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No pain, no gain. The dilemma of a team physician

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In my hometown, a professional footballer has recently sued a club doctor and his football club, alleging that the complications of a local anaesthetic injection given during a football match resulted in a permanent and career-ending injury. As a now-retired football club doctor (over 15 seasons), this news sends shivers up and down my spine. How many similar injections did I administer over my career? Too many to count I suspect. Regardless of the merits of the allegations made in this case, the issue is a very real and concerning one for sports physicians worldwide.

Although clinicians outside the realm of sports medicine are often critical of the treatment administered during professional sports events, few know or experience the reality. It seems that any doctors watching a televised professional sports event have a licence to comment publicly on what they may or may not have seen. I can still remember the vehement letter to the editor of a daily newspaper over the management of a supposedly concussed player who was allowed to continue playing that day having been carried off on a stretcher. When it was pointed out to the neurosurgical author concerned that the player was not concussed at all, he was only grudgingly more obliging. It is a pity that Hippocrates did not add to his list the aphorism, “don't criticise what you don't understand”.

The use of local anaesthetic injections to reduce pain enabling a professional player to continue during a match has been done for many years. Typically it is done to reduce the pain from a soft tissue injury that restricts the player. No sports physicians would condone the use of such agents to mask or aggravate a serious injury or where a long term injury may result. It is not the case that the end justifies the means. The game must always come a distant second to the players long term welfare, and the doctor must always remain an advocate for the player's medical interests.

Although the guiding principle that we all follow in such situations it to preserve health and avoid long term complications, nevertheless there are many soft tissue injuries where local anaesthetic injections may be utilised as part of a return to play strategy. The difficulty however is not in the action, it is in the justification. What is done in the heat of battle may have to be explained in the cold harsh light of a courtroom. In a game situation, informed consent and explanation to the player has no real meaning. When there is big-match pressure, financial rewards, coaching demands, and a player's desire to return to the game outweighing common sense, such actions may be seen by lawyers as being coercive. To ask a player to sign a consent form is simply not practical. Some media commentators have even suggested players sign a general consent or medical release form at the start of the season. Such concepts are not ethical.

The other problem that many club doctors face is that when dealing with a team of players with injuries during the match, the documentation may not necessarily be up to the high standards of the medical care given. As the medicolegal pundits say, good notes = good defence, bad notes = bad defence, and no notes = no defence. From practical experience, I know that I might be faced with 20 injuries during a match—how can I keep contemporaneous notes on all such situations? With the case outlined above, the fear of being in a courtroom with nothing more than your own recollection of what happened is a recipe for disaster.

As well as providing individual athlete care, as team physicians we are often involved in the evaluation of new treatment methods. Such situations can arise directly when an athlete wants to use a particular dietary supplement or indirectly when a coach asks you about a particular therapy. The latter situation often arises when another team is reported in the media as using say hyperbaric oxygen, for example, and coaches seem to have a “keep up with the Jones's” mentality. How can we be balanced in our approach when we know there is no evidence to support such a therapy? Once again mainstream medicine has little understanding of this role that sports medicine plays. Orthodox medicine is often less about “team” performance than about individual care.

Team physicians need to be credible within their teams. Their professionalism must be respected. This in part develops by taking a considered and thoughtful approach to such issues. A genuine attempt should be made to evaluate such therapies when requested. We must also be forthright when required and voice our concerns to the correct people when an issue of medical safety arises. I have often found those coaches when confronted by the negative scientific evidence on a particular therapy of interest often respect that stand point. Coaches are often motivated by the need to have considered all the options rather than hanging on a particular approach. Medicos however often see the same situation as threatening to their role in a team structure if alternative therapies are raised. Often there are no correct answers to be given on safety or efficacy when unproved therapies are suggested.

We need to embrace the issues and not be unnecessarily critical. In addition to following our treatment evidence base, we also need to remind ourselves that all doctors make mistakes. It often surprises me as a team physician in professional sport that more mistakes are not made given the pressure cooker atmosphere and need for split second decisions. In addition, even proven therapies, such as non-steroidal anti-inflammatory drug use in arthritis, carry significant morbidity and mortality. All these aspects of care must be factored in to the medical approach utilised by a physician. Despite this we must always be ready to face the challenges head on and ensure that our athlete medical care remains optimal.

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