Knowing the health care system as well as having a fundamental understanding of the different health care professionals and their areas of expertise can save the patient precious time and money when recovering from a sports injury.
While the health care delivery system will in some ways determine who the patient can see based on his/her insurance policy, having a base knowledge of each of the various sports medicine professionals can help the patient maneuver through the system to get the appropriate type and level of care needed to get the athlete back competing again.
Some medical professional options may be dictated for you depending upon the type of medical insurance that you have. If you have a health maintenance organization (HMO) as your primary insurance, the insurance policy dictates that you see your primary care physician first when injured unless it is a life-threatening injury (referral to nearest hospital). With this type of insurance plan, it is the primary care physician’s job to determine if the patient needs a referral to another specialist.
Many primary care physicians are comfortable with diagnosing and providing care for minor to moderate sports injuries. For many people, this level of treatment and care is sufficient to get the patient back to normal daily activities. However, athletes may need additional care to be able to restore their bodies back to the level of performance they had prior to their injuries.
Unfortunately, in the HMO system, the primary care physician is the “gatekeeper” for all other health care professionals. However, a patient can also request a referral to a sports medicine professional even if his/her primary care physician does not initially recommend it. The challenge with referrals to sports medicine professionals in HMO networks is that the specialists tend to be few and far between leading to long wait times for appointments and even longer wait times for surgery if it is necessary.
For those with preferred provider organization (PPO) insurance, the patient has more immediate options for health care professionals as the patient is able to make his/her appointments directly with different health care professionals without having to go through his/her family physician. This does tend to save time in the overall care and treatment of athletic sports injuries.
Regardless of the type of insurance, understanding what type of professional to see and when to see them will save valuable time. This is an important factor especially for those who do not like to be sidelined with sports injuries.
While a number of allied health professionals can treat injuries, understanding their unique specialties can help speed up the recovery time. Below is a list of sports medicine professionals and their areas and levels of expertise.
Should I see an M.D. or a D.O?
There are two routes to becoming a physician. One is to attend a traditional medical school and graduate with a degree of Doctor of Medicine or M.D. The second is to attend a medical school offering the degree of Doctor of Osteopathic Medicine or a D.O. The curricula are nearly identical in both schools with most states recognizing both degrees as equivalent.
The difference is that the D.O. continues with additional study in hands-on manipulation and study of the musculoskeletal system. Not all D.O.s utilize osteopathic manipulation (similar to that which is done by chiropractors), but many include the manipulations as part of a holistic approach (mind-body-spirit) to medical care.
With a holistic perspective, the D.O. focuses on treating and healing the patient as a whole rather than focusing on one system or body part. While the D.O. degree is not as well known as the M.D., both are licensed to practice medicine, perform surgery, and prescribe medication.
Primary Care or Family Physician
A primary care physician is a physician trained in general medicine. This training does include basic orthopedic diagnosis and treatment. For injuries such as mild sprains, strains, contusions, and overuse injuries, a primary care physician may be all the athlete needs to receive appropriate initial treatment and follow-up care.
Primary Care Sports Medicine Doctor
A primary care sports medicine doctor is a physician that received training in general medicine and then pursued and completed additional training in the field of sports medicine. These physicians complete additional training known as “fellowships” in the field of sports medicine. The fellowships are typically one to two years in length in which the physicians typically shadow orthopedic surgeons in their offices to gain more expertise in diagnosing and treating sports injuries.
As of 1999, a physician is eligible to sit for a sports medicine examination leading to a “Certificate of Added Qualifications in Sports Medicine” once the physician has completed his/her sports medicine fellowship.. There are currently only two organizations that certify physicians in this specialty. They include the American Board of Medical Specialties (ABMS) and the American Osteopathic Association (AOA) Bureau of Osteopathic Specialists.
A physician with this additional credential is qualified to diagnose and treat mild, moderate, and severe sports medicine injuries that do not require surgical intervention. If surgical intervention is necessary, this physician will refer his/her patients to an orthopedic surgeon.
An orthopedic surgeon is a physician who completed his/her general medicine training and then completed an orthopedic surgery residency. This residency prepares a physician to diagnose, treat, and surgically repair musculoskeletal injuries. If the physician chooses, he/she may also pursue a surgical sports medicine fellowship (one to two years) providing additional training and expertise for the physician in surgical techniques for sports injuries.
If the surgeon chooses, he/she may elect to pursue additional surgical training in a specific joint (i.e., shoulder, knee, hand, back). It is not uncommon today to walk in to an orthopedic specialists’ office and find that each orthopedic surgeon in the office specializes in a specific area of the body. When this is the case, the front office will direct the patient to the appropriate orthopedic surgeon.
The expertise of the orthopedic surgeon is in treating conditions that can be improved through surgical intervention. While these physicians can diagnose any and all sports medicine injuries, it is wise to choose this specialist only if the athlete has not seen improvement in his/her condition after initial treatment from his/her primary physician or if the injury is only one that can recover with surgery. The following injuries are examples of some athletic injuries that are commonly corrected with orthopedic surgery:
• Medial or lateral meniscus tear
• Anterior cruciate ligament tear (acl tear)
• Displaced fractures that need internal fixation
• Complications from dislocations
• Unidirectional joint laxity (i.e., repeated dislocations/subluxations)
• Full tissue muscle and/or tendon tears
As with any type of surgery, it is good practice to seek the opinion of a second orthopedic surgeon prior to moving forward with surgery. If a specific surgeon seems too eager to operate or if you are uncomfortable with the pace of treatment, it is wise to take the time to get a second opinion.
While orthopedic surgeons are experts at repairing soft tissue and bone, it is the physical therapist who has the expertise to safely return an athlete to the court, floor, or field after surgery or in cases where range of motion, strength, power, and functional skills need to be improved.
There are a number of different professionals within the field of physical therapy including the physical therapy assistant, registered physical therapist with a master’s degree level of education, and a registered physical therapist with an earned doctoral degree in physical therapy (DPT). A physical therapist with an earned doctorate is at the top tier of this profession.
Physical therapists specialize in restorative rehabilitation. Their education includes several years of clinical training working with different patient populations and in different clinical settings. Just as orthopedic surgeons can specialize in specific joints, physical therapists can also specialize in specific populations (i.e., geriatric, post-surgical, and sports medicine). For those athletes recovering from sports injuries, seeking out a physical therapist specializing in rehabilitating athletes is a wise choice.
While physical therapists all have the education to rehabilitate an individual back to activities of daily living, not all have the expertise and the skills in knowing how to develop and restore explosive power and functional ability in able to return athletes back to full competition. Returning an athlete to sports competition takes additional sports performance knowledge as well as a thorough knowledge of movement skills for a variety of sports.
Depending on the type and severity of the injury, the athlete may choose to seek out an appointment with a physical therapist immediately post-injury. While physical therapists may not currently have access to specific high cost diagnostic tools (i.e., x-rays, MRI), they tend to be extremely well-skilled in diagnosing musculoskeletal injuries using good old-fashioned hands-on diagnostic techniques. A skilled physical therapist can diagnose and fully rehabilitate most sports injuries.
Another aspect for athletes to look for when searching for a quality sports medicine physical therapist is to look for a professional who is less reliant on modalities and machines and more reliant on hands-on therapeutic techniques. While machines and modalities have their place in rehabilitation, as the athlete regains range-of-motion and strength, the therapy should incorporate more functional training and less time on machines.
Current good therapeutic techniques should also include hands-on therapeutic techniques including soft tissue mobilization when appropriate. These techniques might include different types of soft tissue massage (effleurage, petrissage, and friction massage), myofascial release, and deep tissue techniques. For a returning athlete, soft tissue mobilization is critical to keeping healing tissues from scarring down to nearby surrounding structures. Keeping tissues mobile is crucial for athletes to achieve their full range-of-motion.
If an injury has sidelined an athlete for more than several weeks or an athlete has an injury that does not seem to be healing on its own, physical therapy may be the component necessary for returning an athlete back to pre-injury levels. While physical therapists are the specialists in rehabilitation, there is another allied health professional that can provide quality physical therapy for an injured athlete.
Certified Athletic Trainer
The certified athletic trainer (ATC) is an allied health professional who receives training specifically in preventing, diagnosing, treating, and rehabilitating sports injuries. While all of these professionals hold a bachelor’s degree in athletic training or a related field, many hold advanced master’s level degrees and/or doctorate level degrees.
The benefit of the certified athletic trainer is that this professional is typically on the side-line (high school, college, university, and professional sports) when the injury occurs and can provide immediate diagnosis for the athlete. These professionals are trained in how to triage injuries and know how and when to refer an athlete for further medical care if necessary. The certified athletic trainer is also trained in the skills of rehabilitation and can prescribe and administer solid rehabilitation protocols for many sports injuries.
The advantage of this professional is that they are commonly hired by athletic departments in high schools and/or colleges and universities to specifically work with student-athletes. This means that their medical evaluations and treatments are provided at no cost to the student-athletes. The challenge for this professional is that their numbers are inadequate in many high schools and colleges with the ratio of student-athletes to ATCs at hundreds to one. This translates into more of a triage situation for medical care and less time for the administration of long term rehabilitation programs.
However, setting up an initial appointment with a certified athletic trainer is a good first step if one is available to the athlete because he/she can diagnose the injury and refer the athlete to other health professionals (i.e., cardiologist, neurologist, orthopedic surgeon) for more thorough diagnostic tests if the ATC feels that it is warranted.
With the recent attention in the media on sudden death in athletes from hypertrophic cardiomyopathy, a cardiologist is one specialist that is increasingly seen working with young athletes. A cardiologist specializes in the diagnosis and treatment of conditions and disorders of the heart.
While a physician may diagnose an initial problem with the heart, they typically do not have the expertise to perform advanced diagnostic tests. An athlete will be referred to a cardiologist if they have a family history of a heart attack before the age of 50 or if the athlete presents with symptoms that may be associated with a heart condition. In these cases, the athlete should not be cleared to participate in any sports activities until he/she has been cleared by his/her cardiologist.
Another specialist who is becoming more mainstream in the field of sports medicine is the physician who specializes in neurology. This is due to the recent focused attention on the diagnosis, management, and treatment of concussions in athletes. As the research continues to report studies linking athletes who have sustained multiple concussions with permanent long-term brain damage, there is an increased need for athletes to be treated and cleared by physicians specializing in the treatment of concussions.
Any athlete with a history of concussions should be seen by a neurologist prior to being returned to sport. As the knowledge of the repercussions of competing with concussions grows in the sports world, we will continue to see an increase in the use of neurologists in sports medicine to ensure that athletes are not returned to sport too early. Neurologists may even recommend the termination of all sports participation.
A podiatrist is a professional specializing in the diagnosis, treatment, and surgical repair of injuries to the foot. These individuals complete undergraduate studies and then attend a college of podiatric medicine graduating with a degree of Doctor of Podiatric Medicine (DPM). These individuals can diagnose and treat a number of conditions related to the foot, ankle, and lower leg including calluses, ingrown toenails, bunions, arch problems, and other ankle and foot injuries.
For athletes, foot problems can be the source of injuries higher up in the leg including overuse injuries at the knee and hip. Podiatrists can help prevent these types of injuries through the prescription of custom-made orthotics to correct arch problems, over pronation (walk on the medial border of the foot), or supination problems (walk on the outside border of the foot.
There is a wide range of chiropractors from those who rely solely on spinal manipulations to heal injuries to those that combine spinal manipulations with current therapeutic modalities and treatments. Spinal manipulations alone may provide temporary relief of pain but may not alone heal a soft tissue injury.
The theory behind spinal manipulations is that the manipulation can relieve pain caused by a nerve impingement. The manipulation relieves the nerve impingement thereby relieving the pain. While nerve pathology may be the cause of some sports injury pain, it may not be exclusive of itself.
Also, while spinal manipulations may bring short-term pain relief for the athlete, the pain may return over time if additional exercises are not also utilized to improve muscle imbalances and stretch tight tissue. For this reason, effective chiropractors specializing in treating sports injuries combine both chiropractic manipulation and traditional therapeutic exercises to help the athlete return to sports.
Last, chiropractic care should be prescribed for only a specific duration. If the injury has not improved or if it worsens after a specified amount of time, the athlete should be referred to other health professionals for further diagnosis and care.
A massage therapist is an individual who completes a short-term program from either a trade school or independent program. There is no degree requirement for this field, but only a certification process.
These individuals are trained in various massage techniques that can either help relax tight muscles (relaxation massage) or loosen tight tissue (sports massage). Both can be beneficial for an athlete when used in conjunction with traditional therapy. However, this professional is not trained in the science of recognizing, diagnosing, or treating sports injuries.
Regardless of which specialist you choose to see, if the treatment is effective, the pain will start decreasing and your ability to move and use the injured area will improve. If the treatment does not produce positive results or if you are uncomfortable with your diagnosis or treatment plan, you should seek out the opinion of another professional.
Unfortunately, practicing medicine is not an exact science. However, with expertise and experience, sports medicine professionals will be able to get you back moving efficiently and pain free again.
American Osteopathic Academy of Sports Medicine. The Sports Medicine FAQ. (Accessed on November 24, 2010 from www.aoasm.org).
Heisler, J. (September 29, 2009). What is the Difference Between a D.O. Physician and an M.D.? (Accessed on http://surgery.about.com/).
Quinn, E. (July 5, 2010). Should I See a Sports Medicine Specialist for Sports Injury? (Accessed on November 24, 2010 from www.About.com : Sports Medicine).