Doctor, can I play?

The first article in a new series on sports medicine: how physios, doctors, trainers and players seek to strike a balance between injury management and the demands of the market

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	The absence of Sachin Tendulkar in a series due to injury can spell big losses for advertisers and broadcasters © Getty Images  Enlarge
Related Links Players/Officials: Nathan Bracken | Andrew Leipus | Sachin Tendulkar Teams: Australia | India

There is a specialty within elite sports that mostly flies under the radar. Every now and again it pops up for the wrong reasons. The other day an article about Nathan Bracken claiming his career was ruined by mismanagement of a knee injury caught my eye. From what was stated in the article, he was said to have argued that he now suffers reduced quality of life, and that he lost significant future earnings because of poor medical advice. Hence, litigation demanding compensation.

The specialty in question is that of sports medicine. This is an umbrella term for a group of allied professions who work to ensure the optimal health and fitness of athletes, whether in a team setting or as individuals. When things are literally running smoothly (pun intended), it is an area that generally goes unnoticed by all except the athletes themselves. Only when injuries occur to key players or performance is deemed sub-par does this area make the headlines or come under scrutiny from team administrators.

Most professional sporting codes are now part of an industry that involves exorbitant sums of money. This hit home for me many years ago during a Test match when I was treating Sachin Tendulkar's knee. We were discussing money and he casually mentioned with a wink and a smile that the knee under my hands at the time was worth a lot of money. (I won't reveal the exact amount he said it was worth!)

Up until that moment I hadn't given too much thought to the financial implications or consequences of the effectiveness of my management. I treated each player and each injury objectively, on its own merits. But thanks to Sachin, since that day I have been acutely aware of the risk of adverse treatment outcomes and poor decision-making.

Consider the possibility that Tendulkar doesn't play a match because of injury. It hardly affects his earnings, but it might affect the number of people coming to the ground just to see him play. It might even affect the TV viewership. Consider all the talk generated by his absence in some games in the CB Series because of "rotation policies". If an injury is bad enough to keep Tendulkar out of a series, it could affect the marketability of the tournament to sponsors (we have all seen a stadium crowd disappear when Sachin loses his wicket).

A career-threatening injury to a key player can mean huge financial losses to many stakeholders. Poor injury management at the elite level can have intangible financial flow-on effects. Similarly, keeping a squad of players fit for selection throughout a tournament can win you a series.

I like to use an analogy to trust-fund management when explaining the role of the sports medicine professional. Someone qualified and experienced is necessary to ensure a good return on any financial investment. IPL squads are worth over $10 million. Would you trust your life's savings to someone with minimal investment experience?

Most international and IPL teams employ experienced sports physiotherapists for this fact alone. Sports teams and administrations earn their income predominantly through sponsorships, which is linked to their player availability and performance. Clearly it's in everyone's interests to always keep the best players on the field.

But there is always risk management involved when players take the field carrying niggles or injuries. They are putting their bodies on the line, balancing risk with possible reward. This is the nature and the expectation of the game today. This is their job. Obviously our goal is to keep these guys out there but without causing further harm. This last phrase is critical to the sports medico; whatever intervention or decision we choose should not make the injury worse or predispose to other injury. Many treatment techniques are employed, like taping/bracing, pharmacology and injection therapy, with the player's consent. This is the risk management by the sports medico.

	Players are always putting their bodies on the line, balancing risk with possible reward. This is the nature and the expectation of the game today. This is their job. Obviously our goal is to keep these guys out there but without causing further harm

Injury minimisation is another term used. Long-term damage due to minor strains and sprains is often difficult to predict, and the lure of earning a lot in a short career often overrides the medical advice and opinion given.

The recent example of Bracken suing Cricket Australia's sports medical team highlights the legally tricky area of accountability for decision-making when it comes to return to sport after injury. It is clearly inappropriate to comment on this case, but the outcome of the lawsuit will be closely watched. The ethical and medico-legal issues within the current system could certainly be challenged.

Injury rehabilitation is not about following a recipe. The "passing of a fitness test", often discussed in commentary, is not about "ticking the boxes" of physical performance measures. Rehab involves more than the physical repair and re-strengthening of the relevant anatomy. One has to consider the emotional and social aspect, with constant effective communication, education and feedback between the player and the sport medicine team. This is vital to ensure a holistic recovery of the player.

The surgeon, sports physician, sports physiotherapist and trainers are generally all in a good position to know the pathology healing times and the workloads undertaken on the road to recovery. But ultimately, if the player has been an informed participant in the process, he should be responsible and mature enough to make the final decision to return to competition at the end of the rehabilitation.

I can recall a time when my decision to hold a player back was questioned in the media. The player felt he was ready to play, based on a lack of symptoms and perceived good function of his shoulder. Technically I couldn't stop him declaring himself fit but could only inform him of the possible risks involved. My actions were questioned. Who was I to tell an experienced international player when he was ready to play or not? But the phase of healing in this case was still too early to sustain the uncontrolled loads experienced during a match. An early return could have meant a recurrence of the injury and perceived negligence on my part.

Commentary in the media by non-sports medicine professionals can influence a player's psyche and motivation. Recurrence of injury is all too common and academically preventable, given sufficient rehabilitation.

Conversely, sometimes encouragement given to a player to move an injured body or body part is required to overcome fears and anxieties. This pushing of a patient to move through discomfort is controlled and goal-oriented. Ultimately, however, a player should never be forced to play when he is unsure or uncertain. The player knows his body better than anyone else and is the only one who can confidently overcome any fears that reside due to the injury. Pain is real and needs to be respected by all parties involved.

Sport medicine is a complex but important area in an increasingly litigious sporting world. It plays an important role behind the scenes in any professional sports dressing room. Unfortunately, decisions are often misunderstood and it is not always easy for the medicos to make decisions, seeing how they are under pressure from the coach, management, team owners, the press, the captain, and even the players themselves. Best practice management, with the player's health of primary concern, should be the only method employed. But it is a challenging and rewarding profession nonetheless.