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Team Physician Principles for the Management of Athletes

Jessica L. Brozek, MD and Bradley J. Nelson, MD

Serving as a team physician can be a challenging but rewarding aspect of medical practice for a sports medicine physician. Although it is, at its core, no different from any other type of medicine—that is, providing expert knowledge and service to improve and maintain optimal health for an individual—there are many other considerations that can complicate the ultimate achievement of that goal. When a “patient” becomes an “athlete”—or rather, an athlete becomes a patient—this is much more than a simple change in terminology. It brings with it connotations of the impact and goals of treatment, as well as the potential involvement of many other individuals who may have an investment in (and therefore affect) the decision-making process and final outcomes of treatment. The following chapter will discuss many of the nuances integral to acting as a team physician, including being prepared for many various medical scenarios, serving as leader of a diverse medical team, adhering to the ethical principles necessary to providing appropriate medical care to an athlete, and navigating the complex array of individuals involved in an athlete’s care.

BEING A TEAM PHYSICIAN

A team physician’s role is more than simply the medical care of athletes. This title also inherently includes the coordination of all aspects of the medical care from each of the many multidisciplinary professionals in the medical team (to be discussed later in this chapter), oversight of emergency action plans (EAPs) and event preparedness, management of preparticipation physicals, and communication with administrators and other personnel within the athletic organization regarding medical concerns or injuries. The American Academy of Orthopaedic Surgeons (AAOS) defines a team physician as an MD or DO with a full license to practice medicine, knowledgeable in management of on-field medical emergencies, trained in basic life support, with knowledge of musculoskeletal injuries, medical conditions, and psychological issues affecting athletes. Beyond these requirements, the AAOS recommends team physicians also have specific training in sports medicine through specialty board certification, fellowship training, research, and continuing education and a clinical practice focused on sports medicine.¹ Team physicians can come from several different training backgrounds, including orthopedic surgery, family medicine, internal medicine, and pediatrics. Even within these tracks, experience in sports coverage can vary widely between residency programs. In one recent survey² of orthopedic residents, nearly 90% of programs allow or require team/event coverage but just more than half provided training before this coverage. Only one-quarter of those without specific training had direct attending supervision. Formal training provided a statistically significantly higher level of comfort in treating sideline injuries. Many physicians will graduate training and find themselves providing care for athletic events, whether in an official or unofficial capacity; particularly in more rural or underserved settings, this is often without specific fellowship training in sports medicine. Thus, if a team physician is part of an academic institution that trains residents, part of that role may (and arguably should) include development and execution of a sideline preparation training curriculum. A certainly nonexhaustive list of topics includes education on safe spine boarding/precautions, concussion diagnosis, management of common ocular and dental injuries, triage and stabilization of medical emergencies, and a review of basic musculoskeletal physical examination.

Although caring for an athlete is ultimately no more than caring for any patient, providing medical care at an athletic venue is inherently different from providing care in a clinic or hospital. The physician must be prepared for many potential scenarios and come equipped with supplies for such. This frequently takes the form of a medical bag. Like with definitions for the term team physician, the AAOS3 has provided recommendations for what supplies should be available when covering sports events; these are listed in Table 1-1. This is certainly not all inclusive but it does provide a basic idea of some of the medical equipment and supplies that may be required during an athletic event. Although it also does not necessarily represent what is frequently found physically within the team doctor’s bag, the availability and location of these items should ideally be known at each venue. Certain athletic events will include the presence of emergency medical personnel on site, and they can provide some of this equipment (the availability of such emergency medical services support should be included in the EAP, a topic which will be discussed later).

The team physician on the sidelines may encounter and thus must be prepared to handle medical emergencies including cardiac events (eg, hypertrophic cardiomyopathy, commotion cordis), pulmonary distress (eg, asthma, anaphylaxis, traumatic pneumothorax), heat-related injury (eg, heat stroke), and head/neck injuries (eg, subdural hematoma, spinal cord injury).⁴ As always in an emergency situation, the “A, B, Cs” of trauma evaluation (Airway, Breathing, Circulation) should be the initial focus, followed by a more specific secondary survey of the entire body once medical stability has been established.

As leader of the team’s medical care, the team physician is ultimately responsible for the EAP. This should be a site-specific written description completed before the season that delineates location of an automated external defibrillator and other emergency equipment, facility access for first responders, basic chain of command, and communication strategies. This EAP should be distributed to physicians, athletic trainers, safety personnel, coaches, and other administrative staff, and should also be reviewed annually.³ Examples of a basic EAP are provided in Figure 1-1.

Although the rate of injuries during games is 3.5 times higher than those during practices, averaging 1 injury for every 2 games for National Collegiate Athletic Association athletes,5 serving as a team physician also entails medical care of the athletes outside the specific realm of competition. This often includes preparticipation physical exams (and postseason physicals, depending on level of competition) and “training room” (ie, providing on-site clinic services throughout the season). Although preparticipation physical exams are often required for athletic competition, the exact components are up for debate. A comprehensive discussion of this is beyond the scope of this chapter, but preparticipation physical exams should typically include personal and family history (with particular attention to any cardiac events that may prompt further screening) and physical examination.^6,7 Throughout the season (and off-season) the training room can serve as a central location for athletes to receive evaluation and treatment of injuries and illnesses apart from competition days and can require the team physician to manage a wide variety of diagnoses. In one study at a National Collegiate Athletic Association institution,⁸ 73% of initial athlete evaluations and 87% of follow-up visits were regarding musculoskeletal diagnoses, with only 4% of injuries requiring surgical management. Among the other 27% of initial visits that dealt with general medical diagnoses, the most common were for upper respiratory infection, dermatological complaints, concussions, and cardiopulmonary and gastrointestinal issues.

MULTIDIMENSIONAL MAKEUP OF THE MEDICAL TEAM

Whether in the operating room or clinic, or on the sidelines or in a training room setting, a physician can rarely function alone. In serving as a team physician, the doctor will work closely with many other individuals on a multidisciplinary team, including other physicians of various subspecialties (primary care, orthopedic surgery, neurology, ophthalmology, dermatology, etc), physical therapists, athletic trainers, dietitians, sports psychologists, strength and conditioning coaches, and others (such as dentists and optometrists). Depending on the level of athletics, from amateur to professional, the resources available from each of these specialists can help to optimize an athlete’s return to play and ultimate outcome. Each will be discussed in further detail later, but we would recommend that the single most important aspect of a medical team is open communication. When beginning to cover a team, the physician should establish which of these (or other) resources are present and introduce himself or herself to each of them to open that line of communication to facilitate safe, smooth, and comprehensive care of the athletes throughout the season and off-season.

One of the core members of a medical team in sports medicine is the athletic trainer. The American Medical Association defines an Athletic Medicine Unit to include an allopathic or osteopathic physician director, a board certified athletic trainer, and “other necessary personnel.”9 Athletic trainers primarily focus on managing acute on-field injuries and maintaining athletes’ ability to play, whether that be returning to play after an injury or maintaining physical health on a more chronic basis. Athletic trainers are often on the sidelines of games and practice on a daily basis and therefore may have the most insight into an athlete’s individual personality, which can come into play in consideration of the athlete’s goals, ability to progress through the rehabilitation process, and return to sport. Athletic trainers often guide and supervise an athlete’s daily therapy exercises, stretching, and gradual return to practices and competition. Through this process, athletic trainers can provide invaluable insight to the rehabilitation progression. Their training also enables initial on-field assessment and stabilization of acute injuries, which can be particularly critical in settings where they are the sole members of the medical team for an athletic event. In the specific interest of this text, this can apply to reductions of acute shoulder dislocations; however, it is always critical for team physicians to have appropriate preemptive communication and establish a good working relationship with the athletic trainers with whom they work to determine their comfort level and experience with certain common injuries, making the postinjury hand-off discussion and treatment more streamlined.

Physical therapists can also be important members in the medical care of an injured athlete. With training specific to the rehabilitation of injuries through a 3-year graduate degree program, they are well versed in musculoskeletal pathologies, and return to—as well as maintenance of—function from such pathologies. It is beneficial to develop relationships with therapists with whom a team physician often works, so they may become familiar with typical postoperative protocols and restrictions and feel comfortable freely discussing an athlete’s progress. This can be especially crucial because physical therapists have much more contact with the athlete through the recovery process than the physician and can therefore advise on the sport-specific functional progress the athlete has made.

Increasing attention is being paid to the mental health of athletes and its effect on performance and return to play following an injury and surgery. Studies have shown that higher athletic confidence and lower kinesiophobia are associated with higher return to sport,10 whereas fear of reinjury and fear of pain are common reasons for delayed or permanent inability to return to sport after anterior cruciate ligament reconstruction.¹¹ Similar quantitative assessments of psychological readiness to return to sport have been developed for shoulder instability as well.¹² Many athletes have structured their lives—and to no small extent, their identities—around their sports participation. Thus an injury, which suddenly and unexpectedly deprives them of the ability to practice and compete, can be devastating. Time spent in rehabilitation and away from a normal training environment and regimen can also isolate injured athletes from what is often their primary social group: the team. In addition to attention to this topic by physical therapists and athletic trainers on a daily basis, a trained sports psychologist can be a valuable resource throughout the recovery process and in optimizing psychological readiness to return to play. Even in healthy athletes, another facet of mental health—stress—can increase risk of injury. Nearly one-third of male and half of female athletes at the college level have reported feeling overwhelming anxiety in the last 12 months, and up to one-quarter of college athletes may have clinically relevant depressive symptoms. Rates of eating disorders in elite female athletes can be up to 20%, and when present with amenorrhea and osteoporosis are termed the female athlete triad. In a population that often has a “work hard, party hard” mentality, athletes can also be prone to substance abuse. It is critical that team physicians be able to recognize these conditions and refer a struggling athlete for appropriate treatment. Cognitive behavioral therapy and education on stress management and coping mechanisms can all be effective when provided by a licensed sports psychologist. As an often more familiar and trusted face, the team physician can help facilitate the athlete’s involvement in and acceptance of this form of assistance, from both a standpoint of formal referral and removal of the stigma that can be associated with mental health.¹³

Throughout a long season of often complex schedules of training and competition, an athlete’s recovery and performance must be fueled by appropriate nutrition. This includes coordinating the timing, amount, and proportion of the intake of protein, carbohydrate, fat, and various micronutrients. Maintaining this optimal balance requires individualization based on the athlete and the sport. Registered dietitians can receive specialized training in sports dietetics and can serve as an important asset to athletes in maximizing training and performance.14 Although a healthy body composition should be encouraged for the athlete’s overall well-being and peak performance, eating disorders unfortunately can be rampant in highly competitive athletes, and nutritionists can act as part of the medical team to provide education and support in developing healthy eating patterns.¹⁵

Strength and conditioning coaches guide athletes through a large portion of their in- and out-of-season training. The primary aspect of the strength coach’s role is safe training of the healthy athlete, and the team physician as the leader of the medical team has ultimate responsibility—either implicitly or explicitly—over the health and safety of the athletes while training.^1,16 Thus, open communication is key because physicians must often advocate for the safety of the athletes if they have concerns regarding training practices. An example of this includes avoiding excessively intense preseason training, because cases of exertional rhabdomyolysis have been reported.¹⁷ A smooth transition from injury rehabilitation back to normal training is critical to the athlete’s long-term playing career, and although this is typically guided by the athletic trainer and strength coach on a functional level, restrictions must be communicated clearly between the physician and the strength coach throughout the recovery process.

ETHICAL PRINCIPLES

Being a physician in any setting is more than the simple application of scientific knowledge. A doctor is expected to be caring and compassionate, personable and responsible. The 4 main tenets of ethics in medicine—beneficence, non-maleficence, justice, autonomy—still hold true in sports medicine and team coverage. One must always seek to do what is best for the patient, cause no harm, and do what is right, all the while providing the patient with appropriate medical recommendations to allow him or her to make independent, informed decisions without unilaterally dictating care. However, in practice these principles are more than just words on a page and must be interpreted accurately in many unique scenarios, a process that becomes somewhat more complicated when caring for athletes. “Best” and “right” are at best very subjective terms. Is it best to allow an athlete to return to play sooner at the risk of further injury? Is it right to deprive an athlete of the opportunity to participate when he or she understands and accepts the potential consequences of a perhaps objectively inferior treatment plan? This concept of ambiguity is often difficult for many physicians—who spend their training answering multiple-choice questions—to accept. When players are faced with a limited time span of possible participation in their sport, the goals of treatment can change from the long term to the short term. It is a team physician’s responsibility to provide education regarding potential consequences and ramifications of medical choices. He or she has a duty to protect the athletes—both from the athletes themselves and from others. But this is again a concept that can inherently be described only in vague subjective terms because each athlete must be cared for on an individualized basis, with each unique decision based on many factors.

Some of these factors may be determined not by the athletes themselves but by others surrounding them. Nearly all patients have others who assist in their medical decision making (either overtly or subconsciously); in sports medicine this group shifts from encompassing simply family and close friends to also include coaches, teammates, agents, and others, depending on the competition level. One must recognize that all of these groups of people have varying focuses, which may or may not include the overall well-being of the athlete.

Although it is becoming somewhat more common in general medical practice in the age of social media, one aspect of caring for athletes that can create difficulty and frustration for physicians is scrutiny of their decisions on a wider scale. Whereas fans and members of the media can pass judgment on an athlete’s medical care, at times without complete knowledge of the situation, team physicians often find that they are unable to defend themselves. Legally and, perhaps more important, ethically, physicians are bound by the constraints of patient confidentiality to refrain from discussing the specifics of patient care. However uncomfortable it may be to remain silent, this excess scrutiny is part of the territory in being a team physician and the focus must always remain on providing the most appropriate medical care for the individual athlete that the physician is able to provide, without allowing any extraneous factors to interfere.

Discussion of an athlete’s medical condition with coaches and administrators within athletic organizations is often exempt from the rules of confidentiality, either by rule or by specific written consent by the athlete. Situations that involve care of an athlete in a private clinic or hospital are bound by HIPAA (the Health Insurance Portability and Accountability Act), and thus any sharing of protected patient health information requires written consent by the patient. Professional sports organizations and collegiate athletic departments often have their athletes sign a release of information at the beginning of the season to allow open conversation with coaches and administrators to occur, or the information is considered part of the employment record and thus exempt from HIPAA.^18,19 Discussing an athlete’s status and progress following an injury is necessary to anticipate timing of return to play, which is obviously a topic of great importance to coaches and other staff in the proper performance of their jobs. It is always best, however, to clarify the specifics of each particular team, ideally before the season starts, to avoid inadvertent breaches of confidentiality or unnecessary delays in communication when particular situations arise.

Another aspect of navigating the ethical complexities of providing sports team coverage on the sidelines is consent. As with other medicolegal issues, we recommend that physicians seek out and establish the basic regulations of their particular location, institution, and situation. Laws regarding protection for those providing care for athletes may vary based on state, although ultimately it is important from an ethical standpoint that an athlete understands any treatment, intervention, or diagnosis that occurs as it happens. For example, an acute shoulder dislocation may often be immediately reduced on the sideline prior to onset of muscle spasms (further discussion of this will occur in following chapters); however, before any attempt at reduction the physician should perform a physical exam and obtain consent (which will be discussed in further detail later), as well as perform a physical exam following reduction. All of these should be appropriately documented.7,20 In general, consent is required for any medical treatment and represents a discussion between the treating provider and the patient (or appropriate surrogate if the patient is younger than 18 years or otherwise unable to provide consent) regarding the diagnosis, nature, and purpose of the treatment intervention, and expected benefits and potential risks or burdens of said treatment. The physician must also ensure that the patient or surrogate has appropriate understanding of the situation and consequences of the decisions being made, that the information is being presented appropriately for the specific patient and situation, and that the conversation is adequately documented (often via a written form that the patient or surrogate signs). In emergent situations care may be provided without informed consent, with the provider having that discussion at the first available opportunity.²¹ This can create a number of potentially ethically ambiguous scenarios for team physicians. The presentation of information regarding treatment options and the risks and benefits of each to the athlete should be fully inclusive and unbiased. However, one could argue that this cannot ever be truly “unbiased” because, as a human being, any physician’s viewpoint on a situation is affected by his or her previous experience with similar scenarios, as well as outside pressures (coaches, team institutions, media, etc, in the setting of sports medicine), making relaying any information to the athlete in a completely objective manner essentially impossible. It could also be suggested that “informed” consent is also an impossibility; it is unrealistic to assume that any patient will have a full and comprehensive understanding of any potential consequences of a decision based on a brief conversation with a medical professional, however impartial and skilled a communicator he or she may be. This is particularly true for athletes in an in-game setting. In the excitement of the moment it can be difficult for a player to see beyond winning the current game or match, or beyond even getting back to the current play or race. This harkens back to the concept of the team physician serving as the voice of reason and at times erring on the side of necessary paternalism overshadowing patient autonomy. Ultimately all efforts must be made, to the best of the physician’s ability, to objectively present all necessary information to the athlete or surrogate and allow him or her to make a decision, assisting as requested, and ensure that decision is being made by a capable individual with reasonable understanding of the situation. One particular example of this could be in the area of concussion diagnosis; although the athlete may appear outwardly without injury it is medically unsafe to return him or her to play, despite the opinions and desires of the athlete, parents, or coaching staff. Another example would be an athlete who has sustained a shoulder instability event with persistent instability and weakness on examination; although the athlete may feel absolutely certain that he or she is safe to play, premature return to play may result in further injury if the athlete is unable to protect himself or herself appropriately in the game setting. This is a clinical decision that physicians must rest on their training and experience, and be firm in their decision once made.

ATHLETE-PHYSICIAN RELATIONSHIP

As with all physician-patient relationships, the physician-athlete relationship must be based on trust and respect. However, the inclusion of other parties and mitigating factors (as with everything else previously discussed in this chapter) only complicates this scenario. The physician must maintain objectivity, while also establishing the rapport necessary for the level of communication required to provide adequate medical care. This balance can often be difficult. With the amount of time often spent in covering a team, it is only natural to become invested in the success of said team, and overtly showing that enthusiasm can help to develop a connection with the players. However, this interest in the success of the team cannot be allowed to overshadow clinical decision making regarding an individual player. The player, coach, and team are (rightfully) focused solely on the team’s victory, whereas the team physician must at times be a voice of opposition when a player’s overall health is at stake. Caution must also be used in overtly showing excess enthusiasm for one team when—as is often the case—the physician may be called on to evaluate an opposing team’s player. This can create conflict and questioning of motives when the opposing athlete is ruled out of returning to play. It goes without saying that this decision must in fact be made with an appropriate level of objectivity, regardless of which jersey the player may be wearing. Ultimately, professionalism begets trust, and trust avoids unnecessary resistance to and thus delays in appropriate medical treatment.

THIRD-PARTY/AGENT CONSIDERATIONS

Acting as a team physician often requires a significant amount of time, effort, and stress, at times for little quantitative compensation. A perhaps less-tangible benefit of providing a team’s medical care can be the simple fact of being known as “Team X’s doctor,” with the perception being that this position is earned by overall integrity and quality of care. Although this perception is ideally not untrue, the reality of the appointment of team physicians can be a complex and political process, often based on financial bids made by hospitals and health care systems to provide medical care in exchange for advertising rights. A number of professional sports leagues recognize this potential for conflict of interest and try to separate the selection of team physicians from the marketing arrangements. Physicians should make every effort to avoid letting this theoretical source of bias cloud their decision making when it comes to treating athletes, a potentially challenging goal when medical providers may be feeling pressure from the athletic institution and their own medical group to prioritize their interests over those of the athletes, with the threat of “losing” a team coverage position an overshadowing stress. In a perfect world, a team physician would be able to provide completely impartial and straightforward care that would benefit the athlete without concern for anyone or anything else, but the reality is that medicine of any kind—especially sports medicine—is not practiced in a vacuum. The best that one can do is to be aware of potential sources of bias and mitigate them as much as possible, with the best method often being through disclosure and transparency regarding financial or other types of relationships.18,22

CONCLUSION

Providing medical care for an athletic team is a unique subsection of medical practice, carrying with it many complex situations and nuances that require a physician to be dedicated both to medical practice and the institution of sports participation and competition. Athletes suffer many musculoskeletal injuries through their training and games, but a team physician must also be prepared to handle general medical ailments and medical emergencies, in addition to serving as the leader of a multidisciplinary medical team that can include athletic trainers, physical therapists, psychologists, dietitians, and others. Being a team physician requires knowledge and a strong interest in sports medicine, good communication skills, and an awareness of all the ethical complexities involved in caring for athletes. These can range from managing confidentiality and consent, to considering coaches, administrators, and other third parties whose interests may or may not coincide with the best interests of an individual athlete’s overall health. Ultimately, if one can navigate the challenges of team coverage it can be a very rewarding aspect of practice.

REFERENCES

1.      Herring SA, Kibler WB, Putukian M, et al. Team physician definition, qualifications, and responsibilities: a consensus statement. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2013.

2.      Hodax JD, Sobel AD, DeFroda S, Chambers AB, Hulstyn MJ. Orthopaedic resident preparation and confidence in treating on-field injuries. Orthop J Sports Med. 2017;5(5):2325967117708286. doi:10.1177/2325967117708286.

3.      Herring SA, Kibler WB, Putukian M. Sideline preparedness for the team physician: a consensus statement—2012 update. Med Sci Sports Exerc. 2012;44(12):2442-2445. doi:10.1249/MSS.0b013e318275044f.

4.      Chen AW, Archbold CS, Hutchinson M, Domb BG. Sideline management of nonmusculoskeletal injuries by the orthopaedic team physician. J Am Acad Orthop Surg. 2019;27(4):e146-e155. doi:10.5435/JAAOS-D-17-00237.

5.      Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311-319.

6.      Roberts WO, Löllgen H, Matheson GO, et al; American College of Sports Medicine (ACSM); Fédération Internationale du Médicine du Sport (FIMS). Advancing the preparticipation physical evaluation: an ACSM and FIMS joint consensus statement. Clin J Sport Med. 2014;24(6):442-447. doi:10.1097/JSM.0000000000000168.

7.      Kane SM, White RA. Medical malpractice and the sports medicine clinician. Clin Orthop Relat Res. 2009;467(2):412-419. doi:10.1007/s11999-008-0589-5.

8.      Steiner ME, Quigley DB, Wang F, Balint CR, Boland AL Jr. Team physicians in college athletics. Am J Sports Med. 2005;33(10):1545-1551. doi:10.1177/0363546505275491.

9.      American Medical Association. Policy H-470.995: Athletic (Sports) Medicine. 1998. https://www.nata.org/sites/default/files/ama_recommendation.pdf Accessed March 21, 2019.

10.    Czuppon S, Racette BA, Klein SE, Harris-Hayes M. Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br JSports Med. 2014;48(5):356-364. doi:10.1136/bjsports-2012-091786.

11.    Lentz TA, Zeppieri G Jr, George SZ, et al. Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med. 2014;43(2):345-353. doi:10.1177/0363546514559707.

12.    Gerometta A, Klouche S, Herman S, Lefevre N, Bohu Y. The Shoulder Instability–Return to Sport Aft er Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):203-211. doi:10.1007/s00167-017-4645-0.

13.    Psychological issues related to illness and injury in athletes and the team physician: a consensus statement—2016 update. Curr Sports Med Rep. 2017;16(3):189-201. doi:10.1249/JSR.0000000000000359.

14.    Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine joint position statement. Nutrition and athletic performance. Med Sci Sports Exerc. 2016;48(3):543-568. doi:10.1249/MSS.0000000000000852.

15.    Turocy PS, DePalma BF, Horswill CA, et al; National Athletic Trainers’ Association. National Athletic Trainers’ Association position statement: safe weight loss and maintenance practices in sport and exercise. J Athl Train. 2011;46(3):322-336. doi:10.4085/1062-6050-46.3.322.

16.    The team physician and strength and conditioning of athletes for sports: a consensus statement. Med Sci Sports Exerc. 2015;47(2):440-445. doi:10.1249/MSS.0000000000000583.

17.    Smoot MK, Amendola A, Cramer E, et al. A cluster of exertional rhabdomyolysis affecting a Division I football team. Clin J Sport Med. 2013;23(5):365-372. doi:10.1097/JSM.0b013e3182914fe2.

18.    Dunn WR, George MS, Churchill L, Spindler KP. Ethics in sports medicine. Am J Sports Med. 2007;35(5):840-844. doi:10.1177/0363546506295177.

19.    U.S. Department of Health and Human Services, U.S. Department of Education. Joint guidance on the application of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to student health records. Washington, DC: U.S. Department of Health and Human Services; 2008.

20.    Skelley NW, McCormick JJ, Smith MV. In-game management of common joint dislocations. Sports Health. 2014;6(3):246-255. doi:10.1177/1941738113499721.

21.    Code of Medical Ethics Opinion 2.1.1: Informed Consent. American Medical Association. https://www.ama-assn.org/system/files/2019-06/code-of-medical-ethics-chapter-2.pdf Accessed March 21, 2019.

22.    Testoni D, Hornik CP, Smith PB, Benjamin DK Jr, McKinney RE Jr. Sports medicine and ethics. Am J Bioeth. 2013;13(10):4-12. doi:10.10 80/15265161.2013.828114.