CONSIDERATIONS FOR THE TREATMENT OF THE INJURED ATHLETE

When one reviews the content of sports medicine publications, symposia, and other educational materials, there is considerably more emphasis on injuries that involve the lower extremities than those that involve the upper limb. This emphasis exists because these injuries affect the athlete's ability to run, jump, kick, cut, push off, or propel through water. An equally important but often overlooked concern is for contusions, fractures, or ligament injuries involving the small bones, joints, and soft tissues of the forearm, wrist, or hand. In reality, these injuries probably have an equally profound influence on the ability to throw, catch, grasp, shoot, strike, or push off during competition. The tendency to minimize the significance of upper extremity injuries may result in a compromise of diagnosis and treatment that could result in long-term functional sequelae. Athletes with upper-extremity injuries are too often casually diagnosed and treated by trainers, technicians, nonorthopedic team doctors, or even orthopedic surgeons with little or no training in upper-extremity injuries. This may, in part, be the result of a proliferation of sports medicine physicians whose training and concentration is largely in the management of more athletically debilitating conditions such as knee ligament and meniscus injuries. Untrained or inexperienced physicians who are responsible for the management of all sports-related conditions, including upper-extremity injuries, may actually be a disservice to the athlete who may receive less than expert care for his or her injured upper extremity. Although the management of upper-extremity sports injuries can be boiled down to the application of the same principles of care that are used for nonathletic conditions, the difference lies in the understanding that the treating physician may often have to respond to great external pressure to minimize the loss of practice and, more significantly, competition time following an injury. This burdensome responsibility is generated by everyone who is interested in the competitive future of the injured player or the success of the team for whom that individual plays. Parents, coaches, fans, teammates, school officials, team sponsors or owners, team physicians, and the athletes themselves often are vocal and unreasonable in their desire for the athlete to re-enter the sporting arena. To eliminate the effect of outside influences on a physician's ability to make treatment decisions that are truly in the best long-term interests of the athlete, those influences must be isolated so that an athlete's return to competition does not violate time-honored tenets of good orthopedic care. Above all, the management of any athletic injury must be structured so that it does not, in any way, create the possibility of an even worse injury with long-term functional consequences for the athlete. Before initiating a course of treatment for an athletic injury, the treating physician must strongly resist any temptation to demonstrate his or her abilities to restore an injured player to competitive status. Because the physician may have a close friendship or appreciation for the player, the team, the coach, or the family, this is an easy opportunity to gain favor in the eyes of all concerned by performing apparent miracles in the recovery of the athlete's performance capabilities. By sublimating these external pressures to nonfactors, uniform quality care can be ensured for each athlete. Whatever his or her loyalties to the team might be, the physician must honestly consider if the proposed management course for a particular competitor is the most appropriate for the particular injury. Furthermore, if a treatment plan is selected that permits the return to competition prior to the complete healing of the injured part, there must be reasonable assurance that the method will not have greater potential for reinjury and complications than with a more conservative approach. If the potential for reinjury is present, then one must strongly question whether the additional risk is warranted. There are many unique features involved in the management of upper-extremity sports injuries. Specific treatment will depend on the tissues involved, the extent of the injury, the age of the patient, whether he or she is preadolescent or skeletally mature, the level of competition, and the demands of the particular sport or a particular position within that sport. The delicate nature of the musculoskeletal system in the preadolescent athlete makes him or her vulnerable to injury, and there should be absolutely no reason to cut any corners in the management of injuries in this age group. There is, however, no question that certain calculated liberties are taken in the management of athletic injuries of the upper extremity in the skeletally mature athlete. If a decision is made to compromise more conservative and predictable methods in favor of a technique that will permit a more rapid return to the playing field, or if the athlete chooses to “play hurt” and jeopardize the normal healing process of an injury, it is the responsibility of the treating physician to provide a thorough explanation of the injury and the implications of compromising treatment in order to return to play. Athletes, trainers, coaches, parents, and friends clearly must be informed of the potential consequences of premature return to competition. The emphasis on return to competition at the earliest possible moment increases in magnitude depending on the level of participation. Grade-school competitors can almost always be conservatively managed without undo outside pressures while those influences are unquestionably greater for high school athletes. College-level participants create even greater pressures to return to play, and professional players generate the greatest demands of all. In negating the effect of these external demands, we must never lose site of the overriding fact that the treating physician completely dictates the terms of management. As long as the athlete is under the treating physicians care, he or she should not make any alterations in what is deemed to be the best care for an injury based on input from parents, coaches, or fans whose motivations may not be in the best interest of the injured player. The management of upper-extremity sports injuries in school (all levels), noncompetitive, and neighborhood athletics should be conservative and consistent with the safest and surest methods for full recovery. At the college level, some rare and well-thought-out compromises may be permissible, providing the athlete, his parents, and the coach all appreciate the potential consequences of reinjury. On the whole, the basic axiom for the nonprofessional athlete must be that his or her athletic career is almost always secondary to the implementation of therapeutic measures that reliably ensure the best long-term function, regardless of the obligatory loss of playing time that such a method may mandate. Considering the significant financial impact that upper-extremity injuries may have on professional athletes, it may seem appropriate that the physician accede to somewhat greater treatment risks in the professional ranks than in the amateur. Professional athletes often demand whatever methods can return them to the sport that provides their livelihood. They will frequently accept considerable risk or will elect to delay definitive treatment in order to return to competition. Nonetheless, the need for the treating physician to completely advise the athlete of the potential short- and long-term consequences of such premature participation cannot be understated, and it is advisable to document these risks and compromises in writing. Despite the proliferation of padded splints and new, more uniform rules allowing their use in competition, the possibility for reinjury of healing tissues is always present. Both the treating physician and the mature athlete must appreciate that if there is a reinjury, it may unfavorably influence the likelihood of a satisfactory recovery. If appropriate treatment is delayed until the season's end, the expected final result will usually be compromised and everyone involved should be made to fully appreciate that possibility. Physicians managing athletic injuries to the upper extremity also must consider whether the use of local anesthetic agents to facilitate painless sports participation is appropriate. For the most part, these injections should be discouraged because they eliminate the protective discomfort of an injured part during play and increase the likelihood of reinjury. The use of injectible corticosteroid agents to reduce inflammation must also be carefully weighed, with consideration given to their benefits and risks.