A certified athletic trainer (ATC) is specially trained in the diagnosis, management, and rehabilitation of common musculoskeletal injuries in athletics. Owing to daily interaction with athletes and coaches, and regular communication with team doctors, consultants and team administrators, ATCs are central members of the sports medicine team. They continue to play a critical role in the initial on-the-field evaluation of the injured athlete at practice and games (1,2). They also facilitate communication between the other sports medicine team members.

ATCs manage musculoskeletal injuries, from initial diagnosis through treatment and rehabilitation. They are uniquely qualified in the use of modalities such as ice, ultrasound, electrical stimulation, as well as more advanced techniques such as proprioceptive neuromuscular facilitation or manual muscle therapy skills. In addition, ATCs provide general advice for treatment of common medical conditions, for example, “colds,” viral upper respiratory infections, and so on. The ATC may counsel athletes on a number of important issues (3). A critical role played by the athletic trainer is in the area of injury prevention. ATCs also participate in screening for medical and orthopedic problems through the preparticipation examination (PPE) typically coordinated with the team physician.

Owing to the extensive time they spend working with athletes, ATCs are the most knowledgeable members of the sports medicine team regarding the personalities of athletes. The relationships they forge with athletes bolster the overall care and efficacy of a tailored rehabilitation plan. They are in an excellent position to informally counsel athletes about alcohol and drug issues, sexual activity, injury prevention and rehabilitation, nutrition, and eating disorders (3). More formal counseling is usually handled by the psychological consultant (4).

The ATC directs the medical coverage on the athletic playing field in most settings. It is important for the team physician and coach to support this role (2,5). Although it is true that the physician oversees most decisions off the field, the ATC is trained to evaluate and treat a plethora of conditions and injuries on the sideline and at practice.

In cases where inexperienced ATCs are covering an event, the physician may need to take a more proactive role in sideline coverage than is typically provided. Because the physician has the most expertise and training in the management of medical emergencies, the ATC should defer to the physician in emergency situations.

In summary, ATCs provide an invaluable resource for the total care of the athlete and functioning of the sports medicine team. We encourage institutions, beginning at least at the high school level, to have an ATC present at collision sporting events (e.g., football, soccer, wrestling). An ATC–team physician tandem provides the highest quality medical care for sports participants.

The team physician’s role is critical to the overall success of the sports medicine team. The “Team Physician Consensus Statement” (6) describes the requirements for being a team physician. In addition the “Appropriate Sideline Medical Coverage,” consensus statement (7) recommends an element of standardization of training and background for the budding team physician. Organizations and institutions seeking appropriate medical coverage can confidently refer to these documents for guidance on suitable qualifications for a team physician.

First of all, one must define the term team physician and delineate this role further. “The team physician must have an unrestricted medical license and be an M.D. or D.O. who is responsible for treating and coordinating the medical care of athletic team members. The principal responsibility of the team physician is to provide for the well-being of individual athletes, enabling each to reach his/her full potential. The team physician should possess special proficiency in the care of musculoskeletal injuries and medical conditions encountered in sports. The team physician also must actively integrate medical expertise with other health care providers, including medical specialists, athletic trainers, and allied health professionals. The team physician must ultimately assume responsibility within the team structure for making medical decisions that affect the athlete’s safe participation” (6).

The many roles of the team physician are facilitated through building rapport with other members of the sports medicine team (5). It is vital that the team physician review the roles of the various team members with the entire team, so everyone understands their important position in the team. Attendance at practice and in the athletic training room helps to complete the role of the physician. Astute physicians understand the interplay of the different members of the sports medicine team and how to promote collaboration and synergy. Athletic team members are more comfortable sharing personal matters and feel more confident in the team physician’s recommendations if he/she is seen as another “member of the team.” By stepping away from the formal physician–patient interaction, white coat included, the physician actually integrates more effectively into the overall fabric of the athletic team.

The role of the team physician varies with the competitive level being covered, be it junior high school, high school, collegiate, professional, or elite. In addition, coverage of mass events such as marathons (8), triathlons (9), distance running events, or Special Olympic events requires different roles and responsibilities.

The role of the coach as part of the coverage team is significant as the team physician is not present at practice most of the time. Recent events such as the highly publicized heat stroke deaths of athletes have pushed coaches to the forefront of prevention of heat injuries (10). At the middle school or junior high school level, coaches are often the first to evaluate an athletic injury.

The coaches of most sports at the high school and college levels have a powerful influence over the behavior of the athletes and their motivation to pursue healthy lifestyle behaviors (11). A coach can make huge inroads on ensuring proper nutrition for their players. Core requirements for coaching include certification in basic cardiac life support (BCLS), sports nutrition, proper training and conditioning methods, prevention and basic recognition of heat illness, and the potential hazards of dietary and nutritional supplements. Formal first aid training is certainly recommended. If an athletic trainer is not at practice and an athlete has a history of anaphylaxis to insect venom, the coach should be appropriately trained in the proper use of an EpiPen.

The team physician or local community physician may educate coaches through presentations on topics relevant to their particular sport. For instance, education of coaches on the signs and symptoms of eating disorders in sports such as gymnastics is critical to achieve early detection of this enigmatic problem. The coach needs to appreciate the adverse role that subtle messages, often sent by the coaching staff, concerning the perceived relation between performance and body weight, can have. This can facilitate or spawn the development of eating disorders. By providing educational conferences on topics that coaches
find relevant, the physician builds rapport in a less intense environment.

The coach should have a close working relationship with the athletic trainer at the high school, collegiate, or professional level. Communication between these parties is imperative, and respect for the decision making of the athletic trainer and physician on medical issues must be maintained. Under no circumstance is a coach to make isolated medical decisions for athletes or shop for other more desired opinions on care. The coach must understand the “return to play (RTP)” philosophy of the physician and respect it.

Ultimate decisions on RTP after injury or illness always reside with the physician, and part of this duty is to share the diagnosis and RTP considerations with the ATC and coach. Communication with the coach about an athlete’s progress, current limitations in his/her play, and the expected time course to partial and full recovery provides the necessary information for the coach to plan his/her practice and game strategy. It is advisable for the physician to discuss recommendations with the ATC, administrator (athletic director [AD] or school principal in high school) and, when age appropriate, parent.

In many states, it is required for EMS personnel to be present for high school collision sporting events such as football. In states where this is not required, many schools still opt to have EMS on-site for these events. In situations where there is no ATC or team physician present, EMS serves as the on-field responder to injuries. The role of EMS in this situation is to provide first aid care in the case of minor injury, and to stabilize and transport patients in the case of severe injury. There is much debate as to whether EMS personnel should make RTP decisions in this situation.

The role of EMS is significantly different when an ATC and/or team physician is present for the athletic contest. In this situation, EMS is present to provide support to the ATC and team doctor, and to transport injured players to appropriate medical facilities when called to do so. In most cases, they are also the primary responder to spectator medical issues. In this situation, EMS personnel should not respond to on-field injuries unless requested to do so by the ATC or team physician. These protocols must be reviewed so all members of the medical team understand and perform their roles appropriately. When these roles are not defined and understood, the care of the injured athlete suffers.

The AD represents the central administration within the sports medicine team. It is imperative that the sideline physician have a professional working relationship with the AD, which reinforces the overall directive of the sports medicine team: to care for student-athletes at all phases of their participation and to make the preservation of the health and safety of all participants the primary goal of this team.

At all interscholastic and intercollegiate levels, the AD shares the responsibility of overseeing the sports medicine program in collaboration with a team physician and athletic trainer. Regardless of the level of participation, the AD should not attempt to pressure, directly or indirectly, the sideline physician into making medical judgments that benefit the school or organization and put the athlete at risk. Conversely, the team physician must appreciate the vulnerability of the institution to potential medico-legal damage through the unwarranted participation of an athlete at increased risk for injury, illness, or death due to athletic participation.

The sideline physicians should always carry their own set of supplies—the “medical bag”—when covering an event (4,7,13,14,15,16,17,18). Different schools of thought exist on the amount and type of medical supplies, equipment and medication the team physician should have available in the team physician’s bag (4,7,14,15,16,17).

The contents of the team physician bag may be altered as needed, based on the sport, age of participants, location, presence of ancillary personnel at an event, weather conditions, and whether spectator coverage is part of the physician’s coverage duties. In many cases,
ATCs, institutions, and specific facilities provide many of the recommended supplies for the coverage of various events. The team physician is not responsible for providing all medical supplies. For collision sports, the supplies recommended are detailed in Table 9.1. This list is merely a suggested set of supplies and equipment and is not meant to be a fixed requirement (7,15).