The Role of the Primary Care Physician
in the Sports Medicine Chain
Brian Johnston, ATC
Assistant Athletic Director for Sport Medicine
East Tennessee State University
The sports medicine umbrella has
evolved over the years into a very
complex system of specialties
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Today …….
• Sports Medicine (SM) does not fit into one
area of expertise.
• SM does not target one organ, system or
disease - but rather a broad based area that
can encompass many areas simultaneously.
(McCrory 2006)
This need for a more broad based
network of physicians has evolved into
an overlapping of disciplines.
•
•
•
•
•
Athletic Training
Physical Therapy
Chiropractics
Orthopedics
Internal Medicine
•
•
•
•
Primary Care
Emergency Medicine
Internal Medicine
and many more….
Today, a sports medicine physician must be
competent in three levels of care:
1. Sub Optimal
• Exercise as management of medical problems
2. Optimal
• Weekend Warrior
3. Supra-Optimal
• Enhancement of performance in athletics
(McCrory 2006)
The Team Physician in Collegiate Athletics
• #1 Priority is to “provide for the well-being of
individual athletes enabling each to realize
his/her full potential”
• Ultimately responsible for all student-athletes
as it relates to health and welfare
• Must utilize resources to have a successful
program
(Team 2001)
Ultimately, the Team
Physician is responsible for
making medical decisions
that affect the student
athlete’s safe participation in
any athletic event.
Duties and Responsibilities
• Medical Management
–
–
–
–
–
–
–
Physicals
On-field injuries
Illness
Rehab
Return to play
Nutrition
Strength and
Conditioning
– Record Keeping
• Administrative
– Role delineation
– Education of athletes,
parents, coaches, etc.
– EAP
– Equipment
– Coverage
– Environmental
(Team, 2001)
Who is the “right” person for a
job of this magnitude?
What specialty most
appropriately can manage such a
responsibility?
2005 Harvard Study over a 2 year
period
• 73% of initial evals were musculoskeletal
• 27% of initial evals were general medical
• 4% of musculoskeletal injuries required
surgery
(Steiner 2005)
The results of the Harvard study very
closely reflect the injury data collected at
ETSU over the past 10 years.
What does this mean?
• The old model of orthopedic surgeon as the
team MD may need to be changed
• A physician with a more broad scope of
knowledge and a specialization in
musculoskeletal medicine and exercise would
be more appropriate
The Inter-Association Task Force for
Preventing Sudden Death in Collegiate
Conditioning Sessions: Best Practices
Recommendations (2010)
“The right combination of strength, speed,
cardiorespiratory fitness, and other
components of athletic capacity can
complement skill and enhance performance
for all athletes.”
The Facts
• Since 2000:
– 21 NCAA D1 student athletes have died during
conditioning sessions
– 75% were football players (16/21)
– 52% (11/21) occurred on day 1 or day 2
– Three most common causes of death
• Sickle Cell Trait complications
• Heat issues
• Cardiac issues
From 2000 - 2011
• Number of NCAA Division I Football Bowl
Subdivision players who died while practicing
or playing football
0
• Sickle Cell Trait Complication
– Must know the status of every DI student athlete
• Heat Issues
– Recognize heat signs/symptoms
– Manage acclimatization periods
• Cardiac Issues
– ACLS
– EKG/Echo – PPE – Disqualification?
“Concussion Epidemic”
(CDC)
~2-4 million sports concussions/yr in US! (Langlois et al., 2006)
RJ Elbin, PhD
Constant Media Exposure
Sports Illustrated, ESPN, National Geographic, Discovery
Channel…Madden
RJ Elbin, PhD
Prevalence & Incidence of SportRelated Concussion
• 1.6 to 3.0 million sportrelated concussions occur
every year in U.S. (CDC, 2006)
– 5.0% of all collegiate athletic
injuries are concussions
(Gessel et al. 2007)
• Occur more often in
competition than practice
(Gessel et al. 2007)
What do we know?
Number of Concussions
Knowledge/Standard of Care
Pro
Pro
College
College
High
School
High
School
Youth-?
Youth
RJ Elbin, PhD
Concussion Resolution
Unanimous agreement that the majority
(80% - 90%) of concussions will resolve in a short
(7 – 10 day) period.
*college athletes on average recover within 1 – 5 days (Field et
al. 2003; Macciocchi et al. 1996; Iverson et al. 2006; McCrea et al. 2003)
*Young children recover slower than High School
*High School recover slower than College
*College recover slower than Professional
*Senior recover slower than everyone
NCAA Return to Play Protocol(McCrory et al. 2009)
Rehabilitation Stage
Fx Exercise at Each Stage
Objective at Each Stage
1. No Activity
Physical and cognitive rest
Recovery
2. Light Aerobic Exercise
Walk, swim, stationary bike, <
70% of max HR, no resistance
training
Increase HR
3. Sport-Specific Exercise
Skating drills (hockey), running Add movement
(soccer), no head impact
activities
4. Non-contact drills
More complex training drills,
may being progressive
resistance training
Exercise, coordination, and
cognitive load
5. Full-contact practice
Following medial clearance,
participate in normal training
activities
Restore athlete’s confidence;
coaching staff assess
functional skills
6. Return to play
Normal game play
The answer is clear….
• The primary care physician with a certificate
of added qualification in sports medicine most
appropriately fits this new model of a team
physician
• This does not, however diminish
the value of other physician
specialties
Who are the essential members of the
Sports Medicine Team?
• Primary Care Sports Medicine Physician (MD, DO)
• Athletic Trainer (ATC)
• Strength Conditioning (CSCS, CSCCa)
• Sport Science (PhD)
Overlapping Roles
Team MD
Athletic
Training
Strength
Conditioning
Sport Science
Communication
Team MD
Athletic
Trainer
Student
Athlete
Sport
Science
Strength and
Conditioning
What does strength Conditioning have
to offer?
• Negative Trends
• Positive Trends
– Decreases in
performance
– Increases in
performance
– Decreases in energy
– Correcting poor
technique
– Poor Technique
– Mental boost
– Mental Fatigue
– Work ethic
What does Sport Science have to offer?
• Negatives Trends
• Positives Trends
– Predictor of injury
– Baseline testing
– Root of injury
– Increases in training
– “Mental” injury
– Training Design
– Outside the Box
predictor
– Boost Confidence
Athlete Monitoring
Physician
• X-Rays
• Labs
• Manual Muscle
Testing
• Vitals
Sport Science
• Hydration
• Peak Power
• Rate of Force
Development
• Asymmetry
• Labs
Will there be Tension?
• There are going to be
problems/concerns that
should never be “solved”
• If we always agree and
get along, someone is not
doing their job
• If there is
tension/disagreement –
Does mean there is a
problem?
• Know what you know –
not what you’ve heard
Athlete
Coach
Parent
Media
Sports
Medicine
Strength
Staff
So….what IS the role of the Primary
Care Physician?
......to be a leader
To have the right amount
of Truth and Grace
To be Resolute
• Admirable, purposeful,
determined,
unwavering
• Determined, firm,
decided, resolved,
decisive
• “tip of the spear”
• “the end of the line”
http://www.merriam-webster.com/dictionary/resolute
Thank you….
•
•
•
•
•
•
Tom Kwasigroch, PhD
Jerry Robertson, ATC
Todd Fowler, MD
Dough Aukerman, MD
Ralph Mills, MD
Benjamin England, MD
Disclosure Statement of Financial
Interest
I, Brian Johnston
DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could be
perceived as a real or apparent conflict of
interest in the context of the subject of
this presentation.
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