Section 1. Working in sport
Introduction2
Know your role2
Know your sport3
Know your team5
Know your location9
Know your kit bag10
Know your strapping14
Know your first aid26
Know what to document35
Know when to refer on37
Know when to arrange further investigations38
Introduction
Working with a team or individual athletes can be one of the most rewarding aspects of a clinician’s career, but also one of the most demanding. Competition environments are often extremely stressful and it is not unusual for the pitchside clinician to find themselves in unfamiliar territory dealing with an unaccustomed injury or situation. This section is designed to familiarize the clinician with fundamental elements and skills associated with working in a sporting environment, and to highlight key areas for development.
Know your role
It is essential that all pitchside clinicians safeguard themselves by working only within the scope of practice in which they feel competent. In the world of modern medicine, scope of practice is rarely rigidly defined for any profession, be they a doctor, physiotherapist, sports therapist or osteopath. Professional bodies and the legal system have recognized the importance of avoiding restrictive boundaries for practice, as to do so may limit the professional development of the individual.
While this is advantageous in many team scenarios where one clinician is often expected to wear the hats of many professions, it also places the onus for clinical decision-making and action squarely on the clinician’s shoulders. Before undertaking any clinical decision or activity, the clinician must always ask themselves, “Do I feel competent to do this?”.
The question of competency is more than simply, “Have I 
done a course or workshop which qualifies me to do this?”. It is also about undertaking these practices on a regular basis and under similar circumstances, and reflecting on and reviewing your clinical practice with peers and as an individual. Clinicians should refer to their professional bodies (www.csp.org.uk, www.osteopathy.org.uk, www.basrat.org, www.bma.org.uk) for information and guidance on scope of practice specific to their profession.
done a course or workshop which qualifies me to do this?”. It is also about undertaking these practices on a regular basis and under similar circumstances, and reflecting on and reviewing your clinical practice with peers and as an individual. Clinicians should refer to their professional bodies (www.csp.org.uk, www.osteopathy.org.uk, www.basrat.org, www.bma.org.uk) for information and guidance on scope of practice specific to their profession.It is important to recognize that you are responsible for the team you are working with. In the event of an injury, it is your decisions which are important. Do not let yourself be influenced by the comments or opinions of spectators or players, no matter what their qualifications are.
Sometimes, student physiotherapists are approached to act as team physiotherapists for amateur clubs and organizations that struggle to find or fund a qualified physiotherapist. It is essential for student physiotherapists to be aware that under the terms of the Chartered Society of 
Physiotherapy (CSP)’s Professional Liability Insurance (PLI) they are only insured to practise both within their own level of competence and under the supervision of a qualified physiotherapist.
Physiotherapy (CSP)’s Professional Liability Insurance (PLI) they are only insured to practise both within their own level of competence and under the supervision of a qualified physiotherapist.Likewise, qualified physiotherapists sometimes find themselves working alongside students to cover events and tournaments. If they are not happy to take on the responsibility of supervising students in this situation, this needs to be made clear to the organizers and alternative arrangements should be discussed. Having responsibility for students does not mean taking responsibility for any mistakes, but it does mean understanding the students’ level of competency and ensuring they are expected to practise only within these limits, as would be the case in a clinical setting.
In addition, the opposition team should never be relied on to provide medical support, as the level of cover may very well be insufficient or inadequate.In recent years, sport has become an increasingly litigious arena. Clinicians need to be mindful that actions which contravene the rules and codes of the sport they are covering may actually also have legal ramifications and/or place their professional registration in jeopardy.
Know your sport
Confidence in dealing with any situation improves with familiarity. If you are unfamiliar with a sport you are covering it is worth reading up on or discussing with a knowledgeable individual the nature and nuances of the game, the various positions played and the specific demands of these. It is also worthwhile discussing the physical demands and likely injuries with a colleague who has worked in the sport.
If you are working with a sport that is conducted in unusual settings, such as ice skating, skiing, swimming or sailing, special consideration for dealing with injuries, retrievals and evacuations is necessary to ensure you are prepared for these possibilities.
For physiotherapists serious about developing a role within professional sport some national bodies have a structured accreditation process. For example, in the UK the Association of Chartered Physiotherapists in Sports Medicine (ACPSM; www.acpsm.org) has a process in place that incorporates mentorship. Elements of the continuing professional development process include shadowing and observation.
It is not always necessary for your mentor to be involved in the same sport that you are working in; however, as some scenarios and the rules governing them are very sport specific it is worthwhile spending some time with more experienced people working in the same sport.
Scenarios and rules that are specific to certain sports include:
• Dealing with a blood injury – does the player need to leave the field? Can they return to the field of play?
• Treating an injury on/off field – can a player leave the field/court for treatment and return?
• Are substitutions permitted for injuries?
• Is the trainer permitted into the field of play to assess an injury and for how long? For example, in tennis, the trainer must be escorted onto the court by an official. They are permitted as long as necessary for assessment of the injured player but only 3 minutes for treatment once a diagnosis has been made.
• Similarly, Judo has several rules governing medical disqualifications and the presence of medical staff on the mat.
• Many organizations also have specific rules governing a player’s return to competition following a head injury/concussion.
As well as discussing these rules with fellow clinicians and coaching staff, the governing bodies of each sport should be able to provide you with detailed information.
Working alone with a team can be difficult as you have no-one to discuss clinical scenarios with. Finding a mentor that you can speak and meet with regularly is an excellent method of improving your clinical skills. Utilizing web-based resources such as the British Association of Sport and Exercise Medicine (BASEM) forum (www.basem.co.uk) interactive CSP for physiotherapists (www.interactivecsp.org.uk), BASRaT (www.basrat.org), the British Osteopathic Association (www.osteopathy.org) and the Neuro Orthopaedic Institute (NOI; www.noigroup.com) provides even the most isolated clinician with access to other professionals working in the field of sports and musculoskeletal medicine.
Know your team
When starting work with a team, it is invaluable to spend time taking a detailed medical and sporting profile from all athletes. This allows you to determine the need for any preventative management and treatment, and to identify any athlete with special requirements or those who may be more vulnerable to illness or injury while competing. The information may also be invaluable in the event of an emergency when an athlete requires urgent medical care or transfer to hospital.
Form 1.1 provides a list of recommended information clinicians should obtain from all their players. This information should be documented as a confidential record, available at all training sessions and events. Access to the information should be limited to the medical team and head coaching staff. It must 
be signed by the player as an accurate record of their health status. In the event that they are under the age of 18, a parent or legal guardian is required to sign the form.
be signed by the player as an accurate record of their health status. In the event that they are under the age of 18, a parent or legal guardian is required to sign the form.Form 1.1
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Confidential medical information
Name: ………………………………………………………………
DOB:………………………………………………………………
Sex: …………………………………………………………………
Height: ……… Weight: …………
Blood type: (Amenable to transfusions? Y/N) ………………………
Address and contact details:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Occupation:………………………………………………………………
Emergency contact details (including relationship to athlete):………………………………………………………………………………………………………………………………………………………………………………
GP’s contact details: …………………………………………………………………………………………………………………………………………………………………………………………………………………………
Dentist’s contact details: ……………………………………………………………………………………………………………………………………………………………………………………………
Physiotherapist’s contact details: ………………………………………………………………………………………………………………………………………………………………………………………………
Private insurance details (if any): ………………………………………………………………………………………………………………………………………………………………………………………………………
Pre-existing medical conditions (including allergies): ……………………………………………………………………………………………………………………………………………………………………………………………………
Medication (including supplements): ………………………………………………………………………………………………………………………………………………………………………………
Past history – musculoskeletal conditions (plus any residual problems): ………………………………………………………………………………………………………………………………
Any history of:
□ Heart disease/condition
□ Epilepsy
□ Diabetes
□ Asthma
□ Dizziness
□ Loss of consciousness
□ Head injury/concussion
□ Chest pain
□ Fractures
□ Dislocations
Existing injuries (current management): ………………………………………………………………………………………………………………………………………………………………………………………………………………………
Family history (diabetes/heart disease/arthritic conditions): ………………………………………………………………………………………………………………………………………………………………………………………………………………………
Personal habits:
□ Smoking
□ Alcohol
□ Recreational drugs
□ Diet and nutrition
□ Hydration
Hep B status: ………………………………………………………………………………………………………………………………
Tetanus status: ………………………………………………………………………………………………………………………………
HIV status: ………………………………………………………………………………………………………………………………
Female athlete-specific questions:
□ Age at which menstruation started
□ Regularity of menstrual cycles
□ Use of oral contraceptive pills
Sporting history
Level of competition played: ………………………………………………………………………………………………………………………………
Number of years at this level: ………………………………………………………………………………………………………………………………
Position played: ………………………………………………………………………………………………………………………………
Training hours per week: – This season
– Last season
Playing hours per week: – This season
– Last season
Do you wear glasses or contact lenses (specify)?:
Protective equipment:
□ Brace
□ Tape
□ Mouthguard
□ Helmet
Player signature:Date:
All professional organizations and high-level athletes together with many serious amateur teams and individuals will undergo some sort of musculoskeletal screening in pre-season, with the aim of implementing “pre-hab” programmes to prevent injury and enhance performance. The make-up and extent of these screenings is specific to the individual sports and is based on the sporting requirements and competition level.
At present, there is little supporting evidence that current musculoskeletal screening programmes predict or prevent re-injury in sport. Many organizations are therefore moving away from static and non-functional assessments of joint range and muscle strength towards functionally-based programmes that assess a player’s ability to perform a variety of tasks that demand differing joint ranges and elements of muscle strength and control during multi-joint movements. Examples of the types of movement screened in this way include squats and lunges with rotation. It is hoped that future research will show the benefit of these more functional screenings in predicting and preventing injury.
Know your location
Whether you are working with athletes competing at home or abroad, preparatory research into the location of the competition will ensure you are able to deal with any injury or illness in the most efficient and effective way.
Prior to arriving at the venue, you should establish the location and facilities available at the nearest hospital, including the presence of an A&E department. You should also find out the likely transit time to and from the hospital, so that, in the event of an injury, you know how long you may have to manage the situation without ambulance support. In more isolated areas or less developed countries, there may be some time between calling for an ambulance and its arrival.
It is also worthwhile knowing the number for the hospital switchboard to inform them of any serious injuries.
You no doubt know the number for the emergency services in your own country, but it is possible that it is not the same number if you are abroad. Establish what the 
emergency number is in the country you are visiting.
emergency number is in the country you are visiting.In the event that an ambulance is required, you should be able to provide the emergency operator with information about accessing the sporting field or arena. Many sporting competitions are large events with several locations. Specific details regarding your location within the event, as well as the closest access points, will be helpful in an emergency situation. In the case of large events, the organizers will usually have provided the local hospital and ambulance service with details of the competition and will have established procedures for dealing with injuries. It is important to have knowledge of these procedures and the organizer’s contact details to inform them if a serious injury occurs.
When you arrive at a venue, you, or someone designated by you, should check the arena/pitch or court for any potential hazards. These can include broken glass and other rubbish, dog dirt or excess water. Clearing the pitch or court of all hazards is not always possible, and if this is the case, the safety of the venue should be discussed.
You should also locate any medical facilities and the equipment stored within (Box 1.1). In many amateur events, the medical facilities are usually far from ideal. You should never expect to have access to any facilities or equipment 
that you do not carry yourself.
that you do not carry yourself.Box 1.1
• KEY – gaining access
• Telephone
• List of emergency contact numbers and procedures posted next to the telephone
• First aid kit
• Sink with hot and cold water available
• Disposable hand towels and liquid soap
• Towels
• Antiseptic gel
• Examination couch with pillows and blankets
• Chairs
• Lockable cupboard for records and drugs
• Separate containers for sharps/contaminated waste and general rubbish
• Access to electrical power supply
• Access to refrigeration for ice/cold packs/medical supplies
• Clock with a second hand
• Resuscitation equipment – pocket mask ± Ambu bag (bag valve mask, BVM)
• Defibrillator – requires qualified personnel
At many sporting events, no medical room will be available. In these instances, injuries need to be addressed on the side of the field. Make sure you move any injured player a sufficient distance from the field of play to protect them from the risk of further injury and allow adequate room for treatment and ambulance access if required.
Know your kit bag
The most important thing about your kit bag is that you know exactly what it contains and what each item is used for. The exact content of your kit bag will depend on your level of competency and training. You should not carry any item you are not trained or do not feel competent to use.
Do not let other people tamper with your bag. Items should be stored in and returned to the same place each time, so that an item is readily to hand when you need it urgently.
Your kit bag should be:
• Lightweight
• Portable
• Waterproof
• Durable
• Compartmentalized
Within your kit bag, clear plastic containers or plastic zip-lock bags are a useful way of keeping things well separated and easily identifiable. Bags and containers also protect items should you have an unexpected spill or leak. Zip-lock plastic bags also make useful ice packs.
Recommendations for a kit bag are listed in Table 1.1. To make up a kit bag for the sport or activity you are covering, select those items that are necessary to manage the types of injury that occur most commonly. It is always worthwhile discussing this with a colleague who works with the same sport to ensure you have not overlooked anything.
| Taping/strapping and management of soft tissue injuries | Use |
|---|---|
| Tape scissors Safety scissors Zinc oxide tape in 2 sizes – 25 and 38 mm Elasticized crepe bandages Elastic cohesive bandages – various sizes Elastic adhesive bandages (EAB) – 5 and 7.5 cm Ice/ice packs Underwrap Adhesive foam or felt Tape adhesive spray/gel | Cutting tape/removal of tape or clothing For cutting foam/adhesive Taping knees/shoulders / wrists and ankles Apply compression to joints and limit oedema Apply support to joints Prevention of bleeding/swelling For sensitive skin To assist compression or provide protection for bony areas To assist tape adherence and protect skin |
| Management of wounds | Use |
| Disposable nitrile gloves Gauze swabs Adhesive dressings Sterile/non-adhesive dressings (various sizes) Band-Aids – waterproof/non-allergenic Betadine Steri-Strips Tweezers (disposable or sterilized after use) Sterile needles/blood lancets Syringes Sterile solution Gauze bandages Micropore tape Alcohol swabs | Maintaining universal precautions Swabbing wounds and applying creams and lotions Wound dressing Covering and protecting wounds of various sizes Covering small/minor wounds Cleaning antiseptic Bring edges of wounds together Removal of wound debris Wound management/removal of foreign bodies/blisters Wound irrigation Wound irrigation Securing wound dressings in place Securing bandages and dressings Cleaning equipment/prior to needle use on unpunctured skin |
| Splints and braces | |
| Triangular bandages | Arm slings/splints/broad bandages |
| Other items | |
| Injury record forms Pen and paper Resuscitation mask Defibrillator Rigid cervical collar (several sizes required) Oropharyngeal airway Nasopharyngeal airway | Recording injuries in a consistent manner Maintaining universal precautions Restoring normal circulation (must be certified in using this equipment) Management of spinal injury – used in conjunction with a spinal board Airway maintenance Airway maintenance |
| Sports/player-specific items | |
| Shorts Spare studs and screwdriver Spare shoelaces Mirror Contact lenses Prescribed medication – Inhalers – EpiPen® Glucose tablets | Any item prescribed specifically for a player must be obtained by them from their doctor or pharmacist. However, if you are the only medical staff present, it falls to you to be responsible for carrying the medication during the event. You should discuss administration with the player prior to the event Hypoglycaemia |
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