The "Standard of Care"...Is that really what you want?

[Guest Prosoft Admin]

by Mike Napierala, PT, SCS, CSCS, FAFS

Standard.  Interesting word. 

Is the STANDARD good enough for you?  Have you asked the question of what options are available to you when your young athlete gets hurt?  Are you willing to wait to see if the keeping it simple approach or the minimalist approach ends up working? 

Some Youth Sports Now listeners whose son suffered a broken ankle found him still having trouble once he made it to hockey season and weren’t sure what to do.  This is a too commonly heard story in our clinic on a weekly basis. 

Webster’s online defines standard as “something established by authority as a rule for the measure of quantity, extent, value, or quality” OR “That which is established as a rule or model by authority, custom, or general consent; criterion; test.”

Did you even know that for injuries and surgeries there is a standard of care?  Did you know that it can be different in various parts of the country?  Really.  I’m not kidding.  And healthcare providers are to some degree expected to follow their local or area standard of care practices.  So, for example, a young athlete having an ACL Reconstruction in one part of the country might typically have a functional brace for their return to sports while in other areas the tendency may be to never brace unless a patient requests it. 

Now it’s not all really that simple. And Physicians/Surgeons and PTs aren’t across the board forced to follow certain standards as if it were simply a list to be read off.  But think about some of the standards that have been more recently determined by many insurance companies. No MRI allowed until conservative care for 6 weeks fails.  For certain conditions, no surgery until failed conservative measures for a defined time.  Many criteria to meet before undergoing a lumbar fusion, rather than being just another routine procedure.

Many standards are good ones.  Based on evidence and oftentimes on outcome studies showing better results taking certain approaches or by using specific tests or treatments.  Those are the standards we want to go by, right? But unfortunately there are also standards that limit care or intervention, based on studies that ended up revealing that in many cases these expensive tests or procedures that carried higher risks ended up not resulting in any better of an outcome than continued conservative care. 

The real question I guess, is how were the standards of care for your son or daughter’s injury or surgery arrived at? Remember that definition of standard, “established by authority as a rule for the measure of value or quality” and “established as a rule or model by authority, custom, or general consent.” Who are these authorities that decided on the standard?  Was there really intense discussions and debate or did it become more of a by custom sort of means these standards were arrived at? 

From the way the question was posed by this parent, and by the lack of comment about having prior Physical Therapy, I’m guessing their son never went through formal rehab after his injury.  That’s not uncommon.  In fact, for some it’s the standard take the cast off, change to a walking boot, then into a normal sneaker and off the crutches, slow return to normal life and then try sports. 

Sounds sensible on the surface right? Might even satisfy the standard of care definition in that many orthopedists will, by custom, or maybe by their position of authority, choose to roll the dice a bit and hope that normal function will return with gradual activity based on symptoms. 

The real questions are:

• Does this really work? 
• Is full normal function restored by merely gradual return to activity? 
• Are you willing to wait and see if that approach works? 
• Do you want a wait and see approach or take a more proactive approach?

What we often see at PEAK PERFORMANCE is really often very different than that.  We see young athletes like this listener’s son too often.  Ankle sprains, shoulder strains and subluxations, wrist fractures, knee sprains, tendonitis cases, and yes, even ankle fractures. We’ve seen all these things and more, where Orthopedists have chosen to save a patient and the family the “hassle” of going to formal Physical Therapy and just go back gradually to activity. 

You should be asking:

• How was that athlete tested to verify they had physically regained enough ability to safely return?
• Did they go in and measure how deep they could bend the ankle in a squat?
• Did they make them run down the hallway to ensure no limping or favoring?  Did they have them hop not only up and down, but also side to side and twisting, in order to mimic the demands of going back to sports or even just to Physical Education class? 
• Did they put a weight in their hands to test their strength of the injured side vs the good side?

For some the answer is yes and I commend those doctors that have really used a critical eye and mindset in deciding if a young athlete is appropriate for or is responding well to a simple gradual return to activity without formal care.  Unfortunately, for too many, though, patients convey they perceive the doctor implying that the real work has already been done by the healing in the cast or by the surgery and, if you just take it slowly and don’t screw it up, everything will be fine.

Every week we see young athletes like this hockey player who had a prior injury or surgery and weren’t sent for formal care at all or not early enough.  They may lack significant symptoms, and as time passes the pressures to get back in and start participating in sports so they don’t get behind too much cause them to be less discerning about persisting asymmetries.  We see young athletes like this hockey player who may have been taken down the road of standard care, but who actually still have significant measurable limitations in their range of motion, balance, strength, power, deceleration ability, dynamic stability.

Our bodies are incredible machines.  Until things get really bad, our bodies are willing to cheat and compensate in subtle and not-so-subtle ways in order to accomplish whatever it is our brain and our heart is telling it we want to do.  If that hockey player can’t push off his ankle very well then his hip and knee will just cheat for him.  If he can’t control the side-to-side demands on his ankle then his knee might absorb the stress to help out, or he’ll splint other muscle groups excessively to limit what his ankle gets.

But in the long run too many athletes end up like this hockey player.  The time and money saved by avoiding formal Physical Therapy for their injury or surgery, by keeping it simple, and oftentimes by even following some perceived standard of care determined by even a specialist like an Orthopedist ends up resulting in more time and costs when those problems and compensations have become more ingrained by a body that had no choice but to cheat its way through activities it really was never ready for.

Sometimes when you’re seeing a Physician, and even with an Orthopedist, you may need to advocate for your son or daughter and ask for the help of a skilled Physical Therapist. 

Why wait to see if things turn out okay and the body and your athlete’s choices happen to fall into place and things have enough time to proceed to actually good function?  Why not get the help of an expert who can direct and guide your athlete to make the right choices from the start? 

I’ll bet those parents whose son fractured his ankle are wishing now that his doctor would have recommended formal Physical Therapy or if he did see a PT that they’d been more thorough before releasing him to now have him still unable to participate fully in the sport he loves.

If you have a young athlete who needs help getting back from an injury, give us a call at 218-0240 to talk to one of our Physical Therapists