the outpatient clinic and sideline coverage with complementary training room clinic. While the main goal of improving upon the limiting deficit to allow for return to the desired activity remains the same, there are a multitude of differences regarding the approach to diagnosis, treatment, rehabilitation, and even the healthcare providers involved in the overall care.

In the outpatient clinical setting, patient care typically begins by addressing a patient’s complaint of musculoskeletal injury. Workup, diagnosis, and treatment of the underlying etiology subsequently follow. In addition to the sports medicine physician, the outpatient healthcare team commonly includes a nurse and/or medical assistant, physical therapist, occupational therapist, orthopedic surgeon, and other professionals including an athletic trainer, a strength and conditioning specialist, an orthotist, and a chiropractor.

The populations treated in the clinical outpatient setting can be rather diverse: from children to the elderly, the infrequent jogger to the professional athlete, and sedentary patients looking to become more active. Further, adaptive sports are becoming more available nationally and internationally as inclusion and accessibility allow for individuals with disabilities to stay active and compete in organized events. The care of the different patient populations requires a variable approach depending on demographic and activity levels.

In contrast, as an athletic team physician, the patient age range tends to be more homogenous. The sports medicine healthcare team is multidisciplinary and consists of a wide array of healthcare specialists who are in frequent and close communication with one another. The main point of contact for both the athlete and the team physician is the team’s certified athletic trainer (ATC). The ATC works with the team nearly every day throughout the season. Thus, the ATC is extraordinarily familiar with each athlete, not only regarding health, biomechanics, and performance, but also personality and responsiveness to treatment. This access allows for close contact with the athlete and the ATC can help identify any potential issues even before they arise. The physician-trainer relationship is key to providing optimal care for the team.

During sideline coverage, the ATC is generally the first health care professional to evaluate an athlete who requires medical attention and will determine whether the athlete needs assessment by the covering physician. Most sideline evaluations involve a traumatic injury, including lacerations, dislocations, fractures, sprains, strains, contusions, or concussions. However, acute medical conditions can be seen as well, such as asthma exacerbations, ocular foreign bodies, dehydration, hypoglycemia, and heat illness. More serious situations, such as cervical trauma or cardiac emergencies, will require adhering to an emergency action plan (EAP). The sports medicine physician will make the decision whether an athlete can safely return to play for the event, sit out, or even be sent to the emergency room should further resources be needed.

To address the widened scope and myriad of issues that can affect athletes’ participation and performance, a diverse multidisciplinary team is needed. The members of this multidisciplinary team typically include, but are not limited to:

  • Sports medicine physician

  • Certified athletic trainer

  • Physical therapist, occupational therapist

  • Orthopedic surgery specialist

  • Medical specialist, including cardiology, pulmonology, endocrinology

  • Registered dietician

  • Other professionals including chiropractor and prosthetist/orthotist

  • Coach

  • Sports psychologist

  • Exercise physiologist

  • Strength and performance coach

  • Agent (for professional athletes)

  • Athlete’s family (depending on age and capacity)

Figure 1.1 demonstrates the typical interaction among members of the team. At the collegiate level, the sports medicine healthcare team will also work closely with academic advisors, counselors, and even professors to ensure the athlete is able to prioritize academics.

Fig. 1.1
figure 1

Typical interaction dynamic in the multidisciplinary healthcare team. Blue circles and arrows denote healthcare team and flow of health information, gray circle and arrows solely involve play status

Full size image

Musculoskeletal injuries are the most prevalent complaint encountered by the sports medicine physician. Familiarity with the sports as well as the other activities in which the athlete participates can yield many advantages: understanding typical biomechanical loads and requirements, familiarity with common injurious positions and situations the athlete may encounter, developing rapport and trust with the athlete, and having a better understanding of limitations for training as well as an accurate prognosis for return to play.

Musculoskeletal injuries can be separated by chronicity: acute and chronic. Acute injuries are typically related to a single traumatic event, whereas chronic injuries are related to overuse and repeated improper or excessive loads over time. The structural components that are commonly injured are evaluated by a sports medicine physician during a full orthopedic and biomechanical functional exam. Not only are the areas of pain fully assessed, but the kinetic chain is explored to determine if the pain is caused by dysfunction in another part of the body – a concept often referred to as “victim and culprit”, in which the painful body part is the “victim” and the dysfunctional body part is the “culprit”.

Treatment of an elite athlete differs from that of the average active person. Time missed from training due to workup or rehabilitation can be detrimental to performance and even the athlete’s career. Therefore, a lower threshold is often used for tests that will aid in diagnosis, prognosis, and return to play. Imaging, especially magnetic resonance imaging (MRI) and ultrasound, is used regularly to assess for structural damage. Not only can this information guide the diagnosis and prognosis, but it can also assist orthopedic surgeons in surgical planning, if needed. Knowing the indications for surgical referral, particularly with in-season athletes, is vital to optimal care of an athlete.

Recommendations made by the treating physician direct return to play/return to sport for the athlete. Return to play guidelines and consensus statements are rarely concrete due to the many factors that need to be considered. However, knowledge of the variables that contribute to return to play parameters as well as general experience with the rehabilitation process can assist sports medicine physicians in appropriately estimating the time needed for an athlete to return to sport.

Medical conditions may also threaten the overall health of the athlete and, at times, can be even more detrimental to athletic performance than musculoskeletal complaints. Infectious pathologies can be easily spread among athletes based on their proximity to other athletes with traveling, competition, and living quarters in athletes and military personnel. Overtraining can also put the athlete at greater risk for frequent infections. Common infections include viral illnesses, such as upper respiratory infection, influenza, mononucleosis, gastroenteritis, and conjunctivitis. Further, dermatologic infections and disease are relatively frequent, especially in athletes engaged in contact sports such as wrestling. The myriad of non-life-threatening illnesses can limit an athlete’s participation in training and competition, and the sports medicine physician will determine activity restriction and full return to play planning.

Other more serious medical conditions can be found in the athletic population. Sudden cardiac death (SCD) in athletes is a rare but devastating event. This is understandably a priority of physicians to prevent; therefore, any complaints related to cardiopulmonary etiology that may increase the risk of SCD are thoroughly evaluated in the pre-participation exam.

Additional cardiopulmonary disorders of note include asthma and exercised-induced bronchospasm. Respiratory conditions are particularly common in sports such as indoor swimming, in which athletes have frequent exposure to inhaled chemicals [1]. Monitoring the air quality can be an overlooked but important task to ensure both optimal performance and prevention of respiratory emergencies in athletes with these conditions.

During sporting events, the sports medicine physician must be prepared to coordinate the emergency action plan (EAP) should the need arise. As such, the covering physician will need to know the location of the designated ambulance access as well as equipment such as an automated external defibrillator (AED), bag-valve mask, spine board, and bleeding control materials including a tourniquet. Communication with local emergency medical services is paramount in the EAP. A medical bag with supplies for laceration repair, splinting, intravenous access, and medications including an epinephrine injector can be helpful during sideline coverage.

Fatigue, particularly in elite athletes, can be a frequent complaint with a wide differential of potential etiologies. It can be seen as a symptom of female athlete triad, which is a syndrome that exists on a spectrum and involves low energy availability, menstrual function, and bone health [2]. Male athletes can experience a similar spectrum of disease that likewise involves nutrition, hormonal balance, and bone health [3]. Overtraining syndrome is typically a diagnosis of exclusion; it can interfere greatly with performance but, often overlooked, it can also manifest with mood dysfunction. Recovery from overtraining syndrome can unfortunately be prolonged, requiring months or longer [4]; thus, prevention is key.

One of the more disruptive injuries an athlete can sustain is a concussion and the related sequelae. Proper identification of a concussion is vital to prevent second impact syndrome. Concussion testing tools are used to augment the neuromuscular physical exam done by the sports medicine physician. Many concussion testing tools are available, such as the fifth edition of the Sport Concussion Assessment Tool (SCAT5), King-Devick test, ImPACT assessment, Vestibular/Ocular-Motor Screening (VOMS), and the Eye-Sync eye tracking headset. The multidisciplinary health care team coordinates the athlete’s return to play using a progression protocol.

Elite sports can take a toll on not only the body, but the mind as well. Sports psychologists are an integral part of the multidisciplinary team. Literature supports that athletes are at risk for developing pathological psychological responses to injuries, which can interfere with the recovery process [5]. Further, the recommendations of sports psychologists can be helpful with management of concussive symptoms as well as school or work accommodations [6]. Sports psychologists also work with athletes who have been diagnosed with mental health disorders, providing valuable insight and advice for care.

Adaptive sports are an exciting and evolving focus in sports medicine. Special considerations should be made for medical conditions that are specific to the adaptive athlete. In wheelchair athletes, rotator cuff injuries can be seen in up to 75.7% involved in overhead sports [7]. Additionally, wheelchair athletes with spinal cord injury are at risk for autonomic dysreflexia, hyperthermia, urinary tract complications, and pressure injuries [8].

While the setting of a sports medicine physician generally includes musculoskeletal injuries, there are some diseases that mimic musculoskeletal etiology but in fact are due to another root cause. Therefore, knowledge of rheumatologic, disorders, vascular disorders, regional pain syndromes, and even bone and soft tissue tumors is essential to patient care.

The pre-participation exam (PPE) is yet another unique feature of sports medicine. Numerous medical conditions, prior injuries and musculoskeletal conditions, and even suboptimal biomechanics can put an athlete at risk of significant injury. PPEs can be administered in a one-on-one clinic appointment or in a mass athlete physical setting. Depending on the level of participation, an athlete will typically undergo a PPE annually or upon entry into a new level of participation (such as for high school and college). While PPEs are not standardized, they generally include a comprehensive medical history including screening for cardiopulmonary health and female athlete triad, family health history, prior musculoskeletal injuries, and medication/supplement use. A thorough physical examination, including core stability and kinetic chain testing is recommended in order to fully evaluate the athlete for risks of high intensity athletic participation. Depending on the institution, an electrocardiogram may also be administered in all or select “at-risk” athletes. At the high school and collegiate levels, baseline concussion assessments are completed during PPEs so that diagnosis and even prognosis of a concussion can be accurate in the case of head trauma during the season.

The multidisciplinary sports medicine healthcare team is well-suited to provide the foundation for not only injury prevention and treatment of injuries, but also sports performance optimization. Physicians provide functional assessment and preventative screening through the PPE. Multiple members of the healthcare team may counsel on the importance of sleep hygiene, appropriate hydration, and nutrition habits as well as stress management techniques. Sports psychologists may work with athletes to improve their performance from a mental standpoint. Psychological skills training [9] and mindfulness practice [10] have been shown to improve sports performance. Human performance labs may offer a variety of methods for evaluation including dynamic biomechanical evaluations, maximal oxygen uptake testing, lactate threshold testing, and body composition analyses. Performance testing can be utilized for injury prevention or sports optimization purposes.

When it comes to human performance, doping is an unfortunate reality in sports competition. Most elite level sports have anti-doping procedures for testing athletes to discourage the use of substances deemed to be “illegal” in competition by the responsible sport governing body. Anti-doping agencies whose rules and regulations may apply to athletes competing in the United States include the drug-testing program of the National Collegiate Athletic Association (NCAA), U.S. Anti-Doping Agency (USADA), and the World Anti-Doping Agency (WADA). These agencies work to facilitate fair and safe competition. Doping may include use of banned substances, manipulation of blood products, use of intravenous infusions, tampering with a sample collected for doping control, and gene and cell doping. Depending on the governing body, there may also be whereabouts requirements such that an athlete could be randomly tested at any time even outside of competition.

Sports medicine teams should be vigilant when it comes to any substances that an athlete may put into their body both to ensure the safety of the athlete and to avoid disqualifying drug tests. Sport substance rules should be taken into consideration when reviewing an athlete’s medications, counseling on illicit substance use, and providing in-season pharmacological treatment recommendations. Athletes must be advised that even over-the-counter vitamins may contain substances which could result in a positive drug test. When medications are required for the treatment of an athlete, they should be chosen carefully and banned substances reported immediately to the appropriate testing board(s) with adequate documentation that includes clear therapeutic justification (such as a Therapeutic Use Exemption). Failure to be mindful of and adhere to these rules may potentially lead to a devastating disqualification from sport.

As previously mentioned, sports medicine is growing and becoming more diverse. There are multiple training routes once can pursue in order to practice in sports medicine. For primary care sports medicine, this training includes a residency in family medicine, internal medicine, pediatrics, emergency medicine, or physical medicine and rehabilitation (PM&R). For the surgical counterpart, training includes a residency in orthopedic surgery. Some physicians develop competence to practice sports medicine by augmenting their training without a formal sports medicine fellowship, but for those looking to work with higher level teams or pursue a career in academia, the trend is to complete an ACGME-accredited sports medicine fellowship.

Physicians can apply for primary care sports medicine fellowships in a variety of specialties: as of 2020, there are 158 family medicine department-based programs, 23 PM&R, 18 pediatric, and 9 emergency medicine participating in the NRMP matchFootnote 1. As one might imagine, the specialty in which the fellowship is based will guide the experience and training background of that fellowship.

There are specific requirements a fellowship program must fulfill in order to be ACGME-accredited. These requirements relate to patient care, clinical experience, procedural exposure, sporting event coverage, and scholarly activities. Further, in order to obtain post-fellowship CAQ (certificate of added qualifications), one must successfully complete the one-year ACGME sports medicine fellowship and pass the written sports medicine board examination. There is also maintenance of certification (MOC) that must be completed every 10 years in addition to continuing medical education (CME) credits to maintain the CAQ.

Sports medicine organizations provide opportunities for CME, research and networking, and represent the field as advocates in government. The American Medical Society for Sports Medicine (AMSSM) is the largest American organization for sports medicine physicians. The members are described as “physicians for active people and athletes,” and the organization partnered with NATA and AAOS to work on passage of the Sports Medicine Licensure Clarity Act that was signed into law October 5th, 2018 [11]. This law ultimately makes participation safer for athletes by allowing physicians to travel with athletes and provide medical care, even if the travel brings them to states outside of their licensure. The American College of Sports Medicine (ACSM) is an international, multidisciplinary organization with greater than 50,000 members and represents 70 occupations within the sports medicine field. In 2007, the ACSM partnered with the American Medical Association to co-launch the Exercise is Medicine (EIM) initiative in order to promote the ACSM’s physical activity guidelines [12].

A mounting body of evidence supports exercise improving health metrics, reducing risk and/or morbidity of numerous diseases, and reducing overall mortality and morbidity. Some even regard physical activity level as a vital sign that is obtained during a clinical visit [13]. Therefore, utilizing exercise and physical activity as medicine and a path to overall well-being is becoming more commonplace. Sports medicine physicians are viewed as the leaders to bring exercise as medicine to patients. Exercise prescription can lend itself toward engaging to introduce exercise into their schedule as a regular activity, thus promoting adoption and improving the probability of adding its health benefits.

One of the most prominent changes in sports medicine practice involves the use of bedside or portable ultrasonography. Ultrasound can evaluate tissues including bones, muscles, tendons, ligaments, nerves, and vessels. Compared to MRI, it is less expensive, can show finer superficial detail, and is useful as a point of care diagnostic evaluation [14]. Ultrasound can be used non-invasively for sono palpation and both static and dynamic diagnostic exams. In addition to being used for diagnostic purposes, ultrasound can also be used to facilitate minimally invasive procedures from simple injections to more advanced procedures. These second- (tenotomies, peripheral nerve hydrodissections, calcific tendinitis barbotage) and third-generation (A1 pulley releases, muscle compartment fasciotomies) advanced procedures [15] offer diagnostic and therapeutic benefits via minimally invasive techniques. The utilization of outpatient diagnostic musculoskeletal ultrasounds has been increasing tremendously [16], and there is evidence that ultrasound-guided injections provide greater accuracy than landmark-guided or fluoroscopic injections for a number of different procedures [15].

Regenerative medicine is a developing area in sports medicine. Injected biologics have been used since the 1950s [17]. Biologics used today include steroids, prolotherapy, platelet rich plasma (PRP), and mesenchymal stromal cells. Unfortunately, there is a lack of standardization of protocols for indication, injectate preparation, and injection technique. Even nomenclature can be controversial [18]. Though evidence in the literature remains mixed with regard to efficacy, this is a significant focus in current research and is an area expected to continue expansion.

Sports medicine healthcare teams constantly seek to improve methods for injury prevention, improved sports performance, and more effective treatment options for injuries. Accordingly, sports medicine physicians are always looking toward the future and anticipating the next advancement in the field of sports medicine.