Can a patient with chronic left knee pain, who experiences improvement with a knee brace, be cleared for a football game despite difficulty with functional activities like the duck walk?

Clearance for Football with Chronic Knee Pain

A patient with chronic left knee pain who cannot perform a duck walk should not be cleared for football participation, even with a knee brace that improves symptoms, due to the significant risk of worsening the underlying condition and potential for more serious injury.

Assessment of Risk Factors

• The inability to perform a duck walk indicates significant functional limitation that could compromise the player's safety during a high-impact sport like football 1
• Chronic knee pain that requires bracing suggests an underlying structural or functional issue that could worsen with the cutting, pivoting, and contact demands of football 1
• Football is classified as a high-risk sport with significant potential for knee injuries, which account for up to 36% of all football-related injuries 2

Evaluation of Knee Brace Effectiveness

• While knee braces may provide subjective improvement in symptoms, they do not necessarily provide adequate protection against the forces encountered during competitive football 1
• Functional knee braces may give athletes a false sense of confidence that exceeds the actual stability provided, potentially exposing them to additional risk 1
• The American Academy of Family Physicians has concluded that prophylactic knee braces lack sufficient evidence of efficacy in reducing the incidence or severity of ligamentous knee injuries 1

Decision-Making Framework

1. Functional Assessment:

   • Inability to perform a duck walk indicates compromised knee function 1
   • This functional limitation suggests the player cannot safely execute essential movements required for football 1

2. Risk Stratification:

   • The player falls into a high-risk category due to:
     • Pre-existing chronic pain 3
     • Functional limitation (inability to perform duck walk) 1
     • Reliance on external support (knee brace) for symptom management 1

3. Medical Clearance Decision:

   • Athletes at high risk should be restricted from training and competition 1
   • The status should be provisional with specific health goals that must be met before reconsidering clearance 1

Recommendations

• The player should be referred for comprehensive evaluation to determine the underlying cause of the chronic knee pain 1
• A rehabilitation program should be implemented to address the functional limitations before reconsidering sports participation 1
• Return to play criteria should include:
  • Full range of motion
  • Normal strength
  • No joint swelling or instability
  • Ability to run and sustain contact without pain
  • No intake of pain medication 2

Legal and Ethical Considerations

• Physicians have a responsibility to prioritize athlete health and safety over competitive desires 1
• While the 36th Bethesda Conference guidelines and other medical recommendations are not absolute mandates, they provide a framework for good medical practice in determining sports eligibility 1
• Courts have recognized the appropriateness of physician reliance on consensus guidelines in making medical clearance recommendations 1
• Clearing an athlete with significant functional limitations could potentially expose the physician to malpractice liability 1

Conclusion for This Case

• The player should not be cleared for football participation at this time due to:
  • Functional limitation (inability to perform duck walk)
  • Chronic pain requiring external support
  • High risk of worsening injury in a contact sport like football
• A written contract outlining specific rehabilitation goals and return-to-play criteria should be established 1
• Reassessment should occur after rehabilitation has addressed the underlying issues and functional limitations 1, 2