The success or failure of a sports medicine practitioner is often judged on their ability to help an athlete get back to sport as quickly as possible. To do this we often prescribe medication, tape or brace their joints or in some cases provide an injection of steroid or local anaesthetic. While the athlete and their coach are often very enthusiastic about these treatments, and highly motivated to get back to play, I wonder whether sometimes we are doing them a disservice.
The key tenet of medicine is to “do no harm”. In some cases, however we know that returning to sport does just this. Perhaps the best example of this is an athlete returning to sport after an anterior cruciate ligament (ACL) injury. Unfortunately, when an athlete tears their ACL the ligament does not heal. This often leads to them developing an unstable feeling knee and as a result they have surgery to reconstruct their ACL. This operation helps restore a feeling of stability – but does not make the knee normal.
We know that athletes who tear their ACL are more likely to have future surgery, have shorter careers than those who have not injured their knee and are more likely to develop osteoarthritis later in life. They are also at an increased risk of a further ACL injury (either to the injured or contralateral knee). In fact, the act of returning to change of direction sport (like football, netball and rugby) increases the probability of all of these things happening. Is this facilitating harm? If we are to do what is best for the patient’s knee in isolation we would encourage them to not have surgery and to avoid pivoting sports.
We all live and practice in the ‘real world'. The majority of those who injure their ACL are young, very active and very motivated to return to sport. As a result, they are unlikely to be very receptive to advice to quit sport – especially when we do have a very good treatment that we know can help them get back to near their pre-injury level of function (reconstruction). I do however think that it is essential that we clearly explain the future risks as well as the potential alternative treatment options. This allows the athlete to make an informed decision about their treatment. It is also very important that their rehabilitation be optimised to limit the risk of re-injury and that we make considered and unpressured decisions about return to play.
In summary our job is to be the most ‘aggressive’ doctors and physiotherapists to try to facilitate a prompt return to play. We cannot however forget our obligation to “do no harm’.