Managing The Expectations Of Athletes For Return To Competition

As we get deeper into September, I find an interesting thing happening with respect to my sports medicine practice. A confluence of many factors creates challenges this time of year when dealing with an athletic population.

School starts and many young athletes are getting involved with their school or club teams and increasing the intensity of their participation. The Chicago Marathon is less than a month away and as people are ramping up their mileage, many issues start to emerge. Professional athletes are either finishing their seasons and planning their off-season medical regimens or getting ready for the upcoming season and getting in their final tune-ups.

Each group of athletes mentioned above has different needs, expectations and challenges. It is important to understand all of these things as you try to return athletes successfully to their chosen sport. The most important thing you can do as their treating physician is manage their expectations appropriately. Each group has different external forces that you need to consider when managing these expectations.

Assessing Injuries In Young Athletes

When evaluating young athletes, one must first assess where they are in their athletic career and what is at stake with their given sport. Rarely is the young athlete’s sport going to be their road to college or professional sports. When these young athletes come into the office, it is important to assess whether the injury or pain is truly an athletic injury, or if the athletes themselves are crying out for help in an attempt to lessen the pressure on them from parents and coaches.

Too often, I will see very talented young athletes with questionable problems and when one looks deeper, we realize that some athletes are just trying to find a way to slow down without disappointing the parents or coaches. When we identify these types of athletes, we will take them out of sports and tell the parents or coach it is extremely necessary to allow this problem to heal properly. This is not always a black and white situation but one that experience and judgment help identify. I have had many young people come back to me later in life and thank me for helping them through a difficult situation. They admit later that they were just trying to slow down as they were not enjoying the sport any longer.

More often, young athletes come in with true injuries. Frequently, they want to get back to their sports quickly, other parents want them to get back to their sports quickly and their coaches are putting pressure on them to return. It is very important in this situation for the physician to take a very strong position and not let those desires dictate the proper course of action.

When I am getting the history of a young athlete’s problem or injury, I talk directly to him or her and try to get the athlete to engage with me, tell me the problem from his or her perspective and try to get the young athlete to answer all of the questions and not let the parents influence the discussion. I will always give the parents an opportunity to give their thoughts but I want the young people to have my full attention and let them speak for themselves.

Once I have determined the proper course of care, I always address the young athletes directly, explain the problem and the treatment we are going to follow before explaining it again to their parents. I always emphasize the importance of following the course of action and not allowing the athlete to return to sport until I have given approval and not letting the parent or coach determine when it is appropriate for the athlete to return to their sport. Sometimes parents and coaches do not appreciate the bigger picture.

A more difficult situation is dealing with very high-level high school athletes who might be in their junior or senior year. These athletes may feel like they have to play in order to get the scholarship that they are hoping for. In many situations, the only opportunity for the athletes to attend college will be through athletics and the stakes are very high.

It is very critical to assess the injury and to determine whether continuing to play could lead to worse problems that could prevent the athlete from continuing his or her sport in the near future but also in the long term. It is also critical to have a very frank discussion with the athletes and parents about what problems could occur by continuing participation in their sport and how their injury could affect them now as well as the long term. If athletes participate when they are less than 100 percent, that could negatively impact their scholarship potential and, of course, further injury could prevent them from playing altogether in the future. It is critical for the physician to outline the risks so the family can make the best decision possible for the athletes.

Dealing With The Unique Considerations Of Marathon Runners

It is always interesting working with marathon runners. There are two types of people we see with respect to marathon runners. One is the person who is a chronic marathon runner and the other is the person who is running either his first marathon or rarely runs a marathon. They provide different challenges.

The people who are chronic marathon runners are typically “know-it-alls” when it comes to their body. They are usually coming in telling you what their problem is and what they want to do for solutions. They usually do not want any specific medical advice and would rather have you confirm what they already believe. Sometimes when the situation dictates, you have to have a very strong conversation with them to explain that their problem is more severe than they expected and not running the upcoming marathon may be in their best interest for their continued desires to run marathons in the future.

For first-time marathon runners, the conversation has to be a bit softer. They are interested in what you have to say and are hopeful that you can provide some solutions and support that will allow them to participate and complete the upcoming marathon. Many of these people have overused their shoe gear and their training methods have not been the best. Often, I am forced to slow down their training routine at this point to allow their body to start to recover. They become very scared that this alteration in their training routine will result in their inability to complete the marathon. However, I explain to them that if they do not slow down, their problems will get worse and they won't be able to even start the marathon. 

Additionally, it is difficult to institute much treatment with only a few weeks left until the marathon and things like orthotics are an unreasonable alternative at this juncture. Even a medical grade over-the-counter arch support may not be appropriate this late in the game. Usually, it is about the standard protocol: ice, rest and anti-inflammatory medications with reduction of mileage and hope that they recover in time to give the marathon their best shot.

Why High-Level Athletes Have High-Level Challenges

I have been fortunate (or unfortunate) enough to have treated many Olympic and professional athletes. They present a whole different challenge. There are millions of dollars at stake when dealing with professional athletes and the outside influences are their families, their agents, the coaches, the trainers, the other doctors and the owners of the team, not to mention the fans and media.

High-level athletes are hearing all kinds of noise about their problems with advice from all directions. When it comes to these athletes, during the season, there are key considerations to keep in mind. You need to assess whether resting early in the season will lead to better opportunity for success later in the season versus playing through the injury now, which could lead to problems later. These athletes always want to get back on the field or court as quickly as possible. Often the decision to play through an injury or rest and let it heal is a combination of the advice of the head team physician, the trainer, the coach, the agent and the player. One of the big differences in these athletes in comparison to the amateur is the access to daily care at their training facilities. These athletes have people and modalities that provide the opportunity to heal much faster than others with similar problems. They also want all treatment options to start as quickly as possible as expense is never an issue.

That being said, I have always found the best way to handle the situations is to be as honest and frank about the problem as possible, and let athletes know what the opportunities to return to play are and what the risks would be if this return happened too early. Ultimately, the combination of all of these people will make the decision but each group has its own agenda. The team wants the player on the field as quickly as possible and the agents want to protect their investment so they are not always aligned with one another. Coaches may be worried about their job and want the player to compete, no matter the consequence. Players always want to get back to their sport as quickly as possible as they see the possibility of future financial opportunities and the desire to succeed for their teammates and the fans.

While few of us will have the opportunity to treat professional athletes, there are many ways to get involved with amateur athletes. Some things that have worked well for me over my career have been volunteering at local high schools or small colleges. In most of these situations, the head athletic trainer is the gatekeeper for care. I will contact the head athletic trainer and offer to come and provide preseason screenings. I will then offer to come into the training room once or twice a week to take a look at the different foot and ankle issues that may be going on at the time. I provide advice and when necessary, recommend to the trainers that athletes should see a doctor. Nearly all the time, that athlete will end up in my office.

Providing free screenings to running clubs or any other type of athletic club is also effective. Contacting the head coaches or the organizer of athletic clubs has also proved successful.

In Conclusion

Treating athletes is extremely gratifying, especially when you see their successes and they come back and thank you for the help. Despite the desire to get all athletes back to their sports as quickly as possible, you have to have a realistic approach to their return and not be influenced by factors that are not always in the best interest of the athlete. More often than not, the appropriate management of expectations is the key to successfully treating athletes.