SPORTS MEDICINEJust the Facts

http://dx.doi.org/10.1036/007144632X

EDITORS

Francis G. O’Connor, MD, FACSMDirector, Sports Medicine Fellowship Program

Associate Professor of Family MedicineDepartment of Family Medicine

Uniformed Services University of the Health Sciences Bethesda, Maryland

Robert E. Sallis, MD, FAAFP, FACSMCo-Director, Sports Medicine Fellowship

Kaiser Permanente Medical CenterFontana, California

Robert P. Wilder, MD, FACSMAssociate Professor Physical Medicine and Rehabilitation

Medical Director the Runner’s Clinic at UVATeam Physician, UVA Athletics, The University of Virginia

Charlottesville, Virginia

Patrick St. Pierre, MDAssistant Professor of Orthopedic Surgery

Uniformed Series University of the Health SciencesBethesda, Maryland

Associate Director Nirschl OrthopedicSports Medicine Fellowship

Arlington, Virginia

SPORTS MEDICINEJust the Facts

Francis G. O’ConnorRobert E. SallisRobert P. WilderPatrick St. Pierre

McGraw-HillMedical Publishing Division

New York Chicago San Francisco Lisbon London MadridMexico City Milan New Delhi San Juan Seoul

Singapore Sydney Toronto

The views in this manuscript are those of the authors and do notreflect the official policy or position of the US Army, US

Department of Defense, or the US Government.

http://dx.doi.org/10.1036/007144632X

Copyright © 2005 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. 0-07-144632-X The material in this eBook also appears in the print version of this title: 0-07-142151-3. All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. For more information, please contact George Hoare, Special Sales, at george_hoare@mcgraw-hill.com or (212) 904-4069. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting there from. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. DOI: 10.1036/007144632X

http://dx.doi.org/10.1036/007144632X

CONTENTS

Contributors xiPreface xix

Section 1GENERAL CONSIDERATIONS IN SPORTS MEDICINE 1

1 The Team Physician Christopher B. Ranney, Anthony I. Beutler and John H. Wilckens 1

2 Ethical Considerations in Sports MedicineRalph G. Oriscello 4

3 Legal Issues Aaron Rubin 84 Field-Side Emergencies

Michael C. Gaertner and Loren A. Crown 115 Mass Participation Events Scott W. Pyne 206 Catastrophic Sports Injuries Barry P. Boden 247 Orthopedic Sports Medicine Terminology

Scott A. Magnes 308 Basics in Exercise Physiology

Patricia A. Deuster and David O. Keyser 349 Articular Cartilage Injury

Stephen J. Lee and Brian J. Cole 4610 Muscle and Tendon Injury and Repair

Bradley J. Nelson and Dean C. Taylor 5511 Bone Injury and Fracture Healing

Carlos A. Guanche 6112 The Preparticipation Physical Examination

Robert E. Sallis 6613 Basic Principles of Exercise Training

and Conditioning Craig K. Seto 7514 Nutrition Nancy M. DiMarco and Eve V. Essery 8315 Exercise Prescription Mark B. Stephens 91

v

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16 Exercise and Chronic Disease Karl B. Fields, Michael Shea, Rebecca Spaulding, and David Stewart 95

17 Playing Surface and Protective EquipmentJeffrey G. Jenkins and Scott Chirichetti 102

Section 2EVALUATION OF THE INJURED ATHLETE 107

18 Diagnostic Imaging Leanne L. Seeger and Kambiz Motamedi 107

19 Electrodiagnostic Testing Venu Akuthota and John Tobey 111

20 Exercise Testing David E. Price, Kevin Elder, and Russell D. White 118

21 Gait Analysis D. Casey Kerrigan and Ugo Della Croce 126

22 Compartment Syndrome TestingJohn E. Glorioso and John H. Wilckens 130

23 Exercise-Induced Asthma TestingFred H. Brennan, Jr. 135

24 Drug Testing Aaron Rubin 137

Section 3MEDICAL PROBLEMS IN THE ATHLETE 141

25 Cardiovascular ConsiderationsFrancis G. O’Connor, John P. Kugler, and Ralph P. Oriscello 141

26 Dermatology Kenneth B. Batts 14927 Genitourinary Michael W. Johnson 15728 Ophthalmology Ronica A. Martinez

and Kayvan A. Ellini 16229 Otorhinolaryngology Charles W. Webb 16630 Dental Elizabeth M. O’Connor 17031 Infectious Disease and the Athlete John P. Metz 17332 Endocrine Considerations

William W. Dexter and Shireen Rahman 18133 Hematology in the Athlete William B. Adams 19334 Neurology Jay Erickson 19935 Gastroenterology David L. Brown

and Chris G. Pappas 20536 Pulmonary Carrie A. Jaworski 21137 Allergic Diseases in Athletes

David L. Brown, David D. Haight, and Linda L. Brown 220

vi CONTENTS

CONTENTS vii

38 Overtraining Syndrome/Chronic FatigueThomas M. Howard 228

39 Environmental Injuries Brian V. Reamy 232

Section 4MUSCULOSKELETAL PROBLEMS IN THE ATHLETE 239

40 Head Injuries Robert C. Cantu 23941 Cervical Spine Gerard A. Malanga, Garrett

S. Hyman, and Jay E. Bowen 24342 Thoracic and Lumbar Spine Scott F. Nadler

and Michele C. Miller 24843 Magnetic Resonance Imaging: Technical Considerations

and Upper Extremity Carolyn M. Sofka 25744 Shoulder Instability Robert A. Arciero 26345 Rotator Cuff Pathology Patrick St. Pierre 26846 Sternoclavicular, Clavicular, and Acromioclavicular

Injuries Carl J. Basamania 27347 Shoulder Superior Labrum Biceps

and Pec Tears Jeffrey S. Abrams 28148 The Throwing Shoulder Carlos A. Guanche 28749 Elbow Instability

Derek H. Ochiai and Robert P. Nirschl 29150 Elbow Articular Lesions and Fractures

Edward S. Ashman 29351 Elbow Tendinosis Robert P. Nirschl

and Derek H. Ochiai 29752 Soft Tissue Injuries of the Wrist in Athletes

Steven B. Cohen and Michael E. Pannunzio 29953 Soft Tissue Injuries of the Hand in Athletes

Todd C. Battaglia and David R. Diduch 30554 Wrist and Hand Fractures

Geoffrey S. Baer and A. Bobby Chhabra 31155 Upper Extremity Nerve Entrapment

Margarete DiBenedetto and Robert Giering 32056 Magnetic Resonance Imaging: Lower Extremity

Carolyn M. Sofka 32957 Pelvis, Hip, and Thigh Brett D. Owens

and Brian D. Busconi 33758 Knee Meniscal Injuries John P. Goldblatt

and John C. Richmond 34259 Knee Instability Alex J. Kline and Mark D. Miller 35060 The Patellofemoral Joint Robert J. Nicoletta

and Anthony A. Schepsis 356

61 Soft Tissue Knee Injuries (Tendon and Bursae)John J. Klimkiewicz 359

62 Ankle Instability Todd R. Hockenbury 36663 Surgical Considerations in the Leg

Gregory G. Dammann and Keith S. Albertson 37364 Tibial and Ankle Fractures Edward S. Ashman

and Brian E. Abell 37765 Foot Injuries Mark D. Porter, Joseph J. Zubak,

and Winston J. Warme 38266 Lower Extremity Stress Fracture

Michael Fredericson 39067 Nerve Entrapments of the Lower Extremity

Robert P. Wilder, Jay Smith, and Diane Dahm 396

Section 5PRINCIPLES OF REHABILITATION 405

68 Physical Modalities in Sports MedicineAlan P. Alfano 405

69 Core Strengthening Joel Press 41270 Medications and Ergogenics Scott B. Flinn 41571 Common Injections in Sports Medicine:

General Principles and Specific TechniquesFrancis G. O’Connor 426

72 Footwear and Orthotics Eric Magrum and Jay Dicharry 433

73 Taping and BracingTom Grossman, Kate Serenelli, and Danny Mistry 442

74 Psychologic Considerations in Exercise and SportNicole L. Frazer 446

75 Complementary and Alternative MedicineAnthony I. Beutler and Wayne B. Jonas 453

Section 6SPORTS-SPECIFIC CONSIDERATIONS 461

76 Baseball James R. Morales and Dennis A. Cardone 46177 Basketball John Turner and Douglas B. McKeag 46478 Boxing: Medical Considerations

John P. Reasoner and Francis G. O’Connor 47079 Crew Andrew D. Perron 47380 Cross-Country Ski Injuries Janus D. Butcher 47581 Bicycling Injuries Chad Asplund 48082 Figure Skating Roger J. Kruse and Jennifer Burke 485

viii CONTENTS

CONTENTS ix

83 Football John M. MacKnight 49184 Golfing Injuries Gregory G. Dammann

and Jeffrey A. Levy 49785 Gymnastics John P. DiFiori and Julie Casper 50086 Ice Hockey Injuries Peter H. Seidenberg

and Tory Woodard 50687 Rugby Injuries Peter H. Seidenberg

and Rochelle Nolte 51388 Running Robert P. Wilder, Francis G. O’Connor 51989 Soccer Nicholas A. Piantanida 52690 Swimming Nancy E. Rolnik 53191 Tennis Robert P. Nirschl 53492 Triathlon Shawn F. Kane and Fred H. Brennan 53893 Weightlifting Joe Hart

and Christopher D. Ingersoll 54394 Lacrosse Thad Barkdull 54895 Wrestling Michael G. Bowers

and Thomas M. Howard 553

Section 7SPECIAL POPULATIONS 559

96 The Pediatric Athlete Amanda Weiss Kelly and Terry A. Adirim 559

97 The Geriatric Athlete Cynthia M. Williams 56598 The Female Athlete Rochelle M. Nolte

and Catherine M. Fieseler 57399 Special Olympics Athletes

Pamela M. Williams and Christopher M. Prior 581100 The Disabled Athlete

Paul F. Pasquina, Halli Hose, and David C. Young 586101 The Athlete with a Total Joint Replacement

Jennifer L. Reed 594102 Cancer and the Athlete Brian Whirrett

and Kim Harmon 598103 The Athlete with HIV

Robert J. Dimeff and Andrew M. Blecher 602

Appendix 609Index 615

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xi

Brian E. Abell, Orthopedic Resident, Dwight D. Eisenhower Army MedicalCenter, Augusta, Georgia

Jeffrey S. Abrams, MD, Director, Princeton Orthopedic and RehabilitativeAssociates, Attending Orthopedic Surgeon, University Medical Center atPrinceton, Princeton, New Jersey

W. Bruce Adams, MD, Senior Medical Officer, Director of Sports Medicine,Officer Candidate School, Quantico, Virginia

Terry A. Adirim, MD, MPH, Associate Professor, Pediatrics and EmergencyMedicine, George Washington University School of Medicine and HealthSciences Washington, DC

Venu Akuthota, MD, Associate Professor, Department of RehabilitationMedicine, University of Colorado Health Sciences Center, Aurora, Colorado

Keith S. Albertson, MD, Chief, Orthopedic Service, Dewitt Army CommunityHospital, Fort Belvior, Virginia

Alan P Alfano, MD, Associate Professor of Clinical Physical Medicine andRehabilitation, Department of Physical Medicine and Rehabilitation,Medical Director, UVA-HEALTHSOUTH Rehabilitation Hospital,University of Virginia Health System, Charlottesville, Virginia

Robert A. Arciero, MD, Professor, Orthopedic Surgery, OrthopedicConsultant, University of Connecticut, Department of Orthopedics,University of Connecticut Health Center, Farmington, Connecticut

Edward S. Ashman, Sports Medicine Fellow, Nirschl Orthopedic Center forSports Medicine and Joint Reconstruction, Arlington, Virginia

Chad A. Asplund, MD, Chief Resident, Family Practice Residency Program,DeWitt Army Community Hospital, Fort Belvoir, Virginia

Geoffrey S. Baer, MD, PhD, Resident in Orthopedic Surgery, University ofVirginia Health System, Charlottesville, Virginia

Thad Barkdull, MD, Clinic Director, US Army Health Clinic, DugwayProving Grounds, Utah

Carl J. Basamania, Chief, Adult Reconstructive Shoulder Surgery, Division ofOrthopedic Surgery, Duke University Medical Center, Durham, NorthCarolina

Todd C. Battaglia, Resident in Orthopedic Surgery, University of VirginiaHealth System, Charlottesville, Virginia

Kenneth B. Batts, DO, Chairman, Department of Family Practice andEmergency Medical Services, Tripler Army Medical Center, Honolulu,Hawaii

CONTRIBUTORS

Copyright © 2005 by The McGraw-Hill Companies, Inc. Click here for terms of use.

Anthony J. Beutler, MD, Director, Sports Medicine, Family PracticeDepartment, Malcolm Grow Medical Center, Assistant Professor of FamilyMedicine, Uniformed Services University of the Health Sciences

Andrew M. Blecher, Primary Care Sports Medicine Resident, Department ofOrthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio

Barry P. Boden, MD, The Orthopedic Center, Rockville, Maryland, AdjunctAssociate Professor, Uniformed Services University of the Health Sciences,Bethesda, Maryland

Jay E. Bowen, DO, Attending Physician, Kessler Institute for Rehabilitation,Assistant Professor, Department of Physical Medicine & Rehabilitation,UMDNJ-New Jersey Medical School, West Orange, New Jersey

Michael G. Bowers, DO, Chief Resident, Department of Family Medicine,Dewitt Army Community Hospital

Mark D. Bracker, MD, Founding Director, Primary Care Sports MedicineFellowship, Clinical Professor, Department of Family and PreventiveMedicine, University of California, San Diego, La Jolla, California

Fred H. Brennan, Jr., DO, FAOASM, Director, Primary Care Sports Medicine,Dewitt Army Community Hospital, Ft. Belvoir, Virginia, Assistant TeamPhysician, George Mason University, Fairfax, Virginia

Kevin J. Broderick, DO, Family Medicine Associates, Middletown,Massachusetts

David L. Brown, MD, Director, Sports Medicine, Madigan Army MedicalCenter, Fort Lewis, Washington

Linda L. Brown, MD, Director, Allergy and Immunology Clinic, MadiganArmy Medical Center, Fort Lewis, Washington

Jennifer Burke, MD, Clinical Assistant Professor, Department of Communityand Family Medicine, Team Physician, St. Louis University, Director ofSports Medicine, Forest Park Hospital, St. Louis, Missouri

Brian D. Busconi, MD, Associate Professor of Orthopedic Surgery, Universityof Massachusetts Medical School, Chief of Sports Medicine, UMassMemorial Medical Center, Worcester, Massachusetts

Janus D. Butcher, MD, FACSM, Assistant Professor of Family Medicine,University of Minnesota, Duluth, Team Physician, US Cross Country Skiing,Staff Physician, Duluth Clinic, Duluth, Minnesota

Robert C. Cantu, MA, MD, FACS, FACSM, Chief, Neurosurgery Service,Director, Services of Sports Medicine, Emerson Hospital, Concord,Massachusetts, Co-Director, Neurologic Sports Injury Center, Brigham andWomen’s Hospital Boston, Massachusetts, Medical Director National Centerfor Catastrophic Sports Injury Research, Adjunct Professor Department ofExercise and Sport Science, University of North Carolina at Chapel Hill,Chapel Hill, North Carolina, Neurosurgery Consultant, Boston CollegeFootball and Boston Cannons

Dennis A. Cardone, DO, Associate Professor, Director, Sports MedicineFellowship and Sports Medicine Center, Department of Family Medicine,UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey

Julie Casper, MD, Clinical Instructor and Sports Medicine Fellow, Department ofFamily Medicine, David Geffen School of Medicine at UCLA, Los Angeles,California

A. Bobby Chhabra, MD, Assistant Professor of Orthopedic Surgery,Division of Hand, Microvascular, and Upper Extremity Surgery, VirginiaHand Center, University of Virginia Health System, Charlottesville,Virginia

Scott Chirichetti, DO, Chief Resident, Physical Medicine & Rehabilitation,University of Virginia, Charlottesville, Virginia

xii CONTRIBUTORS

Steven B. Cohen, MD, Resident Physician, Department of Orthopedic Surgery,University of Virginia Health Sciences Center, Charlottesville, Virginia

Brian J. Cole, MD, MBA, Associate Professor, Departments of Orthopedics &Anatomy and Cell Biology, Director, Rush Cartilage Restoration Center,Rush University Medical Center, Chicago, Illinois

Ugo Della Croce, PhD, Associate Professor, Physical Medicine & Rehabilitation,Systems Engineer, Motion Analysis Lab, University of Virginia, Charlottesville,Virginia

Loren A. Crown, MD, Emergency Medicine Fellowship Director, Universityof Tennessee College of Health Sciences, Covington, Tennessee

Diane Dahm, MD, Assistant Professor, Orthopedic Surgery, Mayo Clinic,Rochester, Minnesota

Gregory G. Dammann, MD, Director, Sports Medicine, Department of FamilyMedicine, Tripler Army Medical Center, Honolulu, Hawaii

Thomas M. DeBerardino, MD, Chief, Orthopedic Surgery Service, Keller ArmyCommunity Hospital; Team Physician, United States Military Academy,West Point, New York

Patricia A. Deuster, PhD, MPH, Department of Military and EmergencyMedicine, Uniformed Services University of the Health Sciences, Bethesda,Maryland

William W. Dexter, MD, FACSM, Director, Sports Medicine Program,Assistant Director, Family Practice Residency Program, Maine MedicalCenter, Portland, Maine

Margarete DiBenedetto, MD, Professor and Former Chair (retired),Department of Physical Medicine and Rehabilitation, University of Virginia,Charlottesville, Virginia

Jay Dicharry, MPT, CSCS, Staff Physical Therapist, University ofVirginia/Healthsouth, Charlottesville, Virginia

David R. Diduch, MD, Associate Professor of Orthopedic Surgery, Co-Director, Division of Sports Medicine, Director, Sports MedicineFellowship, University of Virginia Health System, Charlottesville, Virginia

John P. DiFiori, MD, Associate Professor and Chief, Division of SportsMedicine, Department of Family Medicine, David Geffen School ofMedicine at UCLA, Los Angeles, California

Nancy M. DiMarco, PhD, RD, LD, Professor, Department of Nutrition andFood Sciences, Nutrition Coordinator, The Institute for Women’s Health,Coordinator, Masters Program in Exercise and Sports Nutrition, TexasWomen’s University, Denton, Texas

Robert J. Dimeff, MD, Assistant Clinical Professor of Family Medicine, CaseWestern Reserve University; Associate Professor of Family Medicine, TheOhio State University; Medical Director, Section of Sports Medicine, Vice-Chairman, Department of Family Practice, Cleveland Clinic Foundation,Cleveland, Ohio

Kevin J. Elder, MD, Bayfront Medical Center Sports Medicine Program, FPResidency, St. Petersburg, Florida

Kayvan A. Ellini, MD, Department of Internal Medicine, University of NewMexico Health Sciences Center, Albuquerque, New Mexico

Jay Erickson, MD, Assistant Professor of Family Medicine, UniformedServices University School of Medicine, Director, Primary Care Clinics,Robert E. Bush Naval Hospital, Twentynine Palms, California

Eve V. Essery, Doctoral Candidate, Department of Nutrition and FoodSciences, Texas Women’s University, Denton, Texas

Karl B. Fields, MD, Director, Family Medicine, Residency and Sports MedicineFellowship, Moses Cone Health System, Greensboro, North Carolina

CONTRIBUTORS xiii

Catherine M. Fieseler, MD, Head Team Physician, Cleveland Rockers,Division of Sports Medicine, Cleveland Clinic Foundation, Cleveland, Ohio

Scott B. Flinn, MD, Consultant to the Surgeon General, Navy SportsMedicine, Naval Special Warfare Group ONE Logistics Support, MedicalDepartment, San Diego, California

Nicole L. Frazer, PhD, Director of Clinical Psychology, Assistant Professor ofFamily Medicine, Uniformed Services University of the Health Sciences,Bethesda, Maryland

Michael Fredericson, MD, Associate Professor, Physical Medicine &Rehabilitation, Team Physician, Stanford University, Palo Alto, California

Michael C. Gaertner, DO, Instructor, Emergency Medicine Fellow, Universityof Tennessee, Tipton Family Practice, Covington, Tennessee

Robert Giering, MD, Fellow, Pain Management, Department of Anesthesiology,University of Virginia, Charlottesville, Virginia

John E. Glorioso, MD, Brigade Surgeon, SBCT Brigade, Second InfantryDivision, Fort Lewis, Washington

John P. Goldblatt, MD, Assistant Professor, University of Rochester,Division of Sports Medicine, Rochester, New York

Tom Grossman, ATC, Department of Athletics, University of Virginia,Charlottesville, Virginia

Carlos A. Guanche, MD, Clinical Associate Professor, University ofMinnesota, The Orthopedic Center, Eden Prairie, Minnesota

David D. Haight, MD, Department of Family Medicine, Madigan ArmyMedical Center, Tacoma, Washington

Kimberly Harmon, MD, FACSM, Clinical Assistant Professor, Department ofFamily Medicine, Clinical Assistant Professor Department of Orthopaedicsand Sports Medicine, Team Physician, University of Washington, Seattle,Washington

Joseph M. Hart, MS, ATC, Athletic Trainer, University of Virginia, SportsMedicine/Athletic Training, Charlottesville, Virginia

R. Todd Hockenbury, MD, Assistant Clinical Professor of OrthopedicSurgery, University of Louisville, Blugrass Orthopedic Surgeons, PSC,Louisville, Kentucky

Halli Hose, Internist, San Diego VA Healthcare System, Assistant ClinicalProfessor, University of California, San Diego

Thomas M. Howard, MD, Chief, Department of Family Medicine, AssociateDirector, Sports Medicine Fellowship, Dewitt Army Community Hospital,Fort Belvoir, Virginia

Garrett S. Hyman, MD, MPH, Sports, Spine, and Musculoskeletal Fellow,Kessler Institute for Rehabilitation, Department of Physical Medicine &Rehabilitation, UMDNJ-New Jersey Medical School, West Orange, New Jersey

Christopher D. Ingersoll, PhD, ATC, FACSM, Director, Graduate Programs inSports Medicine/Athletic Training, University of Virginia, Charlottesville,Virginia

Carrie A. Jaworski, MD, Family Practice and Sports Medicine, AssociateDirector, Resurrection Family Practice Residency, Team Physician and MedicalDirector, Athletic Training Program, North Park University, Chicago, Illinois

Jeffrey G. Jenkins, MD, Assistant Professor of Clinical Physical Medicine andRehabilitation, University of Virginia School of Medicine, Charlottesville,Virginia

Michael W. Johnson, MD, Primary Care Sports Medicine and Family Practice,Private Practice, Tacoma, Washington

Wayne B. Jonas, MD, Director, Samueli Institute, Associate Professor FamilyMedicine, USUHS, Bethesda, Maryland

xiv CONTRIBUTORS

Shawn F. Kane, MD, Primary Care Sports Medicine Fellow, USUHS,Bethesda, Maryland

Amanda Weiss Kelly, MD, Assistant Professor of Pediatrics, Case WesternReserve University, Rainbow Babies and Children’s Hospital

D. Casey Kerrigan, MD, Professor and Chair, Department of PhysicalMedicine & Rehabilitation, University of Virginia, Charlottesville, Virginia

David O. Keyser, LCDR, MSC, USN, Department of Military and EmergencyMedicine, Uniformed Services University of the Health Sciences, Bethesda,Maryland

John J. Klimkiewicz, Associate Professor of Orthopedic Surgery, Director,Sports Medicine, Georgetown University, Washington, DC

Alex J. Kline, Medical Student, UVA Health System, Department ofOrthopedic Surgery, Charlottesville, Virginia

Roger J. Kruse, MD, Head Team Physician, University of Toledo, ProgramDirector, Sports Care, Sports Medicine Fellowship at the Toledo Hospital,Vice Chair, Sports Medicine and Sports Science of the U.S. Figure SkatingAssociation, Toledo, Ohio

John P. Kugler, MD, MPH, Director of Primary Care and CommunityMedicine, Dewitt Army Health Care System, Fort Belvoir, Virginia

Stephen J. Lee, Fourth year medical student, Northwestern University FeinbergSchool of Medicine, Rush-Presbyterian-St. Luke’s Medical Center, Chicago,Illinois

Jeffrey A. Levy, DO, Sports Medicine Fellow, Uniformed Services Universityof the Health Sciences, Bethesda, Maryland

John M. MacKnight, MD, Associate Professor, Clinical Internal Medicine andOrthopaedic Surgery, Medical Director, Sports Medicine, Primary CareTeam Physician, University of Virginia, Charlottesville, Virginia

Scott A. Magnes, MD, FACSM, Staff Orthopedic Surgeon, Naval Hospital,Great Lakes, Illinois

Gerard A. Malanga, MD, Director of Sports, Spine, and OrthopedicRehabilitation, Kessler Institute for Rehabilitation, Associate Professor,Physical Medicine & Rehabilitation, UMDNJ-New Jersey Medical School,West Orange, New Jersey

Eric M. Mangrum, PT, OCS, FAAOMPT, Staff Physical Therapist, Universityof Virginia/Healthsouth, Charlottesville, Virginia

Ronica A. Martinez, MD, Family and Sports Medicine, Kaiser PermanenteFontana, Fontana, California

Augustus D. Mazzocca, MD, Assistant Professor, Department of Orthopedics,University of Connecticut Health Center, John Dempsey Hospital,Farmington, Connecticut

Douglas B. McKeag, MD, MS, AUL Professor and Chair, Department ofFamily Medicine, Director, IU Center for Sports Medicine, IndianaUniversity School of Medicine

John P. Metz, MD, Assistant Director, JFK Family Practice Residency,Edison, New Jersey

C. Michele Miller, DO, Chief Resident, Department of Physical Medicine &Rehabilitation, UMDNJ-New Jersey Medical School, Newark, New Jersey

Mark D. Miller, MD, Associate Professor of Orthopedic Surgery, UVA HealthSystem, Charlottesville, Virginia

Danny Mistry, MD, Assistant Professor, Physical Medicine & Rehabilitation,Co-Medical Director, University of Virginia Athletics, Charlottesville, Virginia

Kambiz Motamedi, MD, Assistant Professor, Musculoskeletal Imaging, DavidGeffen School of Medicine at UCLA, Los Angeles, California

James R. Morales, MD, Silver Bay Medical Center, Toms River, New Jersey

CONTRIBUTORS xv

Scott F. Nadler, DO, Professor, Physical Medicine & Rehabilitation, UMDNJ-New Jersey Medical School, Newark, New Jersey

Bradley J. Nelson, MD, Chief, Department of Surgery, Keller ArmyCommunity Hospital, West Point, New York

Robert J. Nicoletta, MD, Orthopaedic Associates of Rochester, SportsMedicine/Arthroscopy, Rochester, New York

Robert P. Nirschl, MD, MS, Associate Clinical Professor of OrthopedicSurgery, Georgetown University, Founder and Director, Nirschl OrthopedicSports Medicine Clinic, Medical Director, Virginia Sports MedicineInstitute, Arlington, Virginia

Rochelle Nolte, MD, Sports Medicine Fellow, Uniformed Services Universityof the Health Sciences, US Coast Guard Training Center, Health ServicesDivision, Cape May, New Jersey

Derek H. Ochiai, Sports Medicine Fellow, Nirschl Orthopedic Center forSports Medicine and Joint Reconstruction, Arlington, Virginia

Elizabeth M. O’Connor, DDS, Clinical Associate, Department of Dentistry,St. Joseph’s Hospital Health Center, Syracuse, New York

Ralph P. Oriscello, MD, FACC, FACP, Director, Division of Cardiology,Veteran’s Administration Medical Center, East Orange, New Jersey

Brett D. Owens, MD, Resident in Orthopedic Surgery, University ofMassachusetts Medical School, Worcester, Massachusetts

Michael E. Pannunzio, MD, Assistant Professor, Department of OrthopedicSurgery, University of Virginia Health Sciences System, Charlottesville, Virginia

Chris G. Pappas, MD, Department of Family Medicine, Madigan Army MedicalCenter, Tacoma, Washington

Andrew D. Perron, MD, FACEP, FACSM, Residency Program Director,Maine Medical Center, Portland, Maine

Paul F. Pasquina, MD, Director, Physical Medicine and RehabilitationResidency Program, Walter Reed Army Medical Center, Washington, DC

Nicholas A. Piantanida, MD, Director, Primary Care Sports Medicine, DeWittArmy Hospital, Ft. Belvoir, Virginia

Mark D. Porter, Orthopaedic Service, William Beaumont Army MedicalCenter, Texas Tech UHS, El Paso, Texas

Joel Press, MD, FACSM, Medical Director, Center for Spine, Sports, andOccupational Rehabilitation, Rehabilitation Institute of Chicago, Chicago, Illinois

David E. Price, MD, Sports Medicine Fellow, Bayfront Medical Center, St.Petersburg, Florida

Christopher M. Prior, DO, Director, Sports Medicine, Department of FamilyMedicine, Darnall Army Community Hospital, Fort Hood, Texas

Scott W. Pyne, MD, Team Physician & Director of Sports Medicine, US NavalAcademy, Annapolis, Maryland

Christopher B. Ranney, MD, Department of Family Practice, Offut Air ForceBase, Nebraska

Brian V. Reamy, MD, Associate Professor and Chair, Department of FamilyMedicine, Uniformed Services University of Health Sciences, Bethesda,Maryland

John P. Reasoner, MD, Member, USA Boxing Sports Medicine Committee,Clinic Director, Emergicare Medical Clinic, Colorado Springs, Colorado

Jennifer L. Reed, MD, Assistant Professor, PM&R, Eastern Virginia MedicalSchool, Norfolk, Virginia

John C. Richmond, MD, Professor, Orthopedic Surgery, Tufts UniversitySchool of Medicine, Chairman, Department of Orthopedic Surgery, NewEngland Baptist Hospital

xvi CONTRIBUTORS

CONTRIBUTORS xvii

Nancy E. Rolnik, Sports Medicine Fellow, Kaiser Permanente, Fontana,California

Aaron Rubin, MD, Staff Physician and Partner, Southern CaliforniaPermanente Medical Group, Program Director, Kaiser Permanente SportsMedicine Fellowship Program, Kaiser Permanente Department of FamilyMedicine, Fontana, California

Anthony A. Schepsis, MD, Associate Professor of Orthopedic Surgery, Directorof Sports Medicine, Boston University Medical Center, Boston, Massachusetts

Leanne L. Seeger, MD, FACR, Professor and Chief, Musculoskeletal Imaging,Medical Director, Outpatient Radiology, David Geffen School of Medicineat UCLA, Los Angeles, California

Peter H. Seidenberg, MD, Director of Sports Medicine, St. Louis UniversityFamily Practice Residency Program, 375th Medical Group, Scott Air ForceBase, Illinois

Kate Serenelli, MS, ATC, CSCS, Staff Athletic Trainer, Department ofAthletics, University of Virginia, Charlottesville, Virginia

Craig K. Seto, MD, Assistant Professor, Family Medicine, University ofVirginia Health System, Charlottesville, Virginia

Michael Shea, MD, Sports Medicine Fellowship Program, Moses ConeHealth System, Greensboro, North Carolina

Jay Smith, MD, Associate Professor, Physical Medicine & Rehabilitation,Mayo College of Medicine, Rochester, Minnesota

Carolyn M. Sofka, MD, Assistant Professor of Radiology, Weill MedicalCollege of Cornell University, Assistant Attending Radiologist, Hospital forSpecial Surgery, New York, New York

Rebecca Spaulding, MD, Sports Medicine Fellowship Program, Moses ConeHealth System, Greensboro, North Carolina

Mark B. Stephens, MD, MS, Staff Family Physician, Medical Director, FlightLine Clinic, Naval Hospital, Sigonella, Italy, Associate Professor of FamilyMedicine, Uniformed Services University of the Health Sciences, Bethesda,Maryland

David Stewart, MD, Sports Medicine Fellow, Muses Cone Health System,Greensboro, North Carolina

Dean C. Taylor, MD, Director, US Army Joint and Soft Tissue Trauma CenterFellowship, Head Team Physician, United States Military Academy, WestPoint, New York

John Tobey, MD, Spine and Sports Fellow, Department of RehabilitationMedicine, University of Colorado Health Science Center, Aurora, Colorado

John Turner, MD, CAQSM, Assistant Professor, Department of FamilyMedicine, Indiana University, Indianapolis, Indiana

Winston J. Warme, MD, Chief, Orthopedic/Rehabilitation Service, ProgramDirector, Orthopedic Surgery Residency, William Beaumont Army MedicalCenter, Texas Tech UHSC, El Paso, Texas

Charles W. Webb, DO, Director of Sports Medicine, Department of FamilyPractice, Martin Army Community Hospital, Ft. Benning, Georgia

Brian Whirrett, MD, Sports Medicine Fellow, University of Washington,Seattle, Washington DC

Russell D. White, MD, Clinical Associate Professor, Department of FamilyMedicine, University of South Florida College of Medicine, Florida Instituteof Family Medicine, P.C., Assistant Team Physician, Tampa Bay Devil Rays,St. Petersburg, Florida

John H. Wilckens, MD, Assistant Clinical Professor of Orthopedics, JohnsHopkins Bayview Medical Center, Baltimore, Maryland

Cynthia M. Williams, DO, MEd, Assistant Professor of Family Medicine,Uniformed Services University of the Health Sciences, Bethesda, Maryland

Pamela M. Williams, Assistant Professor of Family Medicine, UniformedServices University of the Health Sciences, Bethesda, Maryland

Tory Woodard, MD, Chief Resident, Department of Family Medicine,Malcolm Grow Air Force Medical Center, Andrews Air Force Base,Maryland

David C. Young, MD, Sports Medicine, The Permanente Medical Group,Department of Orthopedics, South San Francisco, California

Joseph J. Zuback, Orthopaedic Service, William Beaumont Army MedicalCenter, Texas Tech UHS, El Paso, Texas

xviii CONTRIBUTORS

xix

In the spring of 1993, primary care sports physicians across the country werescrambling to identify good resources to prepare for the first examination for aCertificate of Added Qualification in Sports Medicine. This examination wasco-sponsored by the American Boards of Family Practice, Internal Medicine,Pediatrics, and Emergency Medicine. At review courses a common theme wasthat at that time, there was no identifiable source that reliably identified the dis-cipline of sports medicine, let alone a good review book or study guide. Sincethat time, of course, there have been a number of excellent books published inthe field of primary care sports medicine.

At the Annual Meeting of the American College of Sports Medicine in 2002,Darlene Cook of McGraw-Hill approached me about a new line of textbooksthat their company was developing called Just the Facts. Darlene, who hadmentored Robert Wilder and myself through our first book, Running Medicine,stated that McGraw-Hill’s market research had identified a need by cliniciansfor sources of essential information in an outline format that provided quickreference. Darlene also felt these books would provide excellent sources ofstudy for clinicians facing initial certification examinations or recertificationexams. As I was beginning to prepare for my ten-year recertification in sportsmedicine since my initial examination in 1993, I thought it would be an inter-esting endeavor.

The first task was to assemble a team of quality editors and authors. My firstcall was to Dr. Robert Wilder, a physical medicine and rehabilitation physicianand my colleague on a number of academic pursuits. We decided to include asecond sports medicine physician, as this would be an ambitious project, aswell as an orthopedic surgeon to hopefully recruit the most expertise in opera-tive orthopedics. We were very fortunate to have Dr. Robert Sallis, an author-ity in primary care sports medicine and fellowship program director, accept ourinvitation. Dr. Patrick St. Pierre, a sports trained orthopedic surgeon and edu-cator, graciously agreed to coordinate our orthopedic chapters. As a multi-disciplinary group, our goal became to develop a text that would have valueamong a variety of clinicians involved with sports medicine including medicaldoctors, surgeons, allied healthcare professionals and athletic trainers. Ourvision was a well-referenced, evidenced-based source of material that wouldprovide a resource for both study and practice.

A quick look at the author list identifies for the reader a number of “who’swho” leaders in the field of sports medicine. Interspersed among the “giants” in

PREFACE

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the field are recently graduated fellows and junior clinicians hungry to establishtheir own reputations in their communities. A common theme among all ourselected authors was that all were striving for excellence, and all are “practicing”clinicians. A second look at the list also reveals the multidisciplinary nature of ourteam with family physicians, internists, cardiologists, radiologists, orthopedicsurgeons, neurosurgeons, nutritionists, psychologists, physiologists, physiatrists,allergists, therapists, and athletic trainers, among others all contributing.

Despite the charge of creating a concise book that included only “just thefacts,” we were overwhelmed by the quality, and faced the unenviable positionof editing a considerable amount of material. We tried to replace volume anddetail with concisely written tables and algorithms where applicable. A reviewof any of the chapters will quickly bring the reader to the conclusion that thistext is much more than “just the facts.” We couldn’t be prouder of the finalproduct and certainly hope it meets the initial objectives we discussed for thereader. We believe it does, as this book will be an excellent reference for reviewand for clinical reference in patient care settings.

When we talked about dedicating the book we were all in agreement that thistext should be for those members of our family who have supported us through-out the years; through the long days, the evening training rooms, the volunteercommunity events, and the Friday nights and Saturday afternoons at local sport-ing events. We especially want to thank our wives, Janet, Susan, Kathy, andLinda and all our children, Ryan, Sean, Brendan, Lauren, Stephen, Ryan,Caroline, Samantha, Matt, Shannon, Patrick, Matthew, and Danielle. We wouldadditionally like to thank Darlene Cook for her vision and support, and MichelleWatt, our developmental editor at McGraw-Hill for keeping us on task.

xx PREFACE

SPORTS MEDICINEJust the Facts

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Section 1

GENERAL CONSIDERATIONSIN SPORTS MEDICINE

1 THE TEAM PHYSICIANChristopher Ranney, MDAnthony I Beutler, MDJohn H Wilckens, MD

WHAT IS A TEAM PHYSICIAN?

• Very little has been published about the duties andresponsibilities of a team physician and no formalstudies exist as to the qualifications and skills neces-sary to be effective in these duties.

• The following consensus statement from theAmerican College of Sports Medicine (ACSM)defines the unique role of a team physician:

The Team Physician must have unrestricted medicallicense and be an MD or DO who is responsible fortreating and coordinating the medical care of the ath-letic team members. The principal responsibility of theteam physician is to provide for the well-being of indi-vidual athletes—enabling each to realize his or her fullpotential. The team physician should possess specialproficiency in the care of musculoskeletal injuries andmedical conditions encountered in sports. The teamphysician also must actively integrate medical expert-ise with other healthcare providers, including medicalspecialists, athletic trainers, and allied health profes-sionals. The team physician must ultimately assumeresponsibility within the team structure for makingmedical decisions that affect the athlete’s safe partici-pation. (Herring et al, 2000b)

• Doctors from many specialties serve in the role of teamphysician with primary care physicians comprising themajority. The most common fields of medicine with the

percentage of the total in parentheses is family practice(25.5%), orthopedic surgery (16.2%), osteopathic med-icine (10.9%), internal medicine (10.1%), general prac-tice (6.3%), pediatrics (5.4%), emergency medicine(4.9%), general urgery (4.5%), obstetrics/gynecology(2.8%), cardiology (2.0%), and all others (11.5%)(Melion, Walsh, Shelton, 1997).

• The team physician is part of a team of professionalsthat cares for the athletes and contributes to their suc-cess by maximizing training and competition prepara-tion. He or she also assists by accurately diagnosingailments and promptly, yet completely, rehabilitatinginjuries to get athletes back to competition as quicklyand safely as possible. In addition to expertise in thecommon medical conditions encountered in athletes,other necessary qualities include: flexibility and avail-ability, good communication skills, a desire to edu-cate, and an understanding of injury preventionprinciples (Herring et al, 2000b).

TIME REQUIREMENTS OF A TEAM PHYSICIAN

• A team physician must have an office schedule thatcan accommodate athletes with urgent and time sensi-tive medical needs.

• Most team physicians have designated training roomtime each week, at least one to two evenings, wherethey can evaluate new and follow-up existing injuriesof team members. This is an especially important set-ting in which to communicate with the trainer on therehabilitation progress of athletes’ injuries (Herringet al, 2001). An athlete’s behavior and responses canvary widely depending on the familiarity of the envi-ronment; hence, training rooms should ideally beheld in the athlete’s “native environment,” at a loca-tion convenient to athletes and close to practice ortraining facilities.

1

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• Team physicians often neglect team practices. Whileit is not necessary that all practices be attended, occa-sional, brief appearances during practice will allowthe physician to gain insight into the environment andconditions in which the athletes train, the team’s train-ing regimen, and interactions between coaches andplayers. A better appreciation of all these factors canprove invaluable in the physician’s medical decisionmaking. Additionally, brief appearances at practicehelp the physician build collegial relationships withcoaches and players, establishing his or her role as apart of the team and distinguishing the physician fromother officials, support staff, and media representa-tives who only participate in game-day activities.

• Amount of time spent at the actual competitiondepends on the team physician’s role and availability,as well as state laws and regulations of the governingathletic association. Some laws mandate that a physi-cian be in attendance for every game. Other lawsallow nonphysician medical personnel, such as an ath-letic trainer, to cover an event with on-call physicianbackup (Herring et al, 2000a).

• A doctor who is the team physician for an entire insti-tution must decide whether to attend all the games fora few teams, or to attend a few games for every team.We recommend that team physicians attend at leastpart of one practice and at least one game for eachteam they supervise. Providing good team medicine isvery difficult without observing the interactions andconditions of play and practice.

CORE KNOWLEDGE OF THE TEAM PHYSICIAN

• To perform his or her duties effectively, a team phy-sician needs an understanding of the medical conditionscommon to the athlete. This knowledge should encom-pass many areas of medicine, including but not limitedto—orthopedics, cardiopulmonary medicine, neurol-ogy, dermatology, and sound principles of rehabilita-tion (Herring et al, 2000b).

• The team physician also needs expertise in pharmacol-ogy. Practical pharmacology for the team physicianincludes not only knowing how to treat illnesses, butalso an understanding of performance enhancing drugsand herbal medicines. Team physicians must be familiarwith the substances that are banned by the governingathletic association so that an athlete does not inadver-tently lose eligibility to compete (Melion et al, 1997).

• A team physician must have a general knowledge ofbehavioral medicine and psychology. Mood distur-bances and mental illnesses (like depression) affectathletes and can be very common in injured athletes.

• A team physician’s knowledge of exercise science andnutrition can help prevent injuries, as well as maximizean athlete’s performance. Disordered eating and over-training can prove devastating if not recognized earlyand treated effectively (Herring et al, 2000b).

MEDICAL RESPONSIBILITIES OF THETEAM PHYSICIAN

• The first responsibility of a team physician is to deter-mining whether an athlete is fit to participate. Thisevaluation most commonly occurs during the prepar-ticipation physical. This examination may or may notbe preformed by the team physician, but the teamphysician should review the documentation of thisexamination so that he or she will know of any con-dition that may limit competition or predispose theathlete or other participants to injury. This prepartici-pation physical must be done prior to athletic trainingor participation—preferably 6–8 weeks beforehand sothat all potentially disqualifying conditions can befully evaluated without missing jeopardizing sched-uled participation (Herring et al, 2000a).

• Sideline and event coverage is the most obvious respon-sibility of the team physician. A physician should coverall collision and high-risk sports. Other athletic eventscan be covered by any allied health professional who istrained in recognition and initial treatment of athleticinjuries (Herring et al, 2000a). A team physician mustcontinually remind himself or herself that he or she ismore than a spectator. The physician should be a“dispassionate observer,” meaning that the emotions ofcompetition must not affect medical decision making.Attention should be directed to the safety of the partici-pants, not the immediate passions of the game.

• The team physician should focus attention on aspectsof play and individuals who are more prone to injury.In other words, the seasoned team physician will care-fully follow the game, but not always follow the ball.For instance, in American football relatively little injuryinformation can be gained by watching the flight ofthe ball on punts, kickoffs, and passes. Rather, injuriesoccur and attention should be focused on linemen, quar-terbacks after releasing the ball, and wide-receivers aftercatching the ball. In every sport, special attention shouldbe given to situations and players at high risk for injury.

• The team physician must be prepared to handle non-participant emergencies for it is not uncommon for theteam physician to be called on to treat an ill-fallencoach, referee, or spectator.

• The team physician insures accurate diagnosis throughuse of additional studies and specialty consults, com-municates information clearly and confidentially

2 SECTION 1 • GENERAL CONSIDERATIONS IN SPORTS MEDICINE

CHAPTER 1 • THE TEAM PHYSICIAN 3

regarding the player’s condition to those who need toknow, coordinates the rehabilitation process, anddetermines when the athlete is able to compete again.This essential process involves active communicationwith athletes, parents, athletic trainers, physical thera-pists, coaches, administrators, and other medical spe-cialists as necessary (Rice, 2002).

• Pursuing active follow-up with medical specialists is acritical duty. Team physicians may refer athletes tosubspecialty providers to assist in treatment or withclearance for athletic participation; however, informa-tion from these visits does not naturally flow back tothe team physician. Assuming that the specialtyprovider will call with any important information, orthat all pertinent information will flow back throughthe health care system, will result in confusion for theteam physician and danger for the athletes. Shadowfiles, tickler lists, and other reminder systems can helpteam doctors actively and personally follow up onreferrals, thus preventing the always embarrassing andoften dangerous situations that result from incompletemedical communication between subspecialists andthe team physician.

• Documentation of medical care is often mistakenlyneglected in the team setting. The team physicianneeds to keep formal and confidential medical recordsthat detail communication with consultants, givetreatment and follow-up instructions, and providedetails for insurance and reimbursement purposes(Rice, 2002).

• The team physician should have final say of when anathlete is initially cleared to begin competition andwhen a previously injured athlete may return to play(Herring et al, 2000a).

ADMINISTRATIVE RESPONSIBILITIES OF THETEAM PHYSICIAN

• The team physician’s primary concern is the coordi-nation of medical supervision. This organizationincludes: making sure qualified medical personnel areattending practices and competitions as needed,designing a plan for sideline evaluation, and havingnecessary medical equipment readily available. Theteam physician encourages defined roles and respon-sibilities for all involved in the medical care of theteam, along with establishing a medical chain of com-mand. The team physician may not make all the dailydecisions but should have full authority concerningmedical policy-making.

• The team physician needs to lead the planning for andpracticing of medical emergencies and urgencies. Inaddition to having an emergency treatment and transport

plan, the team physician also must know the medicalcapabilities of surrounding hospitals—particularlyaround away competitions sites—so that injured ath-letes are brought to medical facilities that are bestequipped to handle their specific medical problem(Herring et al, 2000a).

• The team physician should implement protocols thatfacilitate timely and quality medical care for situa-tions when he or she is not immediately available.Preestablished guidelines for return to play are veryhelpful, especially when injuries to impact athletesresult in high pressure for returning to competitionbefore appropriate healing has occurred (Herring et al,2000b). The ACSM consensus statement on return-to-play issues more fully details the responsibilities ofthe team physician when returning athletes to compe-tition (Herring et al, 2002).

• The team physician oversees the playing environment.He or she should evaluate both practice and gamefacilities for safety. A safe playing environment alsoinvolves appropriate and properly fitting protectiveequipment, available hydration, and an activity levelappropriate for the climate.

COMMUNICATION RESPONSIBILITIES OF THETEAM PHYSICIAN

• For a team to receive optimal medical care, the teamphysician and trainer must communicate openly andclearly. Even before the season, they need to discussmedical treatment protocols, which preferably aredocumented in writing (Rice, 2002). When an injuryoccurs there can be no confusion over who will go onthe field for initial evaluation and who will communi-cate to the coach the extent of an athlete’s injury andplaying status.

• A team physician needs to develop good rapport withthe coach. Offering injury prevention suggestions andplayer health education may demonstrate to the coacha shared desire to assist the team attaining their goals.Most importantly, a team physician must keep thecoach informed of an injured player’s ability to con-tinue to compete safely. Without breaching playerconfidentially, the team physician should provide thecoach a timeframe for further evaluation or theplayer’s return. In general, this should be communi-cated in terms of a sport-specific timeline, such as: theplayer is out for a play, out for a series, reassessmentwill be done at half-time or game’s end, or the playeris likely lost for the remaining part of the season.

• A team physician may also be required to discuss aplayer’s medical condition with the school officials.Administrators often need to know specifics regarding

physician recommendations: how long will the playermiss class or be in the hospital. They seldom need toknow medical or personal details of the athlete’s situ-ation. Remember that the athlete’s confidentiality isthe first concern. Members of the media rarely, if ever,need information from the team physician.

• Well-defined criteria for dealing with the media shouldbe established. If a team physician is encouraged toparticipate in an interview, insist that written questionsbe submitted before-hand so that appropriate remarkscan be constructed for the record. These plannedresponses can be reviewed with team coaches, trainers,and administrators to ensure their consistency, accu-racy, and regard for the athlete’s privacy.

• A team physician may need to discuss an athlete’s med-ical condition with his parents, especially if workingwith minors. It may be beneficial to send a letter toparents prior to the season, describing the role of the teamphysician and the continued importance of their personalprimary care physician to the athlete’s overall health.

• As mentioned above, the team physician coordinatesspecialty care as medically indicated. In doing so, heor she should provide the pertinent information neces-sary to the respective medical consultant’s care andreceive written documentation of recommendationsfrom medical specialists.

OTHER CONSIDERATIONS FOR THETEAM PHYSICIAN

• Sports medicine abounds with opportunities forresearch. Simply keeping accurate epidemiologic andinjury data has the potential to impact training regi-mens, competition rules, or mandates for protectiveequipment (Rice, 2000).

• Every would-be team physician must research themedical liability risk and insurance coverage associatedwith the position. A written contract or memorandumof understanding with the institution or team thatdefines responsibilities and level of coverage expectedis essential—even if no compensation is to bereceived (Rice, 2002). Good Samaritan laws exist inmany states but the exact law varies widely betweendifferent jurisdictions. Most Good Samaritan lawsapply only if the physician is receiving no compensa-tion for his or her services. Compensation may bedefined by a specific dollar amount, or as little asreceiving a team shirt to wear at games!

• Compensation as a team physician is variable. Almostall work with teams competing at less than collegiatelevel is voluntary. Deferring offers for nominal remu-neration in favor of paying a trainer’s salary can be abeneficial and time saving option (Rice, 2002). Most

team physicians work with athletic teams solely forprofessional and personal satisfaction owing to theirinterest in sports and athletes.

REFERENCES

Each of these consensus statements is published by multi-ple organizations. They may be downloaded or viewed freeat www.acsm.org/publications/consensusstatements.htm

Herring SA, Bergfeld JA, Boyd J, et al: Sideline Preparedness forthe Team Physician: A Consensus Statement. American Academyof Family Physicians, American Academy of OrthopedicSurgeons, American College of Sports Medicine, AmericanOsteopathic Academy of Sports Medicine, 2000a.

Herring SA, Bergfeld JA, Boyd J, et al: Team Physician Conse-nsus Statement. American Academy of Family Physicians,American Academy of Orthopedic Surgeons, AmericanCollege of Sports Medicine, American Osteopathic Academyof Sports Medicine, 2000b.

Herring SA, Bergfeld JA, Boyd J, et al: The Team Physician andConditioning of Athletes for Sports: A Consensus Statement.American Academy of Family Physicians, American Academyof Orthopedic Surgeons, American College of Sports Medicine,American Osteopathic Academy of Sports Medicine, 2001.

Herring SA, Bergfield JA, Boyd J, et Al: The team physician andreturn-to-play issues: A consensus statement. Med Sci SportsExer 34:1212–1214, 2002.

Melion MB, Walsh WM, Shelton GL: The Team Physician’sHandbook, 2nd ed. Philadelphia, PA, Hanley & Belfus, 1997,pp 1–7.

Rice SG: The high school athlete: Setting up a high school sportsmedicine program, in Mellion MB, EWalsh WM, Madden C,et al (eds.): The Team Physician’s Handbook, 3rd ed.Philadelphia, PA, Hanley & Belfus, 2002, pp 67–77.

Rice SG: Development of an injury surveillance system: Resultsfrom a longitudinal study of high school athletes, in Ashare AB(ed.): Safety in Ice Hockey vol. 3, ASTM STP 1341. WestConshohocken, PA, American Society for Testing andMaterials, 2000, pp 3–18.

2 ETHICAL CONSIDERATIONS INSPORTS MEDICINERalph G Oriscello, MD FACC, FACP

INTRODUCTION

• Ethics in general is the conforming to accepted stan-dards of conduct. No one achieves ethical perfection butsports physicians are good by nature and guided by high

4 SECTION 1 • GENERAL CONSIDERATIONS IN SPORTS MEDICINE

CHAPTER 2 • ETHICAL CONSIDERATIONS IN SPORTS MEDICINE 5

ethical standards. Sports themselves are considered toreflect values generally considered to be important tosociety: character building, health promotion, and thepursuit of competitive excellence and enjoyment.

• Ethical considerations in the area of sports medicineare similar to those in medicine in general, includingthe basic principles and rules.

• Beneficence, the principle of performing acts ormaking recommendations only potentially beneficialto an athlete, is the trump principle.

• Nonmaleficence, the principle of prohibiting recommen-dations or actions detrimental to an athlete’s short- andlong-term health, is considered with every action takenin the trainer’s room when tending to an injured athlete.

• Confidentiality informed consent and truthfulness areabsolutely essential for the ethical management of anysports related medical decision.

THE SPORTS PHYSICIAN’SRESPONSIBILITIES

• An athlete’s autonomy, his or her interests and desires,and the third principle of medical ethics must alwaysbe taken into consideration in any decision made by asports physician. Such decisions should always bemade in the athlete’s best interest.

• Whether the decision involves a diagnostic test or theathlete’s eligibility, its end result is the maintenance ofgood health with the least risk to the athlete.

• Conflict between physician and athlete should alwaysbe minimal or absent.

• While autonomy is respected, most athletes can andshould rely on their sports physician to lead them inthe decision making process.

• It is quickly recognized by the sports physician thatone solution rarely fits all with the same problem. Thesame set of circumstances can lead to a different sug-gested solution by the same sports physician.

• Exactness and infallibility, while desirable, are not traitsof even the finest sports physicians (Maron, 1994).

• The sports physician’s primary duty is to make thebest effort to maintain or restore health and functionalability (Howe, 1988).

• The athlete’s welfare must guide all efforts.• To be a good sports physician, he or she must have a

genuine appreciation for the importance of athletics inhis or her client’s life. The precepts of Dr. O’Donoghuefor sports physicians are timeless: accept athletics, avoidexpediency, adopt the best methods, act promptly, andtry to achieve perfection (O’ Donoghue, 1984).

• The injured athlete must know the diagnosis, under-stand its implications, and participate in all therapeu-tic decisions.

• Despite the athlete’s wishes, the sports physiciancannot do less than seek the best possible outcome.

• All sports medicine physicians gain knowledge andbetter judgment with experience, soon recognizingmany recommendations or forms of therapy haverisks as well as benefits.

• Harm can come to the athlete-patient from unneces-sary or excessive restriction as well as from failure torestrict activity when appropriate.

• The sports physician does not operate in a vacuum. Tomake sports oriented medical decisions, one must bewell versed in current recommendations for eligibilityand continued participation and not depend on his orher own limited personal experience or unscientificreasoning (Mitten, 1999).

• Recognizing the wide range of opinions and individ-ual fallibility, athlete-patients can assert their right toanother opinion.

• Continuing education of the sports physician aids in thedevelopment of a suitable level of skill and knowledgeand their maintenance (26th Bethesda Conference,1994).

• While sports physicians will be able to treat mostreferrals, they must be aware of their own level ofcompetence. They must know when and where torefer for specialized consultation or therapy. It isessential to know their colleague’s ability, personality,and empathy for athletes in order to make competentreferrals (Rizve and Thompson, 2002).

• The referred patient should not be abandoned. Theconsultant may gain insight from the referring physi-cian. This affords the athlete continuing support fromhis or her primary sports physician.

• There is no obligation to accept without question therecommendations of consultants, especially if incon-gruent with the referring physician’s knowledge of thepatient.

• All the above lead to trust established between athleteand physician, allowing for more comfortable resolu-tion of the decision making process.

POTENTIAL FOR DIVIDED LOYALTIES

• While rare in high school and uncommon in collegesports, there is major distrust between professionalathletes and team physicians (George, 2002).

• Athletes may feel that there are too many instanceswhen the quality of their treatment is often secondaryto the doctor’s obligation to team owners and coaches.

• A salaried position can interfere with the traditionaldoctor–patient relationship.

• To many the role of the salaried physician leads to aconflict of interest. Such a conflict exists when the

employed sports physician’s objective professionalduties are compromised by personal interests, e.g., thefinancial reward of his or her association with a pro-fessional team as well as the publicity and high visi-bility one gets from such a position.

• It is an ethical breach for anything but the athlete’shealth interest to be considered, again, recognizingjudgment errors in too conservative or too liberal ther-apy can occur.

• The ultimate welfare of the athlete may seem in con-flict with the wishes of parents or spouse, coaches orteam management. The fact that an organization orsomeone other than the athlete pays the physician isimmaterial. The loyalty of the sports physician is tothe continued healthy physician–patient relation-ship.

• Decisions must be made solely based on sound med-ical judgment. A reasonable third party, e.g. a univer-sity or professional team, will understand this. If itdoes not, the physician should remove his or her serv-ices from that party.

• Occasionally, wishes of the athlete-patient conflictwith what the physician believes are in the athlete’sbest interest. If after negotiation and additional con-sultation the sports physician feels uncomfortablewith another’s recommendation, continued care ofthe athlete-patient could be difficult or impossible.The athlete should be reassigned to another physi-cian.

• For the professional athlete, the unfavorable mix ofhigh salaries and short careers can make for riskydecision making by both the athlete and the physician.Coaches often encourage physicians to rush playersback on to the field to win games. Players themselvesoften desire to rush back too quickly.

• Teammates should not be allowed to pressure injuredathletes by suggesting they are malingering while col-lecting a substantial income. Under these circum-stances many physicians play by the rules of thecoaching staff.

• An untimely death or worsening injury sets the stagefor lack of trust in the team physician.

• By actions alone, the team physician demonstratesthat his or her utmost responsibility is to protect theplayers. If a player should not be on the playing field,that players will not be there.

DRUG USE

• It is common knowledge that there is illicit drug useby athletes at all levels: recreational drugs, anabolicsteroids, pain controlling agents, ergogenics, andalcohol.

• Therapeutic medications are an integral part of sportsmedicine. Used appropriately, they control pain andinflammation, speed recovery, and hasten return tofunction.

• It is the obligation of the sports physician to knoweach drug thoroughly, especially its potential effect(s)on the safety or effectiveness of the athlete’s perform-ance. Appropriately prescribed drugs must not exposethe athlete to potential disqualification, e.g., as in theprevention of exercise-induced asthma, when aneffective legal medication can be found.

• Nowadays, available testing makes it impossible tocatch all participants who use banned substances.That is rapidly changing.

• There are those who would remove all bans onenhancing agents, hormones for instance, allowing fora “free-for-all” with unrestricted use.

• There are two major arguments against such an atti-tude: one should not condone cheating; and the essenceof sport itself.

CONFIDENTIALITY

• There is no grade to confidentiality: more for a highprofile athlete; less for one with a lesser public persona.

• Confidentiality must be inviolate, despite the fact thatathletes are very public persons.

• Society wants to know the most intimate details ofathletes’ lives, including medical evaluations andtreatments.

• No athletes forfeit their right to medical privacy.• All inquiries made of sports physicians by the press or

other interested parties should go unanswered unlessspecifically permitted by the athlete.

• Even with permission, the sports physician must beextraordinarily sensitive about details revealed.

• Despite claims regarding the public’s “right to know,”the right to privacy remains with the athlete–patient.

• The press is very resourceful in gaining information—inaccurate on more than a few occasions. If inaccurateinformation is printed, the physician may, with theathlete’s permission, attempt to correct it.

• On occasion, the sports physician will advise the ath-lete–patient about the amount of information torelease to coaches. This is important when restrictionfrom practice or competition is necessary. The athleteusually grants such permission. Here we refer to theathlete’s private sports physician, not one employedby a school or professional team.

• No greater breach of confidentiality can occur than ifany health information is released to anyone remotelyrelated to the athlete’s career without forewarning theindividual.

6 SECTION 1 • GENERAL CONSIDERATIONS IN SPORTS MEDICINE

CHAPTER 2 • ETHICAL CONSIDERATIONS IN SPORTS MEDICINE 7

• When a sports physician is employed by a school,team, or similar entity, the expectations of both ath-lete–patient and sports physician are agreed on at theoutset. That sports physician must always maintain hisor her position as an advocate for the athlete–patient’swelfare.

• An employed sports physician must still respect theathlete–patient’s autonomy in medical decisionmaking, while advising against any decision thatcould compromise the patient’s future health and ath-letic career.

RELATIONSHIP WITH COLLEAGUES

• Among the problems that can arise for a team physi-cian are those involving other physicians participatingin the care of the athlete–patient. There must be sen-sitivity demonstrated to the relationship of all medicalprofessionals involved.

• The sports physician must never criticize the actionsof another physician to the athlete–patient. Privatediscussions with the primary care physician regardingrecommended therapy should be undertaken.

• The sports physician is in a position to positivelyinfluence his or her colleague’s care of athletes in thefuture by such positive input.

• If playing restrictions have been imposed on an ath-lete by a primary care physician, while not counter-manding them, the sports physician must always insiston an individual assessment of the athlete’s return toplay status.

• Consultation between the sports physician and theathlete’s primary care physician usually solves theproblem and provides an opportunity for education.

• Sports medicine is a team effort involving physiciansand many paramedical disciplines. The sport’s physi-cian recognizes that these can be helpful while coor-dinating the athlete’s care. The sports physician mustinsist that such assistants adhere to the same high eth-ical standards he or she practices.

• The sports medicine physician has an obligation toexpose quackery and unproved practices employed inthe guise of improving performance, thus protectingathletes and their careers.

FEAR OF LEGAL ENTANGLEMENT

• There is always a question as to what the sports med-icine physician should do in the presence of a life-threatening situation or a potentially disablingcondition. Under these circumstances, the physician

must be cautious and recommend against participa-tion.

• When operating at the highest ethical level withsupport from the medical literature and the medicalcommunity, such an event should never alter aphysician’s role in the future evaluation of otherathletes.

• A sports physician not afraid to make the difficult callshould be sought out by other physicians and athletes.

SUMMARY

• Sports medicine offers awesome responsibilities and amagnitude of potential problems exceeding manyother specialties.

• Familiarity with many disease states that can affect anathlete’s ability to participate is required.

• Athletes can only be allowed to participate if they donot endanger themselves or others.

• The physician must be familiar with unethical meansto enhance performance.

• The physician must be aware of resources available toaid him or her in rendering an authoritative opinion.

• The physician must be devoted to the rules of confi-dentiality, informed consent, and truthfulness.

• The physician must be aware that occasional deci-sions may require legal enforcement.

• The physician must be aware that there is no table ofcontents to refer to for every decision. A backbone,on occasion, is more important than an ethicsprimer.

REFERENCES

26th Bethesda Conference: Recommendations for determiningeligibility for competition in athletes with cardiovascularabnormalities. J Am Coll Cardiol 24:845, 1994.

George T.: Care by team doctors raises conflict issue. N Y Times(print) Sect.8 (col 5), Jul 28, 2002.

Howe WB.: Primary care sports medicine: a partimer’s perspec-tive. Phys Sports med 16:103, 1988.

Maron B.: Surviving competitive athletics with hypertrophic car-diomyopathy. Am J Cardiol 73:1098, 1994.

Mitten MJ.: Medicolegal issues, in Williams RA (ed.): TheAthlete and Heart Disease: Diagnosis, Evaluation & Man-agement. Philadelphia, PA, Lippincott Williams & Wilkins,1999, p 307.

O’Donoghue DH.: Treatment of Injuries to Athletes, 4th ed.Phildelphia, W.B. Saunders, 1984, p 7.

Rizve AA, Thompson PD.: Hypertrophic cardiomyopathy: Whoplays and who sits. Cur Sports Med Rep 93, 2002.

3 LEGAL ISSUESAaron Rubin, MD, FAAFP, FACSM

INTRODUCTION

• The advice of an attorney should be considered beforemaking any legal decisions.

• Sports is a microcosm of society.• There are rules of sports and society that must be cre-

ated, interpreted and, at times, argued.• Medical practice in sports is held to the same stan-

dards as any other medical practice.• Legal issues in the area include—but are not limited

to—malpractice, contracts, licensure, insurance, GoodSamaritan laws, and confidentiality issues.

• These issues may be complicated by the practice ofsports medicine in the public arena and the traditionsof team and game coverage.

• This chapter is by no means meant to substitute for theadvice of an attorney, but is presented to draw atten-tion to potential legal issues that may arise in the prac-tice of sports medicine.

DEFINITIONS

• Law: A body of rules or standards of action or con-duct ordained or established by some authority. Thelaw of a state is found in statutory and constitutionalenactments as interpreted by its courts and contem-plates both statutory and case law.

• Lawful: Legal, permitted by the law. Not forbiddenby law, not illegal.

• Contract: An agreement between two or more par-ties which creates legally binding obligations to do ornot to do a particular thing. A valid contract mustinvolve competent parties, proper subject matter, con-sideration, and mutuality of agreement and of obliga-tion.

• Expressed: An express contract is openly expressedin writing or orally stated in distinct and explicit lan-guage.

• Implied: An implied contract is one inferred by theconduct of the parties to exist.

• Bilateral: A bilateral contract is one involving mutualpromises between parties.

• Unilateral: A unilateral contract is a one-sided prom-ise where one party undertakes an obligation withoutreceiving in return any express engagement or prom-ise of performance from the other.

• Civil law: Body of law that a nation or state hasestablished for itself. Law determining privaterights and liabilities as distinguished from criminalor natural law. Laws concerned with civil or privaterights and remedies as contrasted with criminallaws.

• Criminal law: The branch of law which defines whatpublic wrongs are considered crimes and assigns pun-ishment for those wrongs. It declares what conduct iscriminal, and prescribes the punishment to beimposed for such conduct.

• Natural law: The moral or ethical law, formulated inaccordance with reason, natural justice, and the origi-nal state of nature.

• Case law: Law based on judicial precedent ratherthan legislative enactment. The body of law foundedin adjudicated cases as distinguished from statute,common law. It includes the aggregate of reportedcases that interpret statutes, regulations, and constitu-tional provisions.

• Tort: A wrongful injury, a private or civil wrong. Atort is some action or conduct by someone (defendant)which causes injury or damage to another (plaintiff).Torts may be intentional (when the defendant intendsto violate a legal duty) or negligent (when the defen-dant fails to exercise the proper degree of care estab-lished by law). A legal wrong committed on theperson or property independent of contract. It may beeither (1) a direct invasion of some legal right of theindividual; (2) the infraction of some public duty bywhich special damage accrues to the individual; or (3)the violation of some private obligation by which likedamage occurs to the individual.

• Negligence: The inadvertent or unintentional failureto exercise that care which a reasonable, prudent, andcareful person would exercise; conduct which violatescertain legal standards of due care. Negligence consti-tutes grounds for recovery in a tort action, if it causesinjury to the plaintiff.

• Liability: Any type of obligation or debt owed toanother party. An obligation or mandate to do orrefrain from doing something. An obligation one isbound in law or justice to perform.

• Plaintiff: Person who brings a lawsuit; the com-plainant; the prosecution in a criminal case. The partywho complains or sues in a civil action and is sonamed on the record.

• Defendant: The person accused in a criminal case orsued in a civil action. The person defending or deny-ing wrongdoing.

• Captain of the ship doctrine: This doctrine imposesliability on the surgeon in charge of an operation fornegligence of his or her assistants when those assis-tants are under the surgeon’s control, even though the

8 SECTION 1 • GENERAL CONSIDERATIONS IN SPORTS MEDICINE

CHAPTER 3 • LEGAL ISSUES 9

assistants are also employees of the hospital (Nolanand Nolan-Haley, 1990).

DUTIES, ROLE, AND RESPONSIBILITIESOF THE TEAM PHYSICIAN

• The duties of the team physician to a team may beoutlined in a letter of agreement or contract betweenthe organization and physician.

• The duties to the individual athlete should be consid-ered as with any other patient–physician relationship.

• Balancing this duty to team and athlete must be con-sidered in every situation.

• A consensus statement on the duties of the teamphysician has been created by several organizationsand available in its entirety from these groups:a. American Academy of Family Physicians (AAFP)b. American Academy of Orthopedic Surgeons

(AAOS)c. American College of Sports Medicine (ACSM)d. American Medical Society for Sports Medicine

(AMSSM)e. American Orthopedic Society for Sports Medicine

(AOSSM)f. American Osteopathic Academy of Sports

Medicine (AOASM)• Qualifications from this consensus statement include

the following:a. Medical or osteopathic degree with unrestricted

license to practice medicineb. Fundamental knowledge of emergency care

regarding sporting eventsc. Trained in CPRd. Working knowledge of trauma, musculoskeletal

injuries and medical conditions affecting the ath-lete

• Medical duties from this statement stated that theteam physician has ultimate responsibility to includecoordination of the preparticipation screening; man-agement of on-field injuries; medical management ofinjury and illness; coordination of rehabilitation andreturn to participation; coordination of medical care,education, and documentation; and record keeping.

• Administrative duties include establishing relation-ships, education, development of a chain of com-mand, plan and train for emergencies, addressequipment and supply issues (as needed to provideadequate medical coverage), provide for event cover-age, and assess environments concerns and playingconditions.

• Standard definitions of negligence generally apply.The physician is held to what the reasonable, pru-dent man would do. As guidelines become more

established, these may become the basis for dutiesand responsibilities of the team physician.

DUTIES, ROLE, AND RESPONSIBILITIESOF THE TEAM AND ATHLETES

• The responsibilities of the team (organization, owner-ship, administration) should also be outlined in a con-tract.

• The team should provide a safe venue (including ade-quate security), appropriate safety equipment, sup-plies needed to treat injured or ill athletes (unlessotherwise specified in the agreement) and appropriateresponse for an emergency situation.

• The team (including coaching staff) should not inter-fere with care of the athlete including return to playissues.

• The athlete should be prepared for participation andparticipate safely and according to the rules of thesport. If not, they may share in responsibility forinjury.

• The athlete or team has a duty to report conditions tothe team physician and not conceal illnesses, injury, orsymptoms that may occur.

CONTRACTS

• Traditionally, many team physicians work with aslittle as a handshake or loose agreement.

• One should consider “putting it in writing.”• This contract should outline duties, responsibilities

for providing supplies, compensation, travel expecta-tions, provision of coverage in your absence, length ofcontract, responsibilities for providing preparticipa-tion examinations, liability coverage, and game deci-sion processes (such as who has the final word onreturn to play issues).

• An attorney can be extremely helpful in creating sucha document.

LIABILITY

MALPRACTICE COVERAGE

• Malpractice is defined as unreasonable lack of skill orprofessional misconduct.

• Failure to render professional services under cir-cumstances in the community by the “average, pru-dent reputable member of the profession” withresultant injury or damage to the recipient of thoseservices.

• Negligence is the predominant theory of liability in med-ical malpractice suits. It requires the following to occur:a. Physician’s duty to the plaintiffb. Violation or breach of applicable standard of carec. Connection (causation) between the violation of

care and harmd. Injury (damages) that can be compensated

• Physicians should have adequate coverage to defendany case brought against them and to compensate anyjudgments decided against them.

• Coverage may not be in effect if a physician is prac-ticing beyond the scope of his or her expertise or in anunlicensed area.

• Physicians traveling out of state or country with teamsshould be aware of this possibility and check withtheir malpractice carrier.

• Malpractice insurance should include an adequate tailto cover physicians when they change jobs

FALLACY OF THE GOOD SAMARITAN

• Good Samaritan doctrine: One who sees a person inimminent and serious peril through negligence ofanother cannot be charged with contributory negli-gence as a matter of law, in risking his own life or seri-ous injury in attempting to affect a rescue, provided theattempt is not recklessly or rashly made. Under thisdoctrine, negligence of a volunteer must worsen theposition of person in distress before liability will beimposed. This protection from liability is provided bystatute in most states (Nolan and Nolan-Haley, 1990).

• These laws and protection vary from state to state.• These are a defense in a lawsuit and must be presented

by your attorney as such.• A person expected to act, such as a team physician at

a game, may not be covered by the Good Samaritandoctrine, whether compensated or not.

• The Good Samaritan doctrine should not be a substi-tute for adequate malpractice coverage.

• The doctrine should be adequate in most states tocover a physician who renders aid when an unex-pected medical situation arises, such as at an autoaccident or if as a spectator at an event where anotherspectator has a cardiac arrest.

• Some jurisdictions may require a physician to providecare under these circumstances.

PATIENT (ATHLETE)—PHYSICIAN RELATIONSHIP

• The patient (athlete)–physician relationship should beone of mutual trust and teamwork.

• The athlete (or parents or guardian if a minor) hasrights to autonomy, self determination, privacy, andappropriate medical care.

• Even if a minor, an athlete has certain rights to seekmedical care in most jurisdictions for treatmentrelated to pregnancy, drugs, and sexually transmitteddisease. Check with local laws.

• Privacy is a difficult issue owing to the public nature ofathletic events—evaluation is done on the field or court-side. All attempts must be made to maintain privacy.

• Professional and college organizations may considerwaivers to allow certain information regarding athleticinjuries or illnesses to be discussed with press repre-sentatives. Some organizations require reporting ofinjuries and illness (such as professional sports andsome college sports). Care must be taken to avoid dis-closing information.

• It is probably best to have an administrative person, suchas a sports information director or public informationofficer, deal with the press to prevent the physician frominadvertently releasing private issues. If the physician isto talk with the press he or she should speak with cau-tion and only with the athlete’s permission.

DRUGS AND THE ATHLETE

MEDICATIONS: PRESCRIBING; DISPENSING

• Legal medications are generally divided into twogroups, prescription and over-the-counter (OTC).Prescription medications are further divided into con-trolled substances (narcotics, sedatives, and the like)that have a higher potential for abuse and misuse andstandard prescription drugs (such as antibiotics, anti-inflammatory medication, and medication for bloodpressure and diabetes).

• In some states, a special prescription is needed for dis-pensing of the highest level of controlled substances.

• Medication prescribing and dispensing falls undermany laws including state medical laws, pharmacylaws, and consumer safety laws.

• In general a physician may prescribe medication orprovide medications under the state laws which usu-ally include examination of the patient.

• A licensed pharmacist may provide medication as pre-scribed by a licensed physician.

• There are generally strict labeling requirements oftenincluding the name of the patient, name and strengthof the medication, directions for use, date dispensed,quantity dispensed, and warnings of common sideeffects. In addition, many states require the pharma-cist to counsel the patient on the medication.

10 SECTION 1 • GENERAL CONSIDERATIONS IN SPORTS MEDICINE

CHAPTER 4 • FIELD-SIDE EMERGENCIES 11

• Dispensing medications by individuals not licensedto do so, even if OTC, may not be allowed andcould open those doing so to prosecution underappropriate laws. This may also open the individu-als to liability for negligence if an untoward effectoccurs.

DRUG TESTING (SEE CHAPTER 20)

• The team physician may be asked to participate indrug testing program for teams.

• Careful consideration regarding the physician’s role asan enforcer of rules versus a counselor for medicalcare must be undertaken.

• Proper protection of rights and “due process” of theathlete must be maintained.

• Testing may include recreational as well as perform-ance enhancing drugs.

• Testing may be voluntary or mandated by certainorganizations, such as the National College AthleticAdministration (NCAA) or International OlympicCommittee (IOC).

CAPTAIN OF THE SHIP

• Though the doctrine relates to surgeons and assistants,the philosophy could be expanded to team physiciansand those they work with.

• Choose your partners in sports medical care wisely toavoid being drawn into bad situations.

RISK MANAGEMENT

• Manage risk by being prepared, documenting care,working with likeminded professionals, anticipatingproblems, and communicating with athletes and,where appropriate, their families.

• Advice of legal counsel should be sought in planningteam coverage, writing contracts, and if any eventsoccur.

• Bad outcomes often lead to legal actions (lawsuits).

REFERENCES

Nolan JR, Nolan-Haley JM: Black’s Law Dictionary, 6th ed.St Paul, MN, West Publishing, 1990.

BIBLIOGRAPHY

Birnie B: Legal issues for the team physician, in Rubin AL (ed.):Sports Injuries and Emergencies, a Quick-Response Manual.New York, NY, McGraw-Hill, 2003.

Davi