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AAOS Now

Published 9/1/2011
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Nancy M. Cummings, MD; Matthew J. Matava, MD

Ethical issues and sports medicine

Does the Hippocratic maxim apply to the modern-day athlete?

“Do no harm” seems pretty simple. Yet, it is important to define “harm”: Is it purely physical or could it be psychological or financial?

In today’s sports medicine arena, this definition is not so clear. The traditional physician-patient relationship now has become, at the least, a triad—doctor-patient-team relationship. In some cases, the financial “health” of the patient threatens to cloud the picture.

The priority in treating a child’s sports injury is pretty clear when the child’s physical health is the first priority of all interested parties. But what about the scholarship-level high-school athlete whose ticket out of an impoverished background or means to a college education is his or her athletic ability? What about the professional basketball player in game 7 of the final round of the playoffs? Does the Hippocratic rule—the basic tenet of all of medicine—change? When does the black and white of clinical sports medicine turn a shade of gray?

Sideline and locker room injections are routinely performed in the elite college and professional arenas to facilitate participation of the individual athlete. Where and how the line is drawn will be the ethical footprint for future sports medicine professionals. Should the relationship between the physician and the injured athlete become a team sport with multiple participants?

The Olympic hopeful
A conflict can exist in the treatment of the skeletally immature athlete who has an injury and whose parents have professional or Olympic aspirations for that child. In this case, the long-term physical health of the child overrides the parents’ dreams. Treating patients who are not yet legally adults, but are old enough to reason, involves obtaining consent from the parents for any treatment rendered, and assent from the minor patient.

Older children should be seen as rational, autonomous decision makers. Review of the limited relevant empirical data suggests that adolescents, especially those age 14 and older, may have skills that are as developed as adults for making informed healthcare decisions. By involving the patient, the physician fosters trust as well as a better physician-patient relationship.

But what if the young athlete’s selection of a treatment is motivated by the short-term gain of a quicker return to play over another treatment that might prevent the development of a chronic condition (ie, osteoarthritis) in the long-term? It is plausible that the inability to play because of an injury would keep the young athelete from obtaining a college scholarship and thus matriculation into postsecondary education.

The physician’s focus on obtaining assent should include the following goals:

  1. to help the patient achieve a developmentally appropriate awareness of the nature of the condition
  2. to inform the patient what he or she can expect with various tests and treatments
  3. to clinically assess the patient’s understanding of the situation and factors influencing how he or she is responding
  4. to solicit an expression of the patient’s willingness to accept the proposed care without coercion or deception

Consider the dilemma faced by the physician who must treat an injured adolescent amateur athlete, such as a high-school senior who is no longer a minor, and who possesses the ability to garner an athletic scholarship. When this patient asks to receive a shoulder or elbow injection so that he or she can play in a game attended by collegiate scouts, what is the ethically appropriate response? In this case, the patient’s wishes supersede those of the parents, and under the rules of the Health Information Portability and Accountability Act (HIPAA), the physician is precluded from discussing the injury with the parents without the patient’s written permission.

The professional athlete
Another challenging situation arises when the patient is a paid, professional athlete. In this situation, the patient is clearly an adult responsible for his or her own medical decisions. Yet, the issue is complicated by the influence of the potential monetary gain from competing with an injury.

For example, the player may be a rookie free-agent trying to make the team and prove his worth to the team’s management and his teammates. In this situation, not playing with an injury may result in loss of income as well as the respect of his teammates and coaches, and may end a career. On the other hand, the patient may be the team’s star player who is in his contract year and thus wants to do everything in his power to enhance his perceived value so as to garner a multi-year contract. In both situations, nonmedical factors may heavily influence the athlete patient’s decision to play with an injury.

The team’s management may also influence the decision of the player as well as the recommendations of the team’s orthopeadist. The lay public and media constantly point to the way professional sports teams may coerce or otherwise influence the return-to-play decisions of their team’s medical staff. In our experience, however, the short-term gain of an athlete’s early return to playing is outweighed by the potential long-term loss to the team, especially when the end result of an early return to play would be a longer convalescence or the player’s premature retirement.

In professional sports today athletes often want to either preemptively prevent pain through the use of prophylactic medication (ie, pregame ketorolac injection), or return to play with a quick fix (ie, local anesthetic injection) if they are injured during the game. A survey conducted in 2000 of National Football League (NFL) medical staffs showed that 28 of 30 responding teams (93 percent) used pregam ketorolac, with an average of 15 players per team receiving weekly injections. Six of the 28 teams that used ketorolac reported minor complications from its injection.

A 2002 study examined the isolated use of local anesthetics to treat sports injuries that occurred in Australian Rules football and rugby. Over a 6-year period, 221 local painkilling injections (joint and soft-tissue) were administered for game-day pain relief. On a per-game basis, an average of 10.7 percent of all team members played with the aid of a bupivacaine injection. Although low-risk, high-benefit injections can be performed at the acrominoclavicular joint, fingers, second through fifth metacarpals, ribs/sternum, iliac crest, and plantar fascia, injections of ankle sprains, tendon injuries, prepatellar/olecranon bursitis, first metacarpal injuries, and radiocarpal injuries were described as high risk.

Since then, the International Rugby Board has banned painkilling injections. Most other sport governing bodies, including the NFL and the National Collegiate Athletic Association, leave their use to the discretion of the treating team physician.

Clearly, the team orthopaedist and medical staff are responsible for appropriately educating athletes on the risks and benefits of anesthetic injection. They must also avoid performing injections around regional motor or sensory nerves, major weight-bearing joints, and in or around fractures.

When faced with the situation of a potential in-game injection, the treating orthopaedist must quickly factor in the nature of the injury, the time remaining in the contest, the efficacy and potential complications of the proposed treatment, and its influence on both the short- and long-term consequences of the condition. Anesthetizing a dislocated finger on the nondominant hand of a football lineman will have few ill effects compared to administering an anesthetic injection into a running back’s knee following an acute ligament tear. No hard and fast rules cover appropriate use of injections, other than avoiding anesthetizing a weight-bearing joint. Sound medical principles should be used to guide the decision without consideration of the specifics of the game or contest.

Informed consent
Whenever an invasive treatment is considered, the athlete—just as every other patient—must be given appropriate informed consents as to the risks, benefits, and alternatives of the proposed treatment. Ideally, this may be accomplished in the privacy of the orthopaedist’s office or training room facility, but the nature of sports medicine and team care often necessitates rendering treatment in the middle of a game when time is of the essence. Despite this added pressure, the team orthopaedist must provide reasonably thorough informed consent.

Experts in the field of informed consent emphasize the need to discuss the following elements while obtaining consent:

  • Provision of information—patients should display an understanding of the condition at hand, the nature of the proposed treatment and its risks, and any existing alternative treatments with their associated risks and benefits
  • Assessment of the patient’s understanding of the above discussion
  • Assessment of the capacity of the patient to make the necessary decision
  • Assurance that the patient has the freedom to choose among the medical alternatives without coercion or manipulation

The goal of the consent process should be to develop the patient’s comprehensive understanding of the clinical situation at hand, enabling the patient to truly make an educated decision about his or her medical care. It could be argued quite persuasively that informed consent is impossible in the setting of an athletic event where the pressure to return to play potentially outweighs the athlete’s ability to carefully consider all relevant factors associated with the proposed treatment.

The treating orthopaedist must ensure that the player is reasonably informed without consideration of the potential influence of the player’s decision on the outcome of the contest. Failure to do so puts both the athlete and physician at risk if unintended consequences (ie, inadvertent regional nerve block, post-traumatic osteoarthritis) occur. At least five cases of litigation have been documented concerning the long-term negative consequences of local anesthetic injections in American professional sports, including the NFL and National Basketball Association.

In today’s sports environment, defining “harm” is a far more complex concept than Hippocrates ever encountered. Despite the pressure of these external factors, the primary ethical duty of the treating orthopaedist should be to protect the physical health and well-being of the athlete, just as it was in Hippocrates’ time.

AAOS Information Statements:
“Team Physician Definition, Qualifications, and Responsibilities: Consensus Statement”

“Sideline Preparedness for the Team Physician: Consensus Statement”

Nancy M. Cummings, MD, and Matthew J. Matava, MD, are members of the AAOS Ethics Committee.

Online References

  1. Orchard JW. Benefits and risks of using local anesthetic for pain relief to allow early return to play in professional football. Br J Sports Med. 2002;36:209-13.
  2. Orchard JW. Is it safe to use local anesthetic painkilling injections in professional football? Sports Med. 2004;34(4):209-19.