Introduction.

Sports medicine is defined as the multisystem medical care delivered to men and women of any age and with varying sports and recreational commitment and ability. Further, sports medicine goals are to prevent and treat musculoskeletal and other system problems enabling concerned persons to maximize their ability to stay recreationally or competitively active and remain injury free.

While prevention of and treatment for musculoskeletal and other system problems in sports medicine are important, there are larger and more overriding concerns, specifically smoking and obesity. In fact, smoking and obesity are primary physical, lifestyle and overall societal threats and certainly overlap on the greater "sports medicine" effort. Sports medicine is and should remain a key in preventative health promotion in the global sense. A younger athlete playing baseball who smokes cannot heal a musculoskeletal fracture as efficiently. Neither will an overweight 40-year-old smoker who plays office-league softball, and who has a propensity for injury and therefore cannot play at his or her highest level. In addition, the early morbidity in these people, stemming primarily from smoking, lack of aerobic activity, and a failure to observe the proper dietary principles, costs society in dollars and productivity. Thus a most important and corollary goal of sports medicine must be to foster physical fitness and proper dietary habits to combat smoking and sedentary living. There must be a reduction of and progress toward eventual elimination of lifestyle-related diseases. Cardiovascular disease remains the leading cause of death in our society. "Fitness has been shown to be one of the single best predictors of prognosis for longevity." (1)

Obesity is responsible for 300,000 deaths per year, with an overall economic cost estimated at 117 billion dollars in the United States in 2000. Obesity is linked to heart disease, diabetes, high blood pressure, stroke, arthritis and certain cancers. In turn, obesity itself furthers overeating and inactivity and thereby creates an even greater major health issue for this new millennium. Morbidly overweight children and adults point to a chronic problem stemming usually from genetic and environmental factors.

Prototype Musculoskeletal Problems. The musculoskeletal problem in sports medicine can be acute injury, such as an acute inversion ankle sprain, or anterior cruciate ligament (ACL) tear. There also may be the more common repetitive stress injury, such as stress fracture of bone or iliotibial band friction syndrome at the hip and/or knee. All sports medicine providers encounter these problems. The acute injury must be properly recognized and diagnosed. If this does not happen then an acute injury can become chronic. Conversely, a chronic or repetitive stress injury can become acute if it remains misdiagnosed, undiagnosed and/or inappropriately treated. This can create major issues and prolonged rehabilitation including stress fracture completion. An acute inversion ankle sprain, for instance, can be a complicated injury. A significant ankle sprain treated with the proverbial "Ace bandage and crutches" is not appropriate treatment for the initial phase. Furthermore, the eversion or "high" ankle sprain is commonly confused with the inversion ankle sprain. The high ankle sprain needs a higher level of diagnosis and treatment, which may include surgical treatment (Fig. 1). The common inversion ankle sprain needs "functional treatment." This requires ice, elevation, partial or complete immobilization coupled with weight bearing to tolerance, isometric peroneal and posterior tibial strengthening (concentric and eccentric), and heel cord stretching. The "down time" is thereby diminished for return to sport or work and reduces time to proprioceptive return. Up to 30% of significant ankle sprains have an associated injury. If these associated injuries are not recognized and properly diagnosed at occurrence, "functional treatment" and rehabilitation will be unsuccessful. Costly additional treatment may be necessary later. There is an obligation, therefore, for all initial providers, from Emergency Medicine to other primary sports medicine caregivers, to have a high index of suspicion and a "hands-on" diagnosis to avoid prolonged loss of recreational or competitive training.

One of the most common and prototype repetitive stress injuries seen in leg-based athletes is the stress fracture (Fig. 2). If a stress fracture is not properly treated, and particularly if it is an "at-risk" stress fracture, major complications can occur. For most stress fractures and, actually, for most repetitive stress injuries in general, treatment includes a combination of measures. Specific measures include ice, stretching, strengthening, and nonsteroidal antiinflammatory medication (NSAIDS). Generic measures require the athlete to keep the pain or symptoms from the activity at a subthreshold level. It is also important to keep the appropriate substituted activity (ie, cycling, swimming, basketball, tennis) at a level that does not reproduce the symptoms. Another way to explain to the patient the proper sports medicine approach to the stress fracture treatment is that the athlete is permitted to do any and all activities that do not produce repetitive stress injury symptoms.

[FIGURE 1 OMITTED]

An estimated 20% of acute or repetitive stress injuries in the active population may not resolve as expected. These injuries create the question, "when to refer?" For instance, though an ankle sprain may take as long as 20 weeks to completely resolve, there should be progressive improvement with compliant rehabilitation (ie, physical therapy, ATC monitoring in the training room and/or simply a home exercise program [HEP]). If this is not occurring, then further studies and/or referral should occur.

Sports medicine is not the domain of any one specialty or subspecialty. Medical care of active, competitive and recreational athletes can only be optimized when it includes the contribution of all appropriate medical professionals.

Addendum

A number of organizations and their membership have either their primary or secondary focus as sports medicine. Virtually all have state components and subspecialty certification.

National Athletic Trainer Association (NATA)

American Medical Society for Sports Medicine (AMSSM)

American Orthopaedic Society for Sports Medicine (AOSSM)

American College of Sports Medicine (ACSM)

American Academy of Pediatrics (AAP)

Numerous 2005 meetings offer in-depth CME in every sphere of sports medicine:

* AMSSM 2005

Dates are unavailable

* June 1-4, 2005

ACSM Annual Meeting 2005

Nashville, TN

[FIGURE 2 OMITTED]

* March 29-April 1, 2005

ACSM Health & Fitness Summit and Expedition

Las Vegas, NV

* ACSM Team Physician Course

Part II-Site TBD, February 2005

* December 2-5, 2005

AOSSM Advanced Team Physicians Course

Eden Roc Resort

Miami Beach, FL

* February 26, 2005

AOSSM Specialty Day

Washington, DC

* July 14-17, 2005

AOSSM Annual Meeting

Keystone Resort

Keystone, CO

* August 26-28, 2005

AOSSM Surgical Skills Course

Orthopaedic Learning Center

Chicago, IL

* May 31-June 3, 2006

ACSM Annual Meeting

Denver, CO

Disease, as it stalks the land, cannot keep pace with the incurable vice
of scribbling about it.
--John Maynow

Accepted May 21, 2004.

Reference

1. Franklin, BA. Survival of the fittest: evidence for high risk and cardioprotective fitness level. Curr Sports Med Rep 2002;1:257-259.

Angus M. McBryde Jr, MD, FACS, and William R. Barfield, PHD, FACSM 

From the Department of Orthopaedic Surgery, University of South Carolina School of Medicine, Columbia, SC.

Reprint request to Angus McBryde Jr, MD, Two Medical Park, Suite 404, Columbia, SC 29203. Email: [e-mail]