SPORTS MEDICINE
THE ROLE OF THE
SPECIALIST SPORTS
MEDICINE PHYSICIAN
IN ELITE SPORT
Managing Athlete Health while
Optimising Performance a Track
and Field Perspective
Written by Paul Dijkstra, Qatar and Noel Pollock, United Kingdom
The role of the sports medicine physician
has changed significantly over the last 2
decades. In some sporting organisations,
the sports medicine physician served as
a necessary, governance requirement
someone who could sign the scan request
form, dispense analgesia and inject
anaesthetic or other medication when
required or desired. This approach was from
an era when sports medicine doctors did
not have the necessary skills, background
or contractual relationship to critically
evaluate or manage musculoskeletal health.
Sport and Exercise Medicine is now
an official medical specialty in many
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countries. This has engaged governments
and institutions to develop, publish and
implement the criteria for the training of
sports medicine physicians; it has improved
the standards of care for participants in
sport and exercise who have access to
these specialists1. However, the role of the
specialist sports medicine physician is
not always well-understood by medical
colleagues, team management or politicians.
A ROLE FOR SPORTS MEDICINE PHYSICIANS
IN POPULATION HEALTH
In the realm of population health, the
increasing personal and economic health
burden of non-communicable diseases has
escalated to such an extent that it cannot
be sustained indefinitely by government
health department budgets2. There has
been a significant global emphasis on sport
and exercise as key elements to address
this pandemic by organisations such as
the International Olympic Committee
(IOC), FIFA and the UK Faculty of Sport and
Exercise Medicine promoting physical
activity programmes in the community.
The sports medicine physician should have
a key role in the promotion, integration and
facilitation of exercise as medicine within
primary and secondary healthcare. However,
changing existing, disease-based paradigms
where the pharmaceutical industry has
substantial financial and political influence
is challenging. It will require sustained and
co-ordinated effort from the wider medical
community, aligned with bold political
vision to change healthcare systems and
societal culture to promote and support
physical activity.
In addition to the promotion and
implementation of regular physical
activity in the prevention, treatment
and rehabilitation of chronic diseases of
lifestyle, Sport and Exercise Medicine has
been defined as that scope of medical
practice which focuses on:
The prevention, diagnosis, treatment
and rehabilitation of injuries that occur
during physical activity.
The prevention, diagnosis and
management of medical conditions that
occur during or after physical activity3.
The words protect, prevent and promote
often feature prominently in defining
the roles and scope of practice of sports
medicine physicians.
Competitive sport and major events
are increasingly being played in front of
millions of living room spectators from
around the globe. The recent London
Olympic and Paralympic Games were a
huge commercial and media success with
the extensive coverage of the Paralympics
raising the profile of disability sport. A
number of athletes and coaches commented
on injuries and illnesses and also the care
provided by hundreds of employed and
volunteer doctors, therapists and sport
scientists4.
But the cameras dont only focus
on the players; the medical teams and
sports medicine physicians providing the
healthcare to these athletes often find
themselves at the centre of media attention.
Every weekend the actions and decisions
of medical teams in professional sport are
observed and analysed on television and
social media platforms. The recent scrutiny
on concussion in sport has challenged
medical teams and sporting organisations
regarding their governance, decision-
making processes and the protection role
of the sports medicine physician. The
appropriately qualified sports medicine
physician has much to offer the elite
medical support team and the balance of
roles and responsibilities will depend on
each particular organisations structure.
PROTECT AND PREVENT
There are many conflicting opinions
and direction as to the role of the sports
medicine physician in elite sport. Is it,
as the IOC campaign would suggest, to
protect against and prevent injury and
illness? Is it to screen athletes, to ensure
quality injury surveillance or to assist in
optimising performance? Is it to diagnose
and manage the rehabilitation of injuries
or to prescribe pharmaceuticals where
there is some clinical indication to do so?
Is it to request imaging tests and provide
injection therapies, like platelet rich
plasma (PRP), that traditional healthcare
systems may not provide?
Sports medicine physicians have an
important role in protecting, especially
vulnerable athletes like children, against
unnecessary sporting risk. The correct
answer when approached before a rugby
game by an overenthusiastic parent
requesting an urgent local anaesthetic
injection to numb the pain of a recent
ankle ligament injury in a talented
beyond imagination 12-year old is clear.
However is it our role to protect the elite
competitive athlete? And if so, protect
from what?
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SPORTS MEDICINE
Competitive sport at an elite level is not
conducive to the pursuit of optimal health.
Kelly Holmes, the first British woman to
become a double Olympic champion when
she won the 800 m and 1500 m races at the
2004 Athens Olympic Games, was public
about the sacrifices necessary to compete
at the highest level of sport. Aged 34, she
achieved this remarkable double at the end
of a career plagued by injury and health
issues. She wrote: I have lost count of the
amount of physio treatments, stomach
injections, X-rays, blood tests, bone scans
and MRI scans I have had over the years for
my legs, back, Achilles tendons and feet, but
without them I wouldnt have been able to
keep on running5.
None of the track and field medal-
winners at the 2012 London Olympic Games
did so without at some point overcoming
their own struggles with injury and illness.
Greg Rutherford suffered a number of
significant hamstring injuries before his
Olympic long jump gold medal in London6
and London heptathlon gold medalist
Jessica Ennis-Hill missed the 2008 Beijing
Olympic Games due to a navicular stress
fracture. The injury rate in professional
football is estimated to be approximately
1000 times higher than the overall rate for
high-risk industrial occupations7. If our role
as sports medicine physicians was truly to
protect athletes from harm we could never
advocate for or recommend the pursuit of
an Olympic medal or a Football World Cup
title. The journey to an Olympic medal is not
compatible with protecting optimal health.
As an elite sports medicine physician,
protecting the health of the athlete is
perhaps not sustainable as a primary role.
Should our focus then be on prevention?
There is good evidence that simple
measures are effective in preventing injuries
and illness and it would be negligent for any
medical team looking after elite athletes not
to promote these. Measures, such as hand
washing and probiotic use when travelling,
allergy and blood screening programmes or
targeted conditioning programmes can all
help to prevent injury and illness8.
However, the physician must always
be mindful as to the goals of the athlete
or sports team. The easiest way to prevent
a hamstring injury is to ask the athlete
not to run fast or to work with a group of
26
1a
Management of
sports injuries
Circles of sports Management of
Psycho-social health
of the elite athlete medicine physician medical conditions in
the athlete
competencies
Sport specific
knowledge: loading
patterns, skill, training
and competition
schedules
athletes who cannot run fast. However, exercise to improve athlete performance.
these are clearly inappropriate preventative Sports medicine physicians should focus
strategies for an elite sprinter aspiring to on developing and maintaining excellence
Olympic medals. The focus of the sports in structuring and providing continuous
medicine physician and medical team must clinical services to the elite athlete. In
be to mitigate risk for when the athlete is conjunction with the coach and other
running fast, as he or she is required to do members of the sports medicine and science
by the demands of the sport. team (physiotherapists, physiologists etc.)
the sports medicine physician is involved
WHAT IS THE PRIMARY ROLE THEN OF THE in the rehabilitation of acute and chronic
SPORTS MEDICINE PHYSICIAN IN ELITE injuries as well as developing measures
SPORT? to reduce the risk of injury and illness
In British Athletics, the support team occurrence or severity.
physiotherapists, therapists and doctors As physicians we spend years of formal
developed a clear understanding of each training and decades of practice in order to
others role and responsibility regarding achieve optimal competence in the care of
musculoskeletal injury. The sports medicine our patients. Although our education never
physician is responsible for the diagnosis ends, we always fall short of perfection, and
and early management of every injury we remain forever fallible, we do achieve a
presentation. The therapist is responsible vast array of high-level skills that benefit our
for the rehabilitation and exercise patients, their families, our staff and team
prescription and liaison with the coach to members and as well as ourselves and our
return the athlete to full sporting activity. families. We learn to diagnose, treat, and
However, the role of the sports medicine prevent illness, to promote health and well-
physician is much broader than acute injury being, and to communicate9.
management. To provide this primary role of
The primary role of the sports medicine comprehensive health management
physician in competitive sport is the and optimising performance the sports
comprehensive health management medicine physician must wholly under-
of the elite athlete to facilitate optimal stand the demands and requirements of
performance the diagnosis and treatment the athletes sport. A thorough knowledge
of injuries and illnesses associated with of the technical and physiological requisites
1b EBM: integration of best medical evidence, Effective history taking
patient expectations, environment and Environment
clinician experience Sport specific application
Preference vs evidence Individualised
Communication
Implementation
Prevention
History
Management Figure 1: (a) The first step
in developing a clinical
circle of competencies
model identify the
relative importance of key
elements. (b) The clinical
circle of competency
Examinations
model developing
Diagnosis (clinical and injury management
special competencies.
Diagnostic clarity investiga- EBM=evidence-based
Anatomical/pathological AND tions) medicine.
EBM in physical
functional
examination and special
investigations
Radiology
Blood tests

for training and performance in that sport Warren Buffet has used the phrase circle optimising athlete performance than the
is necessary to provide integrated care, in of competence in the business context11. collection of data for surveillance. The sports
the context of optimising performance. In the context of sports medicine, this can physician is well-placed to co-ordinate,
It is difficult to succeed and thrive as a be creatively applied and modified into a monitor and manage a comprehensive
generalist sports medicine physician competency model to facilitate personal illness and injury prevention strategy for
in elite sport, as attaining this detailed reflective thinking, development and peer elite athletes following a PHE. The findings
knowledge, developing relationships appraisal (Figure 1a). Physicians need to of the PHE should be well-documented,
within the sport and delivering medical focus on optimising their appropriate ideally using an Electronic Medical Record
services is a huge challenge within every circles of clinical competencies to deal with keeping system accessible by all the key
sport. The combination of excellence in the health and performance challenges of members of the medical team.
clinical skills, sport specific knowledge, a individual elite athletes, including rapid
thorough understanding of the athletes diagnosis and appropriate intervention. 2. Invest in professional clinical environ-
goal combined with enthusiasm and It is paramount that the best medical ments including data management systems
compassion will make the sports medicine evidence is combined with the athletes The working environment of the sports
physician a trusted and respected member preference when formulating effective and medicine team in elite sport vary from the
of the athlete support team. individualised management plans12. We clinic in a private hospital, sports medicine
Management
illustrate of using sports injuries in institute or at the training venue to track
this model
5 KEY ELEMENTS AND TRENDS IN ELITE general sports(Figure
injuries1b) but this can be applied side and hotel rooms (Figure 3 UK Athletics
ATHLETE HEALTH MANAGEMENT AND in more detail to specific injuries, in specific training camp in Stellenbosch, South
PERFORMANCE OPTIMISATION sports and personal circumstances. Africa). It is therefore important to develop
1. Focus on clinical competencies: the effec- The Periodic Health Evaluation (PHE) of appropriate clinical communication and
tive clinical management of injuries and elite athletes is an important part of health record-keeping strategies to facilitate
illnesses management.
Circles of sports In some organisations this these situations. Integrated personalised
Management of
Injuries and illness will continue
Psycho-social health to occur might be called health screening with healthcare and communication involving
in athletes andofinfluence medicine
performance
the elite athlete the purposephysician medical conditions in
of diagnosing, managing and the athlete, coach and members of the
the athlete
despite our best efforts to protect and competencies
preventing injuries and illnesses. If the healthcare team is a key element to athlete
prevent. In football, the injury rate of PHE is an occasional event largely devoid health management. The Athlete Electronic
ligament injuries has decreased since the of ongoing contact or health management Medical Record (AEMR) is increasingly
start of the UEFA Champions League injury it is likely to have minimal impact on these used by teams and organisations not only
study 11 years ago, but overall training and aims (Figure
Sport specific 2). The follow-up and health to document health events but also to do
match injury rates and the rates of muscle knowledge:
management plan following a screening surveillance of injuries and illnesses and
loading
injury and severe injury remain high10. assessment
patterns, usually more important in clinical audits. These systems give rapid and
skill, istraining
and competition
schedules
27
SPORTS MEDICINE
Discuss HA findings
Further special investigations
(blood tests, urine, imaging,
spirometry)
Diagnoses
Individual performance goal(s)
Integrated electronic medical record and health monitoring system
(Clinical notes and performance readiness monitoring tools)
Injury
Acute/chronic
Implement management
strategies
Risk reduction/prevention
strategy
Health vs Performance RISK: Integrate
best medical evidence & athlete/patient
preference
Training and competition
advice
Continuous monitoring
and re-assessments
remote access to the comprehensive health
file and are updated with real-time health
information (injury and illness events,
blood tests, imaging etc). The Medicine and
Science Profiler EMR system implemented
by UK Athletics prior to the London Olympic
Games is such a system. The personalised
EMR is continuously updated with a traffic
light system for each health event on the
file informing real-time training risk and
readiness to compete. The medical team
also use this system for clinical audits. It is
reasonable to argue that organisations and
clubs failing to implement state of the art
EMR and health data systems in the near
future will significantly compromise their
ability to effectively manage athlete health.
28
Health status
Regular/ongoing HA:
Comprehensive history
Physical examination
Functional assessment
(physiotherapist)
Sports science assessments
(nutrition, psychology, podiatry,
physiology, biomechanics)
Regular health assessments
Illness
Acute/chronic
Implement management
strategies
Risk reduction/prevention
strategy
Health vs Performance RISK: Integrate
best medical evidence & athlete/patient
preference
Training and competition
advice
Continuous monitoring
and re-assessments
3. Develop a clear risk decision-making
strategy
There are some situations in adult
elite sport where the doctor must make
the decision to withdraw the player from
sport. These are usually related to head
trauma, when the athlete does not have
the capacity to make an informed decision
and the coach does not have the expertise
to assess capacity or risk. The recent debates
regarding concussed players continuing
to play in soccer and rugby reinforce
the essential requirements for doctors,
cognizant of the current best practice, to
determine fitness to return to play in this
situation13. The important message is that
only the doctor or a trained and experienced
Figure 2: Regular health
assessments and the
integration of a risk
communication, risk
reduction and continuous
monitoring approach.
HA=heath assessment.
Psychological/emotional
health
Implement management/support
strategies
Risk reduction/prevention
strategy
Sport/clinical psychologist
Strategies to cope with
training and competition
pressure/health issues
Continuous monitoring
and re-assessments
healthcare worker (physiotherapist or
nurse) should be allowed to make a return
to play decision on a concussed player. Other
on field decisions are usually made by the
doctor or physiotherapist in communication
with the coach and player.
However, most management decisions
regarding modification of training or
fitness to return to training or competition
are taken in a different context. In this
environment, the British Athletics
experience is that the role of the sports
medicine physician is to present the
information to the coach and athlete
regarding the nature of the injury, proposed
interventions, the rehabilitation course and
the expected timeframe to return. The risk
 3
4 training camp in
Board
CEO
Performance Director
Head Coach
and
Chief Medical
Officer
and consequences of continuing to train or
compete while injured are presented but
the decision to continue to train or compete
is for the athlete and coach. The doctor may
be willing and able to support this course of
action, even if it does not support optimal
health, if they are satisfied that the athlete
is making an informed decision. There may
be some situations in which the doctor
feels unable to actively support the more
risky course of action, due to the severity
of the potential outcomes or effects on
other players. The decision-making process
in both these circumstances should be
thorough and carefully documented. With
Figure 3: UK Athletics
Stellenbosch, South
Africa.
Figure 4: The Head Coach
and Chief Medical Officer
should be independently
accountable for decisions
and actions to a
Performance Director and
ultimately to the Board of
the sporting organisation.
good relationships, understanding of the
sport and integration within the team,
the sports medicine physician can steer
an appropriate path in these challenging
circumstances.
Optimal risk decision-making can
only be applied when the delivery of
sports medicine and science services to
athletes and players are appropriately
structured and managed within clubs and
organisations. It is ideal if both the Chief
Medical Officer/Head of Sports Medicine
and the Head Coach/Manager are line
managed by the Performance Director/CEO
who are accountable to a board of directors
(Figure 4). In some clubs and organisations
sports medicine physicians have played the
role of Head of Sports Medicine and Science
(e.g. Peter Brukner at Liverpool FC and Peter
Fricker at the Australian Institute of Sport).
In these cases they often dont serve as the
team physician.
4. Prioritise athlete performance
Every member of the support team of
an elite athlete must improve and support
performance. The sports medicine physician
in elite sport has an important role in
optimising athletic performance through
high quality illness and injury management.
Optimising performance through the
management of illness such as asthma,
iron deficiency or allergy may mean that
goals of treatment are somewhat different
than they would be for another patient14.
In the rehabilitation of injury the medical
team does not aim for adequate return of
muscle strength, rather optimal strength
for sporting excellence. Similarly in the
management of asthma or allergy in an elite
athlete the goal should be complete control
of symptoms and correction of pathological
physiology. The setting of an arbitrary cut
off of a drop in FEV1 of greater than 10%,
to make the diagnosis of asthma (and thus
permit pharmacological treatment) in an
elite athlete prior to the Beijing Olympic
The primary
role of the
Sports Medicine
Physician is the
comprehensive
health
management of
the elite athlete to
facilitate optimal
performance
29
SPORTS MEDICINE
Games was an example of an inappropriate
and frustrating restriction on illness
management in athletes. The correction of
vitamin and mineral deficiencies may have
small effects on health and performance but
may be appropriate to identify and treat in
the pursuit of sporting excellence with very
small margins between success and failure.
The role of sports medicine physicians in
optimising health and performance must
be clearly defined and set apart from the
malevolent practice of doping in sport. All
sports physicians in elite sport should be
30
adherent to and advocates of the WADA
code. Doping in sport should be relentlessly
pursued and clearly further deterrents
and punishments are required. In recent
years, it seems evident that WADA is more
specifically and aggressively targeting
performance-enhancing drug use and this
is to be welcomed.
5. Invest in communication and
implementation use social media
Social media platforms are increasingly
being used by athletes, organisations
Figure 5: A tweet by British Journal of
Sports Medicine editor Professor Karim
Khan on the IOC World Conference on
Injury and Illness Prevention in April 2014.
Figure 6: A UK Athletics poster to
emphasise the importance of early and
accurate injury diagnosis (poster design
Anita Man; photo Scott Davies).
and Sports Medicine clinicians, including
physicians. This is a very powerful
medium and when used correctly,
impacts significantly on improved team
communication and the delivery of
important health messages.
Twitter isnt only a powerful team
communication tool but also increasingly
used by sports medicine physicians
(@PeterBrukner; @DrJohnOrchard;
@RoaldBahr), Sports Scientists (@
ScienceofSport; @SweatScience), medical
journals (@BJSM_BMJ; @CJSMonline),
Universities (@HarvardHSPH; @
HarvardHealth; @uclh), sporting
organisations (@iocmedia; @FIFAcom; @
BritAthletics), Hospitals (@AspetarQatar),
athletes (@Mo_Farah; @J_Ennis) and Sports
Medicine Faculties (@FSEM_UK) to spread
health messages to a huge follower base
(Figure 5).
In a global village with instant access to
information of social and scientific nature
the norm, social media sceptics might soon
be wandering in the jungle while huge
sports stadia are being built in the desert!
In addition to social media, UK Athletics
also used health posters (Figure 6) and a
Health and Performance Passport (Figure
7) to complement pre-competition health
strategies before the London Olympic
Games.
SUMMARY
The primary role of the sports medicine
physician in competitive sport is the comp-
rehensive health management of the elite
athlete to facilitate optimal performance.
This can be achieved with an appropriate
focus on the physicians circles of clinical
competencies and will include pre-
participation health evaluations, integrated
electronic medical records, health and
performance-focused risk decision making,
a focus on optimising performance and a
thorough understanding of the integration
of communication and implementation
strategies within the particular sport.
Figure 7: Health and Performance Passport.
Our evolving specialty is facing huge
challenges but also exciting opportunities.
We will be better positioned as sports
medicine physicians to deal with these
when we accept the fact that we first need
to cure ourselves of the doctors disease the
pathological compulsion to cure15.
The role of the sports medicine physician
can be an extraordinarily rewarding one. We
can work with highly talented, interesting,
varied and inspirational athletes and
coaches (from the academic to the artisan!);
a rich tapestry of personalities that many
other medical professionals could never
collaborate with as colleagues in the
traditional medical world. We should run
close to the athlete and coach, managing
health, optimising performance and leading
the way in collaborative, balanced, evidence-
and preference-based, individualised
healthcare12.
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