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CHAPTER 36:
How to Select a Sports Specialist

When an injury does not respond to home treatment, then it's time to seek medical advice. Your family doctor or hospital emergency room personnel may be able to diagnose and treat simple problems. For more subtle or debilitating problems, a qualified sports medicine specialist may be necessary. For serious injuries that may require surgery, you should go to an orthopedic surgeon whose practice is devoted full-time to sports medicine.

Finding a reputable sports medicine specialist can be difficult. Although the ranks of sports doctors have grown from a few hundred in the early 1970s to more than 10,000 today, there is no formal certification in sports medicine. Any doctor who wants to tap this increasingly lucrative market can simply hang out a shingle that says "Sports Medicine." But a sign on the door is no guarantee that the treatment you get inside will cure your tennis elbow or runner's knee.

As a result of this situation, many patients are confused and angry about their care. Typically, a patient comes to me and says, "I went to two other sports doctors, and they didn't do any of the things you did. How can they be sports doctors?" That's a difficult question to answer. Most people don't want to hear that anyone can be a sports doctor. They want to know how to find a good doctor who can help them.

THE TEMPTATION OF TECHNOLOGY

A pseudo sports doctor who doesn't know why, for example, a patient has a sore ankle may be tempted to resort to modalities such as ultrasound or electrical stimulation to cure the patient. Such an approach can only evoke bad feelings.

One of the basic tenets of sports medicine is to make an early, accurate diagnosis and to prescribe a specific treatment. The doctor who is scattered in his approach to treatment is not practicing true sports medicine.

Many pseudo sports doctors order a battery of tests on the principle that it is better to be safe than sorry. Many of the estimated 500,000 arthroscopy procedures done each year, at $2,500 and up, may be unnecessary. As with all surgery, you should consider obtaining a second opinion even if your doctor is convinced that arthroscopy is necessary.

There is an effort underway to cut back on these tests because sports doctors now realize that they have been ordering too many. The true sports doctor uses arthroscopy as a diagnostic tool only when noninvasive diagnostic procedures have failed. Arthroscopy is basically used to correct a specific problem after an accurate diagnosis has been made.

TYPES OF SPORTS SPECIALISTS

There are various types of sports medicine specialists, and each has its own qualifications and training requirements. Before you select a specialist, examine his or her qualifications carefully.

Primary care sports doctors usually are trained in family practice, internal medicine, or physiatry, which is a branch of medicine that treats diseases and body defects with a physical therapy approach. These doctors have an interest in injury prevention, conditioning, flexibility, biomechanics, and nutrition. Their aim is to bring athletes to their peak performance level and to keep them injury-free. They usually do not treat sports injuries that require surgery.

Orthopedic surgeons are doctors who specialize in the bones and the joints. Sports orthopedists have special medical training in sports injuries. They perform operations and repair fractures, and they can treat any type of sports injury. However, sports orthopedists are usually not as concerned with strains, sprains, and overuse injuries as are primary care doctors.

Osteopaths are doctors who utilize both medical approaches and manipulative approaches in caring for athletes, although in recent years, manipulation has been left primarily to chiropractors. There is almost no difference between the medical training of a doctor of osteopathy (D.O.) and that of a medical doctor (M.D.).

Chiropractors are trained in spinal manipulation. In the sports field, they have branched out to manipulation of the limbs and joints as alternative treatments. A chiropractor (D.C.) has gone to a school of chiropractic medicine and is not licensed to prescribe medication or to perform surgery.

Podiatrists are doctors who limit their practice to parts of the body below the knee. They spend four years studying this area, whereas an M.D. spends the same time studying the entire body. Sports podiatrists are particularly knowledgeable about injuries related to running sports and the treatment of conditions that stem from foot problems.

Physical therapists are trained in rehabilitation techniques. They have a broad knowledge of anatomy and are experts in modalities for bringing an injured athlete back to health. They must take special courses to be licensed in physical therapy.

Athletic trainers are skilled in conditioning techniques; injury prevention, including taping and bracing; on-the-field diagnosis; and first aid for acute sports injuries. Trainers also understand how to rehabilitate athletes so that they can return to action from injuries. They are certified through a special training program to aid sports doctors.

A good sports medicine clinic should offer a team approach to patient care, using the expertise of all of the types of sports specialists. The primary care doctor can mix and match these techniques and steer you in the right direction to receive the highest level of care. This has been the basis of the success of my practice over the years.

HOW TO LOCATE A SPORTS SPECIALIST

The first sanctioned board-certifying examination in sports medicine will be offered in 1993. Board-certified family physicians, internists, pediatricians, and emergency medicine specialists will be eligible for a certificate of added qualification in sports medicine. Osteopaths will be able to earn a similar secondary certification in sports medicine. These exams will help control the specialty and let an injured athlete know who is a qualified sports doctor. To pass these board exams, a doctor will need special training and a good working knowledge of sports medicine. Until now, sports medicine practitioners have arranged their own training, and this has contributed to the wide variation in skills seen among the sports medicine fraternity.

The best recommendation for a sports doctor may come from a friend who has just been treated for a sports injury. Or your family doctor or local medical center may be able to make a referral.

The American Orthopaedic Society for Sports Medicine and the American Medical Society for Sports Medicine can provide you with names of members in your area. The American College of Sports Medicine (ACSM) provides a similar service, though not all of the members are doctors. A medical journal, The Physician & Sportsmedicine, publishes an annual list of sports medicine clinics across the country.

Doctors who belong to these two medical societies, as well as the American Academy of Sports Physicians, are the most likely to have up-to-date information, skills, and training. Young doctors in the field should have at least a year-long fellowship at a sports medicine clinic as part of their postgraduate training.

There are many fellowships available at orthopedic sports medicine clinics and a growing number at primary care sports medicine clinics across the country. In the late 1980s there were only a handful of primary care specialty fellowships, including the one that our sports medicine department ran. Now there are several dozen, and more are being added each year.

These fellows have a depth of knowledge in sports medicine. This usually encompasses the physiology of exercise and how to apply it to the training and conditioning of athletes; the functional anatomy and pathology of biomechanical sports injuries; and the diagnosis, first aid, and full rehabilitation of traumatic injuries. Fellows may provide medical coverage of local sports events or be the team doctor for a local team. They often conduct research into sports injuries and the problems of sports and exercise.

If you can't find a doctor who has a fellowship in sports medicine, find one in your area who is a team doctor. Many of today's team doctors learned how to treat athletes on a trial-and-error basis, as I did, and never received a fellowship in sports medicine. The doctors who dash out onto the field to tend to a fallen player, from high school sports to the professionals, may be orthopedic surgeons, family physicians, cardiologists, or eye doctors. Even a high school team doctor who is not trained in sports medicine is used to handling injuries and shows an interest in helping athletes, which is the first step to becoming a good sports doctor.

Certainly, a doctor who takes care of a professional or college team should be well qualified. You can call some local sports teams and ask where their athletes are treated. The ACSM is looking into the prospects of certifying team doctors, which will further help to clarify who is a well-qualified sports specialist.

Another good source is your local running or cycling club. These clubs usually have identified the best local sports doctors and refer their members to them. They know who gets good results and who doesn't.

If you choose a doctor who tells you to go home and stay off your injury for three weeks, choose again. An important part of being a sports doctor is understanding the psychology of athletes, who are determined to play at all costs. Doctors who are not accustomed to treating athletes tend to take the safest course and simply say, "Don't play." They often fail to consider how much of an athlete's life is dedicated to keeping fit and having fun.

WHAT TO LOOK FOR IN A SPORTS SPECIALIST

You can arm yourself with questions to ask about a sports medicine specialist's qualifications:

  • Who will treat me, a physician or a nonphysician? Many insurance companies won't cover care that isn't ordered by a physician. Check with your insurance carrier before receiving treatment from a nonphysician.
  • What are the doctor's professional affiliations? It's a good sign if your sports doctor is a member of one of the medical specialty groups mentioned earlier, although there are good sports doctors who have no professional affiliation.

  • Does the doctor have special training? Look for a doctor with a fellowship in sports medicine, either through orthopedic surgery or family practice. Also, a sports medicine specialist should deal with all areas of sports medicine, not just cardiovascular fitness.

  • Does the doctor or clinic offer a full range of diagnostic and rehabilitation services? The most comprehensive sports medicine clinics include an orthopedic surgeon, an internist, a podiatrist, a physical therapist, and a trainer. A sports medicine clinic is no more reliable than its individual practitioners and should be closely scrutinized. Also, check whether the clinic has state-of-the-art isokinetic machines, such as Cybex, for rehabilitation.

  • How much will the treatment cost? A sports doctor shouldn't charge any more for a procedure than any other doctor. If you have doubts, ask your insurance carrier what the customary fee is for a particular procedure.

  • How much time does the doctor spend on sports medicine? Only a few practitioners are fulltime sports specialists. Many spend about 30 to 40 percent of their time practicing sports medicine.

  • Does the doctor have any special areas of practice? You should choose a specialist to meet your needs. If you have a knee injury, seek out an orthopedist who specializes in knee problems. If you are having irregular menstrual periods, find an obstetrician-gynecologist who specializes in women's sports problems.




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