October 20, 2019
Athletic Trainers in Sports Medicine Practice Cover

The Role and Relationship of Athletic Trainers in Sports Medicine Practice

As sports medicine physicians, athletic trainers likely play a key role in a part of your practice. There is a wide range of duties that are fulfilled by athletic trainers. Some universities use athletic trainers in a clinical setting to help provide care for patients and may be assigned to one team or multiple teams. Athletic trainers at smaller schools or colleges may care for all of the sports at that particular school and may be responsible for every student athlete. Others may be more interested in the research setting, work with surgical hardware representatives in the operating room, or even work to prevent injuries in a large manual labor setting. It is a very diverse field with many opportunities, almost all of which affect many sports medicine physicians or orthopedic surgeons.
Student athletes are generally more physically fit, more engaged socially and are more committed to staying in school. However, there are challenges and risks associated with being a student athlete. Around 90 percent of student athletes report some sort of sports-related injury in their athletic careers with 54 percent report playing while injured. Around 12 percent report a history of concussions sustained from their time on the field. Catastrophic injuries do occur as well, with more than 300 deaths being reported from 2008 to 2015. Athletic trainers are the most likely to be observing the game and are likely the first line of medical care for these athletes.
Most in the general public think of athletic trainers are the first to evaluate an injured athlete in the field of play. This includes both games and practices, with most practices only being supervised by the coaching staff and ATs. Sixty two percent of organized sports-related injuries occur during practice previously, but one recent study reported around 40 percent of injuries occurring in practice in 2014-2015 (1,2). A well trained AT will be able to differentiate many things in less than a minute. If there is a serious injury, they call for additional help. In non-emergent cases, an on-field assessment to determine the next steps is performed. Most sports medicine physicians will wait until the athlete is on the sidelines for a more thorough evaluation and should be watching the game for injuries. The team then works to determine the extent of the injury and whether or not it is safe for the athlete to return to play, stay on the sidelines for observation, leave the field (or go into a tent) for further evaluation (concussion evaluation, x-ray, etc.), or arrange a transport to the hospital. Other duties on the sidelines are sometimes overlooked. Taping or re-taping injuries, fixing equipment or covering abrasions occurs frequently. Most athletes know exactly where to look and who to ask for when things like this occur.
athletic trainers and sports medicine statistics

Image 1. Statistics for athletic trainers (Adopted from at your own risk [3])

Almost all athletic trainers work long hours during their seasons and sacrifice many things. Some games and practices occur very early in the morning or late at night. Football games almost always occur on Friday nights or on weekends. Availability before practice and games is also needed for evaluations and treatments. I always value their input on certain situations in regards to an athlete’s goals, demeanor or reactions in certain situations. ATs spend much more time with student athletes than the team or personal physicians and tend to know most on a more personal level. This brings up the next important role for athletic trainers, which is providing first line recognition of mental health issues or disorders. Regardless of the setting – secondary, collegiate, professional, military, or clinical – every athlete or patient is at risk to experience stressors that could lead to emotional disturbances. 

In a study funded by the National Institute of Mental Health, the prevalence of a broad range of mental disorders in a nationally representative sample of US adolescents (aged 13-18) was examined. One in 10 children had a serious emotional disturbance that interfered with daily activities. In addition, few affected youths received adequate mental health care. Mood disorders affected 14.3% of teens, including twice as many girls as boys. The prevalence of these disorders increased with age: a nearly 2-fold increase between age 13 to 14 years and age 17 to 18 years. One in 3 adolescents (31.9%) met the criteria for an anxiety disorder, ranging from 2.2% for generalized anxiety disorder to 19.3% for a specific phobia (4). Some teams may incorporate mental health assessments or questions into the pre-participation exams to identify at-risk athletes. There may be referrals made before the season or close monitoring may occur. It is the ATs job to speak with team physicians and mental health care providers to help the athlete improve or prevent worsening or relapse (5). Permission may be needed from a parent or guardian, which may or may not know how their child is feeling. Emergency situations with either homicidal or suicidal ideation may also occur and the AT may be the first person a student athlete shares this information with due to their relationship.
athletic trainer sports medicine sideline treatment

Image 2. Picture of an athletic trainer treating an athlete on the field (courtesy of blog.mission-health.org)

Another role that affects sports medicine physicians and student athletes directly is the AT’s role in rehabilitation. Injured athletes often report to ATs with a wide range of injuries, including concussion return to play to ACL reconstruction rehabilitation. This often occurs on a near daily basis on many occasions. Many musculoskeletal injuries undergo treatment either before, during of after practices and a wide range of recovery modalities may be performed. Many orthopedic surgeons and physical therapists will use ATs for a final graded return to play following injuries or surgeries, such as ACL reconstruction, elbow UCL reconstruction, labrum repairs, among many others. ATs also play a vital role in return to play for sport related concussions. They are most likely the medical professional that facilitates and observes the return to play process for sport related concussions. I personally use our ATs to facilitate initial and post-exertion neuropsychological testing, which helps office flow and eases the burden on other office staff. Many universities and health systems use ATs in the clinical setting to assist in rooming patients, administer testing, or cast or splint injuries. This is another emerging role for ATs that can ease the burden on health systems.
Prior reports estimate that roughly half of sports injuries are preventable and other reports estimate around half are also due to overuse (6,7). This is yet another important role for ATs that directly affects other sports medicine professionals. This is done in multiple ways including prophylactic bracing and taping, balance-training exercise programs, neuromuscular conditioning, and data-driven rule and policy changes. The NATA (National Athletic Trainers’ Association) recently published an ACL prevention statement, which recommends that a multicomponent injury-prevention training program include, at minimum, feedback on proper exercise technique for at least 3 of the following exercise types: strength, plyometrics, agility, balance, and flexibility (8). This may be implemented in many ways but including these in the warm up or cool down for practices or games is often done and ATs are critical in implementing these injury prevention programs. Other general lower extremity programs, such as FIFA 11, fall under similar circumstances. Some systems may implement newer techniques for attempts at concussion prevention such as vision training, vestibular training or neck strengthening, although no program or equipment has been shown to prevent sport related concussion (9).
I have had a great personal experience through my own training and practice working as a team with ATs. I have worked with professional, college and high school ATs and have witnessed their diversity and importance to both teams and providers. I always value their opinion on their athletes in training room and during games due to the fact that they spend much more time with their respective teams. At the University of Kentucky, ATs are used to help room patients and are assigned one or multiple teams, depending on the sport. Their AT program also requires participation in research. In my current setting with many high schools and two small colleges, we have implemented injury prevention and screening programs. ATs also fuel the walk in clinics in most areas and universities. In summary, ATs serve an extremely important role of almost all sports medicine practices and are the first line of both offense (prevention) and defense (treatment).

References

1. National Athletic Trainers’ Association. (1989). Injury toll in prep sports estimated at 1.3 million. Journal Athletic Training, 24, 360-393.
2. Comstock, R. D., PhD, Currie, D. W., MPH, & Pierpoint, L. A., MS. (n.d.). National High School Sports-Related Injury Surveillance Study 2014-2015 School Year [Scholarly project]. In UC Denver. Retrieved March 8, 2016, from http://www.ucdenver.edu/academics/colleges/PublicHealth/research/ResearchProjects/piper/projects/RIO/Documents/Original Report_ 2014_15.pdf
3. “A Safer Approach to Sport.”  https://www.atyourownrisk.org/reduce-your-risk/.  National Athletic Trainers’ Association. 2019.
4. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980–989.
5. Gourlay, L., & Barnum, M. (2011). Recognizing psychological disorders, part 2: Referral and management. International Journal of Athletic Therapy & Training, 13-18.
6. Preserving the Future of Sport: From Prevention to Treatment of Youth Overuse Sports Injuries. AOSSM 2009 Annual Meeting Pre-Conference Program. Keystone, Colorado.
7, JS Powell, KD Barber Foss, 1999. Injury patterns in selected high school sports: a review of the 1995-1997 seasons. J Athl Train. 34: 277-84
8. Padua DA, DiStefano LJ, Hewett TE, Garrett WE, Marshall SW, Golden GM, et al. National athletic trainers’ association position statement: prevention of anterior cruciate ligament injury. J Athl Train. 2018;53:5–19.
9. Schneider DK, Grandhi RK, Bansal P, et al. Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med 2016.