What is the recommended comprehensive multidisciplinary management plan—including pre‑participation screening, injury prevention, training, nutrition, safe medication use, and stepwise return‑to‑play—for a healthy adult athlete aged 18‑35 with no significant past medical history?

Management of Athletes: Comprehensive Multidisciplinary Approach

For healthy adult athletes aged 18-35 with no significant past medical history, management should center on a multidisciplinary team coordinated by a team physician, incorporating pre-participation cardiovascular and musculoskeletal screening, sports-specific performance testing, individualized nutrition assessment, injury prevention through workload monitoring, and stepwise return-to-play protocols following any injury.

Pre-Participation Screening

Cardiovascular Evaluation

The American Heart Association recommends a 12-element screening protocol to identify life-threatening cardiovascular conditions, which occur in approximately 0.3% of the general athlete population 1:

Personal History (8 elements):

• Exertional chest pain or discomfort 1
• Unexplained syncope or near-syncope (excluding neurocardiogenic) 1
• Excessive exertional dyspnea or fatigue disproportionate to exertion level 1
• Prior recognition of heart murmur 1
• Elevated systemic blood pressure 1
• Prior restriction from participation in sports 1
• Prior testing for heart problems 1
• Family history of premature death (sudden/unexpected before age 50), cardiovascular disability, or specific conditions (hypertrophic cardiomyopathy, dilated cardiomyopathy, long-QT syndrome, Marfan syndrome, clinically significant arrhythmias) 1

Physical Examination (4 elements):

• Heart murmur (auscultation performed both supine and standing, or with Valsalva maneuver) 1
• Femoral pulses to exclude aortic coarctation 1
• Physical stigmata of Marfan syndrome 1
• Brachial artery blood pressure measurement in sitting position 1

Critical caveat: Parental verification of responses is essential for high school and younger athletes, and any single positive finding warrants cardiovascular referral 1.

Musculoskeletal and Performance Assessment

Extended medical screening should include sports-specific functional testing to identify injury risk factors and establish baseline data for future rehabilitation 2:

• Agility testing correlates with overall injury risk (r = 0.34, p = 0.029), with weaker performers sustaining more injuries 2
• Endurance assessment (e.g., Yo-Yo test) predicts thigh muscle injury risk (r = 0.266, p = 0.012) 2
• Baseline neurocognitive testing for concussion management 1
• Range of motion, strength, and balance testing to establish pre-injury benchmarks 3

Injury Prevention Through Workload Management

Primary Prevention (Pre-Season)

Screen for low training loads prior to competition, as athletes with inadequate conditioning face increased injury risk 4:

• Gradually increase training loads to avoid the "too much, too soon" phenomenon 4
• Monitor acute:chronic workload ratios to identify dangerous spikes 4

Secondary Prevention (In-Season)

Continuously monitor workloads that precede injury development 4:

• Adjust training intensity and volume when risk thresholds are approached 4
• Implement selective prevention measures for asymptomatic athletes exhibiting risk factors 4

Nutrition Management

A sports dietitian should conduct comprehensive nutritional assessment to ensure optimized nutrition that is safe, supported, purposeful, and individualized 1:

• Screen for low energy availability, particularly in female athletes at risk for the Female Athlete Triad 1
• Monitor for disordered eating patterns, as weight stability does not exclude energy deficiency 1
• Provide nutrition education to eliminate unintentional low energy availability 1

For female athletes specifically: All athletes with bone stress injuries or menstrual dysfunction require screening for relative energy deficiency in sport (RED-S) and eating disorders 1.

Safe Medication Use

Concussion Management

Athletes must not return to play while taking medications for concussion symptoms, as this masks underlying pathology and increases reinjury risk 1.

Pain Management

NSAIDs (e.g., naproxen 500mg twice daily) are appropriate for acute musculoskeletal injuries but should not be used to enable premature return to play 5.

Stepwise Return-to-Play Protocol

Universal Principles

No athlete should return to play on the day of injury under any circumstances 1, 3:

• Initial rest period of 24-48 hours following injury 1
• Each progression stage requires minimum 24 hours at that level 1, 3
• Any symptom recurrence mandates return to previous asymptomatic level 1

Graduated Progression Stages

1. Complete rest until asymptomatic at rest 3
2. Light aerobic activity (walking, swimming, stationary cycling at 70% maximum heart rate) with no resistance exercises 3
3. Sport-related drills without full intensity 3
4. Complex drills with progressive loading 3
5. Full contact practice (requires medical clearance) 3
6. Unrestricted competition 3

Objective Clearance Criteria

Before advancing to full contact practice, athletes must demonstrate 3:

• Range of motion: ≥95% of uninjured side for knee flexion, full extension 3
• Effusion: None, or trace at most 3
• Balance: Normalized compared to baseline testing 3
• Functional testing: >90% limb symmetry index on hopping and jumping tests 3

Injury-Specific Considerations

Ankle sprains: Functional support through taping or bracing reduces recurrent injury risk (RR 0.70,95% CI 0.57-0.79) and allows return approximately 4.6 days sooner than immobilization 3.

Concussion: Symptoms persisting >10 days require multidisciplinary management 1. Use graded exertion protocol before medical clearance 1.

Multidisciplinary Team Composition

The team physician coordinates all care and has ultimate authority for clearance decisions 1:

Core team members:

• Team physician (coordinates all care) 1
• Sports dietitian (nutritional assessment and intervention) 1
• Mental health practitioner (psychological evaluation and treatment) 1

Additional members as needed:

• Athletic trainer 1
• Physical therapist 6
• Coach 1
• Family members 1
• Endocrinologist, orthopedic surgeon, or other specialists depending on specific conditions 1

Communication Strategy

Well-defined roles and clear communication protocols within the multidisciplinary team are crucial 1. For athletes at moderate or high risk, written treatment contracts should specify 1:

• Criteria necessary for ongoing clearance 1
• Frequency of visits with each team member 1
• Specific treatment goals and expectations 1
• Monitoring plan for clinical status 1

Risk Stratification for Female Athletes

Low-risk athletes can be fully cleared without mandatory multidisciplinary team referral 1.

Moderate-risk athletes receive provisional or limited clearance with mandatory multidisciplinary team referral and follow-up 1.

High-risk athletes are restricted from training and competition 1:

• Athletes with anorexia nervosa and BMI <16 kg/m² are categorically restricted 1
• Athletes with moderate-to-severe bulimia nervosa (purging >4 times/week) are categorically restricted 1
• Future participation requires BMI >18.5 kg/m², cessation of bingeing/purging, and close multidisciplinary follow-up 1

Rehabilitation Principles

Rehabilitation should emphasize pain management, motion restoration, motor control, and force production in varying degrees based on tissue healing phases 6:

• Design programs collaboratively with the athlete to address specific needs 6
• Use high-value, evidence-based treatments to maximize effectiveness and efficiency 6
• Progress from acute injury management through full competition systematically 6
• Tertiary prevention includes graded return-to-training programs to reduce subsequent injury risk 4

Common pitfall: Simply knowing injury risks does not prevent injuries—active workload modification and monitoring are essential 4.