PART

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Fundamental
Principles

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CHAPTER

Sports Medicine:
The Team Approach

illions of people throughout the world perform

physical exercise and play sport. These people
have specific medical needs. To cater for these people
a branch of medicine known as sports medicine has
evolved.1, 2 Sports medicine includes: injury prevention, diagnosis, treatment and rehabilitation; performance enhancement through training, nutrition
and psychology; management of medical problems;
exercise prescription in health and in chronic disease
states;3 the specific needs of exercising in children,
females, older people and those with permanent disabilities; the medical care of sporting teams and events;
medical care in situations of altered physiology, such
as at altitude or at depth; and ethical issues, such as
the problem of drug abuse in sport.
Because of the breadth of content, sports medicine
lends itself to being practiced by a multidisciplinary
team of professionals with specialized skills who
provide optimal care for the athlete and improve
each others knowledge and skills.4 A sporting adage
is that a champion team would always beat a team of
champions and this also applies to sports medicine.
Individuals who provide specialized skills and who
utilize the skills offered by other members of the team
provide the best athlete care. This team approach can
be implemented in a multidisciplinary sports medicine clinic or by individual practitioners of different
disciplines collaborating by cross-referral.

The sports medicine team

The most appropriate sports medicine team depends
on the setting. In an isolated rural community, the
sports medicine team may consist of a family physician or a physiotherapist/physical therapist alone. In
a fairly populous city, the team may consist of:

family physician
physiotherapist/physical therapist
sports physician
massage therapist
orthopedic surgeon
radiologist
podiatrist
dietitian/nutritionist
psychologist
sports trainer/athletic trainer
other professionals such as osteopaths,
chiropractors, exercise physiologists,
biomechanists, nurses, occupational therapists,
orthotists, optometrists
coach
fitness adviser.
In the Olympic polyclinic, an institution that
aims to serve all 10 000 athletes at the games, the
sports medicine team includes 160 practitioners
(Table 1.1).

Multiskilling
The practitioners in the team have each developed
skills in a particular area of sports medicine. There
may also be a considerable amount of overlap between
the different practitioners. Practitioners should be
encouraged to increase their knowledge and skills
in areas other than the one in which they received
their basic training. This multiskilling is particularly
important if the practitioner is geographically isolated
or is travelling with sporting teams.
The concept of multiskilling is best illustrated by a
number of examples. When an athlete presents with
an overuse injury of the lower limb, it is the podiatrist or biomechanist who has the best knowledge

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PART A FUNDAMENTAL PRINCIPLES

Table 1.1 Staff who provide medical coverage at an Olympic and Paralympic polyclinic
Administration/organization
Chief Medical Officer
Deputy Chief Medical Officer, and Chief, Athlete Services (sports physician)
Director of Clinical ServicesPolyclinic (sports physician)
Director of Nursing
Director of Physiotherapy/Physical therapy
Director of Remedial Massage
Director of Podiatric Services
Director of Dental Services
Director of Emergency Services
Consulting
Medical practitioners: sports physicians; orthopedic surgeons; general practitioners; rehabilitation specialists;
emergency medicine specialists; ear, nose and throat specialists; gynecologists; dermatologists; ophthalmologists;
ophthalmic surgeons; radiologists; amputee clinic physician; spinal clinic physician
Physiotherapists/Physical therapists
Massage therapists
Podiatrists
Optometrists
Pharmacists
Dentists
Interpreters

of the relationship between abnormal biomechanics

and the development of the injury, in clinical biomechanical assessment and in possible correction of
any biomechanical cause. However, it is essential that
other practitioners, such as a sports physician, orthopedic surgeon, physiotherapist/physical therapist and
sports/athletic trainer, all have a basic understanding of lower limb biomechanics and are able to
perform a clinical assessment. Similarly, in the athlete who presents complaining of excessive fatigue
and poor performance, the dietitian is best able to
assess the nutritional state of the athlete and determine if a nutritional deficiency is responsible for the
patients symptoms. However, other practitioners such
as a sports physician, physiotherapist/physical therapist or trainer must also be aware of the possibility of
nutritional deficiency as a cause of tiredness and be
able to perform a brief nutritional assessment.

The sports medicine model

The traditional medical model (Fig. 1.1) has the
physician as the primary contact practitioner with
subsequent referral to other medical and paramedical
practitioners.
The sports medicine model (Fig. 1.2) is different. The athletes primary medical contact may be
with a physician, however, it is just as likely to be a
trainer, physiotherapist/physical therapist or massage
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Patient

Physician

Physiotherapist/
Physical therapist

Others

Podiatrist

Massage therapist

Dietitian

Figure 1.1 The traditional medical model

therapist. Athletes usually present to the practitioner

with whom they have the best relationship or are most
accustomed to seeing. Therefore, it is essential that all
practitioners in the sports medicine team understand
their own strengths and limitations and are aware of
which other practitioners can offer the required skills
for the best management of the patient.
If a patient is not responding to a particular treatment regimen, it is necessary to reassess the situation,
reconsider the diagnosis and consider alternative
methods of treatment. This may require referral to
another member of the sports medicine team.

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CHAPTER 1 SPORTS MEDICINE: THE TEAM APPROACH

Trainer
Physician

Dietitian

Physiotherapist/Physical therapist

Massage therapist

AthleteCoach

Psychologist

Podiatrist
Others

Figure 1.2 The sports medicine model. In professional sport the players agent also features prominently in
athletecoach interaction

The challenges of
management
The secret of success in sports medicine is to take
a broad view of the patient and his or her problem.
The narrow view may provide short-term amelioration of symptoms but will ultimately lead to failure.
Examples of the narrow view may include a runner
who presents with shin pain, is diagnosed as having
a stress fracture of the tibia and is treated with rest
until free of pain; a baseball pitcher who presents
with shoulder pain, is diagnosed as having rotator
cuff tendinitis and is treated with anti-inflammatory
medication and rest from aggravating activities; or
a triathlete who presents with excessive fatigue and
poor performance and is treated with rest.
In all these examples, it is likely that in the short
term each of these athletes will improve and return to
activity. However, in each case there is a high likelihood of recurrence of the problem on resumption
of activity. It is not adequate simply to diagnose the
athletes presenting problem and treat accordingly. The
clinician must always ask Why has this injury/illness
occurred?. The cause may be obvious, for example,
recent sudden doubling of training load, or it may be
subtle and, in many cases, multifactorial.
The greatest challenge of sports medicine is to
identify and correct the cause of the injury/illness.
In the cases mentioned above, the runner with shin
pain arising from a stress fracture will continue to
have problems unless the cause is corrected. The
cause may be one or more factors, such as abnormal
biomechanics, inappropriate footwear, change of

training surface or change in quantity or quality

of training. The baseball pitcher may have shoulder
tendinopathy because of poor throwing technique,
excessive pitching or the presence of mild instability
of the shoulder joint. The triathlete may have fatigue
and impaired performance because of overtraining
and/or inadequate recovery, poor nutrition, accompanying viral illness or a medical condition such as
exercise-induced asthma. In each of these cases, it is
essential to take a broad rather than narrow view of
the problem.
In medicine, there are two main challengesdiagnosis and treatment. As mentioned, in sports medicine, it is necessary to diagnose both the problem and
the cause. Treatment then needs to be focused on
both these areas.

Diagnosis
Every attempt should be made to diagnose the precise
anatomical and pathological cause of the presenting problem. With adequate knowledge of anatomy
(especially surface anatomy) and an understanding of
the pathological processes likely to occur in athletes,
a precise diagnosis can usually be made. Thus, instead
of using a purely descriptive term such as shin splints,
the practitioner should attempt to diagnose which
of the three underlying causes it could bestress
fracture, chronic compartment syndrome or periostitisand use the specific term. Accurate diagnosis
permits precise treatment.
There are, however, some clinical situations in
which a precise anatomical and pathological diagnosis
is not possible. For example, in many cases of low

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PART A FUNDAMENTAL PRINCIPLES

back pain, it is clinically impossible to differentiate

between potential sites of pathology. In situations
such as these, it is necessary to monitor symptoms
and signs through careful clinical assessment and
correct any abnormalities present (e.g. hypomobility
of an intervertebral segment) using appropriate treatment techniques.
As mentioned, sports medicine often requires not
only the diagnosis of the presenting problem but also
the diagnosis of the cause of the problem. The US
orthopedic surgeon, Ben Kibler, has coined the term
victim for the presenting problem and culprit for the
cause.5 Diagnosis of the presenting problem requires
a good knowledge of anatomy and possible pathology,
while diagnosis of the cause often requires a good
understanding of biomechanics, technique, training,
nutrition and psychology. Just as there may be more
than one pathological process contributing to the
patients symptoms, there may also be a combination
of factors causing the problem.
As with any branch of medicine, diagnosis
depends on careful clinical assessment, which consists of obtaining a history, physical examination
and investigations. The most important of these is
undoubtedly the history but, unfortunately, this is
often neglected. It is essential that the sports clinician
be a good listener and develop skills that enable him
or her to elicit the appropriate information from the
athlete. Once the history has been taken, an examination can be performed. It is essential to develop
examination routines for each joint or region and
to include in the examination an assessment of any
potential causes.
Investigations should be regarded as an adjunct
to, rather than a substitute for, adequate history and
examination.6 The investigation must be appropriate
to the athletes problem, provide additional information and should only be performed if it will affect the
diagnosis and/or treatment.

Treatment
Ideally, treatment has two componentstreatment
of the presenting injury/illness and treatment to
correct the cause. It is important to understand that
no single form of treatment will correct all or even the
majority of sports medicine problems. A combination of different forms of treatment will usually give
the best results.
Therefore, it is important for the clinician to be
aware of the variety of treatments and to appreciate when their use may be appropriate. It is also
important to develop as many treatment skills as
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possible or, alternatively, ensure access to others

with particular skills. It is essential to evaluate the
effectiveness of treatment constantly. If a particular
treatment is not proving to be effective, it is important
firstly to reconsider the diagnosis. If the diagnosis
appears to be correct, other treatments should be
considered (Chapter 36).

Meeting individual needs

Every patient is a unique individual with specific
needs. Without an understanding of this, it is not
possible to manage the athlete appropriately. The
patient may be an Olympic athlete whose selection
depends on a peak performance at forthcoming
trials. The patient may be a non-competitive business
executive whose jogging is an important means of
coping with everyday life. The patient may be a club
tennis player whose weekly competitive game is as
important as a Wimbledon final is to a professional.
Alternatively, the patient may be someone to whom
sport is not at all important but whose low back pain
causes discomfort at work.
The cost of treatment should also be considered.
Does the athlete merely require a diagnosis and
reassurance that he or she has no major injury? Or
does the athlete want twice-daily treatment in order
to be able to play in an important game. Obviously,
the latter approach is more costly but may be what
the patient wants. Treatment depends on the patients
situation, not purely on the diagnosis.

The coach, the athlete

and the clinician
The relationship between the coach, the athlete and
the clinician is shown in Figure 1.3. The clinician
obviously needs to develop a good relationship with
the athlete. A feeling of mutual trust and confidence
would lead to the athlete feeling that he or she can
confide in the clinician and the clinician feeling that
the athlete will comply with advice.
As the coach is directly responsible for the athletes
training and performance, it is essential to involve

Athlete + Agent

Coach

Clinician

Figure 1.3 The coach, the athlete and the clinician

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CHAPTER 1 SPORTS MEDICINE: THE TEAM APPROACH

the coach in medical decision making. Unfortunately, some coaches have a distrust of clinicians,
feeling, rightly or wrongly, that the main role of the
practitioner is to prevent the athlete from training or
competing. It is essential for the coach to understand
that the practitioner is also aiming to maximize the
performance and health of the athlete. When major
injuries occur, professional athletes agents will be
involved in discussions.
Involving the coach in the decision-making process and explaining the rationale behind any recommendations will increase athlete compliance. The
coach will also be a valuable aid in supervising the
recommended treatment or rehabilitation program.
Discussion with the coach may help to establish
a possible cause for the injury as a result of faulty
technique or equipment.
A good practitionercoach relationship is a
winwin situation. The coach will develop a better
understanding of what the clinician has to offer and
is more likely to seek help for minor problems which,
if managed appropriately, may prevent subsequent
major problems. The clinician will benefit from an
increased understanding of the demands of the sport
and may have an opportunity to institute various
preventive measures.

Love thy sport

To be a successful sports clinician it is essential to
know and love sport and to be an advocate for physical
activity. The sports clinician needs to understand the
importance of sport to the athlete and the demands
of the sport. These demands may be physical, such
as training and technique, or psychological. As well
as understanding the general philosophy of sport
and the athlete, it is important to have a thorough
understanding of particular sports.

A good understanding of a sport and exercise

confers two advantages. Firstly, if the clinician understands the physical demands and technical aspects of
a particular sport, then this will improve his or her
understanding of possible causes of injury and also
facilitate development of sport-specific rehabilitation
programs. Secondly, it will result in the athlete having
increased confidence in the clinician.
The best way to understand the sport is to attend
both training and competition or to actually participate in the sport. Thus, it is essential to be on site, not
only to be available when injuries occur, but also to
develop a thorough understanding of the sport.

References
1. Matheson GO, Pipe AL. Twenty-five years of sport medicine
in Canada: thoughts on the road ahead. Clin J Sport Med
1996; 6: 14851.
2. Blair SN, Franklin BA, Jakicic JM, Kibler WB. New vision
for health promotion within sports medicine. Am J Health
Promot 2003; 18(2): 1825.
3. Chakravarthy MV, Booth FW. Eating, exercise, and thrifty
genotypes: connecting the dots toward an evolutionary
understanding of modern chronic diseases. J Appl Physiol
2004; 96(1): 310.
4. Hahn A. Sports medicine, sports science: the
multidisciplinary road to sports success. J Sci Med Sport
2004; 7: 2757.
5. Kibler WB, Sciascia A. Kinetic chain contributions to elbow
function and dysfunction in sports. Clin Sports Med 2004;
23(4): 54552.
6. Khan KM, Tress BW, Hare WSC, et al. Treat the patient, not
the X-ray: advances in diagnostic imaging do not replace
the need for clinical interpretation. Clin J Sport Med 1998; 8:
14.

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