Remember when sport injuries were just “part of the game” and knockout blows on the playing field were treated as near-comic “bell ringers” that never prevented a player from returning to the contest? Athletes at all levels—high school, college, and professional—and their families let coaches, trainers, and team physicians make decisions about injuries and health status. Often, players or coaches had the deciding word on a return to play—and that word was “play.”

Over the past decade, however, the approach to standards and practices of medical care for athletes has shifted considerably. The driving force behind this transformation is probably the new awareness of the long-term effects of impacts. First to be noticed were the frequency and severity of concussions and brain injuries in collision-heavy games such as football and ice hockey. However, more “genteel” sports such as soccer, baseball, skiing, and women’s lacrosse have also come under scrutiny.

News reports have uncovered an alarming pattern of suicides by former National Football League (NFL) players, such as that of the 43-year-old San Diego Chargers star Junior Seau in 2012. They drew attention to the number of players affected by chronic traumatic encephalopathy (CTE), a neurodegenerative disease linked to repetitive head trauma. CTE has been linked to patterns of depression, dementia, and even death in retired athletes, often at ages considered within the prime of adult health.

The scrutiny has expanded beyond the concussion issue to the general ways in which sports organizations monitor and care for the health of the athletes. Another high-profile case—the death of Derek Boogaard, a National Hockey League player—resulted in the lawsuit against the New York Rangers. Mr. Boogaard, whose death was due to an overdose of opioids and alcohol, was an “enforcer,” who frequently engaged in pugilistic bouts on the ice.

The lawsuit, according to ABC News, alleges that league doctors prescribed “thousands of painkiller pills” for his injuries, even after learning of his battle with addiction. The family also claims that Mr. Boogaard wasn’t informed of the higher risk of injury and the potential for painkiller addiction associated with his role on the team and that the team management was lax in its concern for his fidelity to rehabilitation for his addiction.

Who is responsible?
Is someone—the coach, the athlete, the manager, the trainer, the team physician—primarily responsible for ensuring that the well-being of the athlete is addressed? Panelists at the “Team Coverage 2015: Who Is Responsible for the Athlete?” symposium during the 2015 annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) in Orlando, Fla., attempted to answer that question.

Moderator Annunziato (Ned) Amendola, MD, a professor at the University of Iowa and head team physician for its football team, opened by posing what he perceives to be the salient questions governing medical care of student and professional athletes.

Displaying a photo taken of the sideline during a game, he noted the various staff members in the shot. They included the team’s physicians, the head and assistant coaches, training staff, and others.

“What is the problem we might face?” he asked. “On the sidelines, where there are multiple people, who makes the decisions on what is in the best interest of the athlete? You have the head coach, head strength and conditioning coach, the head trainer, the orthopaedic surgeon, and the head primary care physician, a fellow in sports medicine.”

He then referred to scrutiny given to the Penn State University program by Sports Illustrated over the issue of whether “athletics had too much power” at that university. The article noted that the school had replaced its medical staff after a review by the head coach. “Is that the person who should be making that decision?” Dr. Amendola asked. “Who oversees the team physician? Who oversees medical care? Who makes return-to-play and concussion policies? Who oversees drug testing for the institution or the league?”

Although the NCAA Big Twelve conference recently developed new standards for concussion treatment, “Physicians were not totally happy with the new concussion policy,” said Dr. Amendola. “This happens at every level. In the NFL, players have sought help from physicians other than the team physicians because they felt that the team physicians were conflicted in terms of who was determining the direction of their care. Internationally, it happens.”

Dr. Amendola noted that liability can be an issue. “There is no national standard of care pertaining to healthcare providers covering athletic teams. A tort is committed when we fail to act as an ordinary and reasonably prudent person under similar circumstances. In other words, you’d get compared to a person of your level and ability when you make a decision for an athlete. So if you are a professional team physician, your decisions will be compared to decisions made by other team physicians.”

The NCAA handbook, he noted, is “a very good document.” It states that member institutions should adopt an administrative structure for integrated sports medicine and athletic training services to minimize potential conflicts of interest that could adversely affect the health of student athletes. According to the handbook, “The team physician’s authority becomes the lynch pin for independent medical care of student athletes.”

The province of the physician
Panelist Ron Courson, director of sports medicine at the University of Georgia, noted that when it comes to college football in Southern states, head coaches are often treated like kings. However, Mr. Courson argued that in the hierarchy of health care, those with medical degrees should have the first and final word.

“When an athlete sustains an injury, a number of people get involved, from certified athletic trainers to emergency medical technicians and paramedics. Whom do they report to?

“We are taught about the concept of patient-centered care. Always make your decisions based on what is best for the patient. This applies to the athlete,” he continued.

“We need to make sure the student has the right information to make a decision both short-term and long-term. That’s easier said than done. Sometimes there can be an ethical dilemma. What may be best for the athlete may not be best for the team or the institution. An example is an athlete with a meniscal tear. How we treat it may affect how long the athlete is out, but the long-term implications might be different for that individual than they are for the team in the short term.”

The University of Georgia also has a “best practices document,” which was assembled with the contributions of 20 associations, including the AOSSM. “This was the first time we put a document together from an administrative standpoint: How do we best organize an administration? A survey found that 53 percent of head athletic trainers felt they were unduly influenced by the head football coach,” he said.

Also at Georgia, he explained, a flow chart governs the protocol for sports medicine.

“Every sports medicine program should have a flow chart,” he advised, noting that coaches are not in the flow of authority for medical decisions.

“At the end of the day, I work very closely with the coach, but I don’t work for the coach. It is an important distinction. For me and our medical staff to make the right medical decision, a clear separation is needed. I am supervised by my athletic director from an administrative standpoint, to make sure I am within budget and follow NCAA rules,” he explained.

He advocated that athletic programs craft a fixed protocol that spells out who does what. “From an orthopaedic standpoint, some orthopaedists may OK with a trainer’s reducing a dislocated joint. Some may not. So rather than run into a conflict when it happens, develop a written protocol. We have written medical protocols for a variety of pathologies. We just put together one for cervical spine injuries.”

He also noted that every athletic trainer and team physician should have a written job description and clear job expectations.

Finally, Mr. Courson discussed the university’s athletic medical review board, which meets once a year. The independent board includes a biomedical ethicist, an NFL team physician, two hall-of-fame certified athletic trainers, a representative of the Centers for Disease Control and Prevention, a retired team physician, a researcher, a former student athlete, and a lay person from the community.

“They have full access to our program. They talk to coaches, staff, and student athletes. They take an objective look at our program and prepare a report for the university president.”

The “team” in teamwork
Offering a perspective from the Ivy League was Margot Putukian, MD, who practices internal medicine and who serves as director of athletic medicine at Princeton University. She noted that the lack of literature about medical customs for the care of athletes has led to the development of “team physician consensus statements.”

“The first one was, ‘What is a team physician?’ In this model, it comes down to looking at a performance team from a coaching standpoint and from a medical standpoint. Coach and physician have to work in concert, and have the same vision and the same objectives,” she said.

“No matter how the organization is set up, it’s important to remember that team physicians don’t make a coach’s decisions, but coaches shouldn’t be making medical decisions,” she continued. “Team physicians look at illnesses and injuries; athletic trainers are often responsible for first point of contact, injury management and rehabilitation, and transitioning to return to play. It also takes into account a wellness model. You have to think of the particular sport— the timing.”

The three most recent consensus statements addressed return to play, sideline preparedness, and team physicians. According to that last statement, she said, “The medical director needs to be a physician with an unrestricted license who has a basic understanding of emergencies on the sideline, as well as a working knowledge of musculoskeletal injuries, other conditions, and other issues that affect athletes.”

Most important is establishing the chain of command, coordinating the assessment and management of injuries on the field, making decisions on both clearance to play and return to play, and integrating the expertise available.

Also on the panel was James Puffer, MD, a family practitioner who addressed the relative roles of orthopaedic surgeons and family care physicians who serve on teams with multiple professional medical providers. “If you have both types, it doesn’t matter who is the head physician, but you need someone designated the head physician,” he said. “There need to be clear lines of authority. All must respect each other’s skills and expertise.”

Disclosure information on the presenters is available online at www.aaos.org/disclosure.

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

• An administrative structure for integrated sports medicine and athletic training services must be clearly outlined to minimize potential conflicts of interest that could adversely affect the health of student athletes.
• Coaches and athletic trainers should not make medical decisions; that role belongs to the team physician.
• Teams with multiple medical providers should designate one provider as the head physician; all providers should respect each other’s skills and expertise.
• Players must be provided with the information necessary to make decisions—and should understand the impact of decisions for both the short-term and the long-term.