Primary Care Perspective

Douglas B. McKeag

James L. Moeller

Section A Philosophy of Primary Care Sports Medicine

Justification

Despite the recent proliferation of sports medicine textbooks and information regarding this specialty area, we believe there is a need for a single source of appropriate and practical sports medicine information for the primary care physician, resident, medical student, and allied health practitioner.

Primary care physicians can find many justifications for studying and practicing sports medicine:

Health care delivery in the United States, if it is to be effective, must continue toward community-oriented medicine. This trend places much of the burden of health care delivery, including sports medicine health care delivery, on the shoulders of primary care practitioners.
Many sources of information about sports medicine for the primary care physician remain poorly organized—the direct result being too much specialization and not enough “big picture” thinking. Although good, practical concepts for treating patients with athletic injuries occasionally appear in primary care medical journals, there are a few practical reference works for the primary care physician that approach sports medicine in a complete, easily referenced manner.
Sports medicine is a rapidly changing field. Technological advances have an impact on both treatment and rehabilitation. Changes in equipment, techniques, rules, and training that allow athletes to perform better have made it difficult for practitioners, even those well versed in sports medicine, to remain current.
Most physicians continue to receive little, if any, formal sports medicine education either in medical school or at the postgraduate level. This is in spite of the growing level of musculoskeletal problems currently confronting the primary care physician. The natural result of this situation is inconsistency in patient care. There are encouraging changes. Several organizations—American College of Sports Medicine (ASCM), American Medical Society for Sports Medicine (AMSSM), American Academy of Family Physicians (AAFP), and the American Orthopedic Society for Sports Medicine (AOSSM)—are presenting quality postgraduate courses in sports medicine. The formation of the AMSSM and the advent of the Sports Medicine’s Certificate of Added Qualification (CAQ) have added professional definition to this important new specialty. The foundation for these changes was built by sports medicine teaching programs that established the curricula to teach. The legacy of these programs will be the definition of sports medicine as a discipline. Recent changes in Family Medicine Residency educational requirements in the area of sports medicine underlie the importance of this specialty area.
Injured athletes are not always treated in the same manner as injured nonathletes. Time constraints, patient motivation, and accessibility to highly technical therapy modalities are factors that contribute to this dichotomy of injury care. What we have learned in treating athletes has been successfully translated to treatment of the nonathlete population.
The number of sports-related injuries has increased. Improved equipment and better supervision have reduced injury rates in certain organized sports settings, but the
total number of sports injuries has been on the rise. Many factors contribute to this increase in injuries, including the following:
- An increase in participation. With more people involved in sports, more will be injured.
- The disappearance of “natural selection”. Most adults involved in recreational sports 25 years ago were individuals who had learned proper training techniques as youngsters. They had developed their exercise regimens over time. Currently, many middle-aged individuals are beginning to participate in exercise after 15 to 25 years of sedentary life. Their lack of knowledge or experience of appropriate training methods generates more injuries.
- Increased variety of sports is available. The rising popularity of such sports as lacrosse, soccer, gymnastics, and aerobics has generated a whole new subpopulation of recreational athletes.
- Individuals have increased opportunities for participation. The “positive economy” of sports has provided more avenues for participation. The increase in recreational sports has created a demand for biking trails, jogging clubs, skateboard parks, tennis facilities, and fitness centers. This, in turn, makes participation in sports more accessible.
- An increased sophistication has gradually developed along with increasing knowledge of the biomechanical aspects of sport. Researchers help players become more successful through better technical skills development. Greater sophistication can, however, lead to cheating, abuse, and the production of additional injuries.
- An increase in intensity usually accompanies increases in level of play. It takes more effort to succeed; more commitment and practice time are required to train. Increased exercise exposures at high intensity increase the risk of injury.
- Many athletes specialize at a young age, playing a sport yearlong. Early specialization can result in overuse injuries, as constant repetition breaks down muscle–tendon units.
- Professionalism in coaching has not kept pace with the increased popularity of sports. Despite scientific revelations in training, poor coaching and training methods remain major factors in the generation of sports injuries.
The educational level of patients with sports injuries has risen. The lay public obtains information about sports medicine from many sources, reliable and unreliable. Much information is contradictory and some are potentially harmful. Often, it is based on studies of elite athletes, not the type of athletes seen by most primary care physicians.
Even those individuals with ill health or chronic disease can benefit from exercise as a component of a medical therapeutic plan. Treatments of psychological disorders, chronic pulmonary disease, hypertension, obesity, coronary artery disease, and even some cancers may include exercise as a powerful adjunct to conventional therapy.
Exercise has a positive effect on every major organ system of the body. Studies have shown that it is not just the cardiovascular and musculoskeletal systems that receive a protective benefit. Exercise holds the promise of decreased morbidity and mortality. Its health promotion potential is staggering. The impact of physical activity in the primary and secondary prevention of chronic disease states is magnified by the ability of primary care physicians to prescribe it to patients.
Sports medicine principles can be used to benefit patients, active or otherwise, as they could encounter maladies and injuries in any of their activities of daily living. Active interest or knowledge of sports is not a requirement of an effective sports medicine practitioner; an understanding and appreciation of the effects of exercise on the human condition is.
There continues to be a lack of quality assurance in sports medicine. Sports medicine is still a young specialty area. To obtain a CAQ in Sports Medicine, practitioners must first be board certified in a primary specialty (Family Practice, Internal Medicine, Pediatrics, Emergency Medicine), successfully complete an accredited fellowship in Sports Medicine, and then pass the CAQ examination. This should be enough to assure quality. Unfortunately, there are many practitioners in various specialties who continue to advertise as “Sports Medicine” practitioners without completing more than their primary training.
Sports medicine care can be an excellent marketing tool. Accepting patients with sports injuries is an effective method for a practitioner to capture new patients.

Primary care residents may find that a general knowledge of sports medicine has additional advantages beyond those already cited:

Sports medicine training allows the resident to integrate a number of medical disciplines previously studied (e.g., cardiology, physiology, nutrition, orthopedics).
The experience of a formal sports medicine rotation gives residents an opportunity to place appropriate primary care emphasis on areas traditionally thought of as secondary or tertiary care. Many concepts of office musculoskeletal medicine are either absent or not emphasized during general orthopedic rotations.
A formal background in sports medicine training can be a definite asset in gaining rapid entrance into a community.
New physicians with a sports medicine interest and background are perceived as more current, knowledgeable, and interested in community affairs. They may be asked to make presentations on exercise and sports to lay groups. They may be asked to serve on committees to establish guidelines for the conduct of community sports programs. The list of potential opportunities is unending.

Medical students now realize the value of exercise in their own lives. Many have a profound interest in the area of sports medicine as early as the first quarter of the first year of medical school. Many medical students come from areas of interest that embrace sports medicine (e.g., kinesiology, nutrition, psychology). It is unfortunate that medical school curricula do not change as readily as society. As has been the case with nutrition, the importance of sports medicine has been overlooked in most medical school curricula. Our experience tells us that because of its interdisciplinary nature, sports medicine offers a natural integrative bridge between disciplines. Where else can the integration of the basic sciences (e.g., physiology, pharmacology) be so naturally incorporated into such clinically related fields as cardiology and orthopedics? Furthermore, psychosocial sciences such as biomedical ethics and psychology also assimilate well. Because of its popularity and preventive medicine aspects, sports medicine becomes a natural common pathway for medical school curricular integration.

Interdisciplinary Approach to Sports Medicine

As we have said, sports medicine draws upon and integrates a variety of disciplines. But what of the approach to sports medicine? It is important to state that this book deals specifically with a primary care perspective of sports medicine. In our view, the first-contact, comprehensive, continuing care given by most primary care physicians to athletes is sports medicine. The primary physician as leader in an ever-evolving well-defined athlete health care system is the philosophy underlying the organization of this book.

Is there an overemphasis on the musculoskeletal injury in the athlete? When some think of sports medicine, do they really mean sports orthopedics? When the public thinks of a sports medicine “specialist” are they really referring to an orthopedic surgeon? Orthopedic surgeons have done much to advance and upgrade the care of musculoskeletal injuries in the athlete. Their contributions include (a) arthroscopic surgery (e.g., knee, ankle, shoulder, elbow), (b) adaptation of conservative approaches to previously operable injuries (e.g., severe ankle sprains, third-degree ligament tears), (c) further definition of many subtle yet common syndromes (e.g., patellofemoral dysfunction, shoulder impingement, cervical stenosis), and (d) delineation of more appropriate diagnostic testing to better examine the musculoskeletal system (e.g., Lachman’s test, shoulder augmentation/relocation tests). Musculoskeletal injuries require a great deal of emphasis in the study of sports medicine. They account for more than 50% of all sports-related injuries.

However, other disciplines have contributed as well. Physical medicine and rehabilitation (PM&R) and athletic training are areas where new modalities have been discovered and new treatment regimens generated. More defined rehabilitation programs for specific injuries have evolved. The principles of biomechanics have been applied to injury etiology and subsequently to the rehabilitative process. Emphasis now is on rehabilitation of isolated muscles or muscle groups. This has produced specific techniques that allow athletes to return to play more quickly than ever before.

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