Practicing as an Athletic Trainer (AT) in a high school setting, I encountered this situation numerous times. An athlete sprains his ankle. We work through his rehabilitation and he is finally functional and able to progress through a return to play protocol. He has returned to practices and games, but comes back to me, stating that his ankle is still sore and hurting him. He wonders if this is ok. And I tell him, “Yes, you will be sore, but you are functional and can play. If you can tolerate it, you can play.”

I have said this countless times, to countless athletes. But is this appropriate? Is playing through pain really ok? Do we, as ATs, have a more important role of protecting our young players from future issues than just getting them back for a game in high school?

According to the International Association for the Study of Pain, pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”¹ So pain typically means that something has happened in the body that goes against the normal homeostatic environment - it is your sensory system recognizing the changes. We should listen to this, shouldn’t we? We have all had those athletes that never seem to get better, and I know I am guilty of writing them off. But, maybe there is something else going on within their system.

After reading the latest Journal of Athletic Training (JAT), I reflected more on my approach to athletes, pain and their potential long-term effects of injuries. Osteoarthritis (OA) is a real concern for those athletes who have had previous injuries and surgeries. According to the article “Epidemiology of Posttraumatic Osteoarthritis” in the most current JAT, persons who sustain a knee injury are 4.2 times more likely to develop OA than those without a history of knee injury. Posttraumatic Osteoarthritis (PTOA) develops after joint injury. Injury may be in the form of fracture, cartilage damage, acute ligament sprain, or chronic ligamentous instability (or a combination of these).² That to me suggests that we are caring for a lot of patients who could potentially have problems with OA in the future. Joint injury is one of the leading causes or PTOA.

I think that at the heart of this, we as ATs have to do what we do best: focus on our patients and understand what they want. What are their goals on recovering from this injury? Are they simply short term, such as getting back on the field to play football? Or maybe they really want to be pain free. I think it is crucial to ask our patients this question.

I know for me personally, when I first started as an AT in a high school setting, I assumed athletes have a main goal to return to play and the sport. But as I matured as a clinician, I realized that this is not always the case. They had other goals in mind. And so, I started asking them directly, “What is your goal, as you recover from this injury?”

It is also beneficial to consider utilizing patient-rated outcome measures (PROMs), as part of practice, to better capture all that an athlete is wanting and focus care on achieving the appropriate end goal. PROMs are important in driving treatment decisions, determining effective treatments and supporting patient-centered care.³ I also found that talking with the parents about goals was important because high school kids are still young people finding their way in the world. As minors, their parents should share in the decision process.

Another key component to protecting young athletes is education. We have a role to educate patients on the risks of injuries, not just in the short term but in the long term of risks like developing OA. Just as we have done with concussion education, it is important to discuss with the athletes and their parents, all risk factors. Armed with this education, I think we can make a more informed decision about long term risks. As a clinician, I want to be honest with my athletes. They deserve to know some potential consequences of being injured and playing through pain.

Continued rehabilitation can also help decrease the risk of OA for athletes. According to the Athletic Trainers’ Osteoarthritis Consortium, injury prevention and the appropriate management of acute injuries are recommended to decrease the risk of OA.⁴ We are in the unique position to see our patients on a continued basis and provide basic rehabilitation and immediate interventions for our athletes. I think that continued rehabilitation exercises are necessary for those who sustain injuries and tend to encourage it with my athletes long after they have returned to sports.

I always tell my athletes to follow up with me, if they continue to have pain or problems following an injury/discharge from my care. That is part of my discharge speech to them. If they do return to me, this will allow me to either re-evaluate and make a new plan for the athlete or refer the athlete back to the doctor, as needed. This can help to manage and potentially decrease the prevalence of future issues with OA.

Above all, our athletes’ wants for their care should be our top priority! As we communicate with our young athletes and families, we can help them make the most informed decisions about returning to sports and the long-term effects of working through pain. In the end, our athletes will have a life outside of sports, regardless of whether they continue into college or beyond with their sport.

References

https://www.iasp-pain.org/Taxonomy

Thomas,A; Hubbard-Turner, T; Wikstrom, E.A;Palmieri-Smith, R.M. PhD. Epidemiology of posttraumatic osteoarthritis. Journal of Athletic Training .2017;52(6):491–496.

.2017;52(6):491–496. Snyder Valier, A. R.;Jennings, A.L;Parsons, J.T.; Vela, L.I. Benefits of and barriers to using patient-rated outcome measures in athletic training. Journal of Athletic Training. 2014;49(5):674–683.

2014;49(5):674–683. Palmieri-Smith, R.M.; Cameron, K.L.; DiStefano,L. J. et al.The role of athletic trainers in preventing and managing posttraumatic osteoarthritis in physically active populations: a consensus statement of the athletic trainers’ osteoarthritis consortium.Journal of Athletic Training.2017;52(6):610–623.

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