The Role of Pain Physicians in Sports Medicine: From “Interventions” to Intelligent Return-to-Play Care
Year: 2025
Type: article
Abstract: Why Sport-Related Pain Needs Pain Medicine Thinking Pain in athletes has distinct features that challenge the conventional “injury-only” approach. Athletes experience pain under performance pressure, often with strong external incentives to continue participation. Pain may be masked by adrenaline, normalized within the team culture, or reframed as a badge of commitment. At the same time, pain can be amplified by fear of re-injury loss of form, career insecurity, and disrupted sleep—factors familiar to pain physicians, but sometimes underestimated in sports settings. The International Olympic Committee (IOC) consensus statement on pain management in elite athletes emphasized that pain care must move beyond a simple analgesic-rest-physiotherapy triad, toward strategies that address contributors across the biological, biomechanical, and psychosocial domains.[1] This resonates strongly with pain medicine’s biopsychosocial foundation and reinforces a crucial point: effective sports pain care is not “less medical”; it is more intelligently medical. In practical terms, the pain physician’s value is highest when we: Differentiate pain mechanisms (nociceptive, neuropathic, and nociplastic; peripheral vs central drivers).[2] Clarify the function-pain relationship (what activities provoke, what protects, and what persists). Select interventions that improve function and reduce harm, not merely reduce pain scores. Coordinate with rehabilitation, strength and conditioning, psychology, and (when needed) surgery. A Broader Clinical Mandate: Four Jobs we are Well-Positioned to do (1) Mechanism-based diagnosis in time-pressured settings Sports medicine often requires timely decisions such as: training modification, competition eligibility, and return-to-play (RTP). Pain physicians can bring structured reasoning to mechanism identification, especially when symptoms do not match scan or when multiple pain generators coexist.[2] Examples include: Persistent groin pain with mixed adductor overload and ilioinguinal/iliohypogastric neuralgia features. Post-ankle sprain pain evolves into disproportionate sensitivity, sleep disturbances, and avoidance behaviors. Lumbar pain where an athlete’s “disc bulge” on magnetic resonance imaging distracts from a dominant facet-mediated or myofascial driver. A mechanism-based diagnosis avoids reflex escalation, whether escalation is repeated steroid injections, unnecessary surgery, or prolonged rest that deconditions the athlete. The adoption of mechanism-based approaches to pharmacological treatment of sports pain has been advocated by leading experts as a means to individualize therapy and optimize outcomes.[2] (2) Musculoskeletal ultrasound as an extension of bedside assessment JMUPM readers know that ultrasound is not merely an imaging tool; it is also a clinical instrument. In sports medicine, point-of-care musculoskeletal ultrasonography can be described as follows: Improve diagnostic confidence (tendon pathology, bursitis, effusions, muscle tears). Enable dynamic assessment (snapping phenomena, tendon subluxation, impingement patterns). Guide interventions with precision and safety, reducing collateral tissue trauma and improving targeting. Pain physicians skilled in ultrasound can create an integrated “see–test–treat–retest” workflow. This is particularly useful in tendinopathy and enthesopathy, where the symptom location is often precise, but the pathology may be patchy. (3) Evidence-aware procedural care that prioritizes tissue and trajectory Interventional options in sports must be chosen with a different lens than in sedentary chronic pain populations: the tissue is loaded repeatedly, timelines are compressed, and the athlete’s risk tolerance may not match that the clinician. Ultrasound-guided biological or regenerative procedures are areas where pain physicians can contribute meaningfully, provided we remain honest about evidence quality and avoid overpromising. for example, a randomized controlled trial of ultrasound-guided platelet-rich plasma (PRP) injections in recreational athletes with patellar tendinopathy showed no short-term superiority over saline placebo at a 3-month follow-up, highlighting the importance of tempering expectations and integrating procedures within comprehensive rehabilitation programs.[3] This underscores that PRP and similar interventions should not be viewed as standalone fixes but rather as adjuncts embedded within structured loading programs. These findings do not mean “never use PRP” but rather that pain physicians can add value by: Selection of appropriate phenotypes (reactive vs degenerative tendinopathy; partial tears vs diffuse degeneration). Using ultrasound to optimize placement and reduce complications. Embedding procedures within structured loading programs, rather than treating them as standalone fixes. Monitoring outcomes that matter in sports: function, training tolerance, and sustained RTP—not just pain at rest. Just as importantly, pain physicians must set boundaries: repeated corticosteroid injections into tendons, indiscriminate peripheral nerve blocks for performance, or interventions done primarily to “get through the match” can convert short-term relief into long-term harm. Ethical sports pain care is not an anti-performance; it is a pro-career. (4) Analgesic stewardship and prevention of iatrogenic harm Sport culture can drift into casual analgesic use—sometimes with the belief that “everyone does it.” However, systematic evidence has revealed substantial analgesic exposure in young athletes, especially non-steroidal anti-inflammatory drugs, with non-trivial adverse event rates.[4] Opioid exposure is an even greater concern. Opioid use during an athletic career may predict later misuse, and among adolescents, participation in high-injury sports has been associated with higher odds of nonmedical opioid use.[4] Pain physicians are specifically trained to handle opioid stewardship, multimodal analgesia, risk assessment, and patient education, skills that fit sports medicine perfectly. Recent evidence demonstrates that opioid-sparing strategies in arthroscopic surgery, including multimodal non-opioid regimens and select adjuncts, significantly reduce early postoperative opioid consumption without compromising pain control.[5] These findings support the development of structured stewardship programs tailored to athletic populations. We can help teams and clinics develop: Clear protocols for acute injury pain management.[4] Opioid-sparing postoperative pathways.[5] Criteria for escalation and de-escalation. Education that reframes pain management as performance protection, not just symptom suppression. Return-to-Play is not a Date—It is a Decision RTP decisions are often portrayed as binary (fit/unfit), but are better understood as risk negotiations informed by data, function, and context. Pain physicians can contribute by: Assessing whether pain is proportional, stable, and mechanically modifiable. Identifying red flags (neurologic compromise, escalating night pain, systemic features). Quantifying function using sports-relevant measures (e.g., hop tests and kinetic chain assessments in collaboration with physiotherapy). Addressing fear-avoidance, catastrophizing, or overconfidence that leads to re-injury. Expert consensus has emphasized that RTP criteria should prioritize functional measures—specifically strength, performance tests, and sport-specific skills—over imaging findings, which often do not correlate with readiness to return.[6] This functional approach aligns perfectly with pain medicine’s emphasis on capacity restoration rather than symptom elimination alone. Most importantly, pain physicians can help shift the RTP conversation from “How quickly can we silence pain?” to “How safely can we restore capacity?” This is also where communication is important. Pain physicians are often skilled translators who explain complex mechanisms in plain language. This skill is powerful in sports, where athletes and coaches need clarity, not jargon. A good explanation of pain can reduce anxiety, improve adherence to rehabilitation, and prevent the spiral from acute injury to chronic pain. Ethics in Sports Pain Care: The Quiet Pressure We Must Name Sports medicine sits at a unique ethical intersection: clinician duty of care versus external performance pressure. Pain physicians may face requests for ethically uncomfortable interventions: “Just block it.” “Just inject it again.” “We only need him for this tournament.” The IOC has highlighted the need for balanced, harm-minimizing strategies and careful consideration of medication and intervention choices in elite sport.[1] Pain physicians can lead by anchoring decisions, as follows: Informed consent (including discussion of tissue risk and longer-term consequences). Medical necessity over convenience. Documentation that protects both athlete and clinician. A clear boundary between therapeutic care and performance manipulation. Ethical practice also means respecting an athlete’s autonomy without abandoning our duty to warn. An athlete may accept risk; our role is to ensure that the risk is real, understood, and not driven by coercion or misinformation. Integrated Care: The Perioperative and Biopsychosocial Model Modern sports pain management requires a multidisciplinary, biopsychosocial framework. Perioperative care for athletes should extend beyond traditional surgical pathways to include psychological support, sleep optimization, nutritional guidance, and clear communication strategies that aim to minimize opioid reliance and support functional recovery.[7] This integrated approach recognizes that pain is multifactorial and that optimal outcomes require coordination across the medical, psychological, and performance domains. With their training in comprehensive pain assessment and multimodal treatment, pain physicians are ideally positioned to champion and coordinate such integrated care models. Research and Reporting: Journal of Musculoskeletal Ultrasound and Pain Medicine (JMUPM) Can Shape the “Sports Pain” Evidence Base Sports pain medicine is still being developed in a coherent academic space. Pain physicians can help generate better quality data, particularly in ultrasound-guided interventions, outcome measures, and longitudinal follow-up. Heterogeneity is a major barrier to: inconsistent injury definitions, exposure tracking, and reporting of outcomes. The IOC consensus statement on methods for recording and reporting sports injury and illness epidemiology, including the STROBE extension (STROBE-SIIS), provides a roadmap for strengthening consistency and comparability. JMUPM is well placed to champion this approach for sports-related ultrasound and pain intervention research by encouraging the following: Standardized reporting of sport exposure and training load context. Clear pain mechanism characterization where possible.[2] Function-centered outcomes and RTP durability.[6] Safety reporting that includes tendon integrity, recurrence, and adverse events. If we want sports teams and athletes to trust pain physicians, we must publish works that are clinically honest, methodologically transparent, and relevant to real-world sports timelines. A Practical Integration Model: How Pain Physicians Can Fit Without Fragmenting Care To avoid duplication or turf conflicts, pain physicians should join sports medicine through a collaborative, rehabilitation-first model: Co-located sports pain clinics (sports medicine + physiotherapy + pain medicine + psychological access). Early stratification pathways: acute nociceptive injuries versus high-risk for persistent pain. Ultrasound-driven decision support: diagnostic clarity + targeted procedures when indicated. Rehab-embedded interventions include: transcutaneous electrical nerve stimulation, cryotherapy and nerve blocks as part of a graded loading plan, not replacements.[7] Medication stewardship protocols: especially in youth and high-load competitive seasons.[4,5] Shared RTP conferences: brief multidisciplinary discussions for complex cases.[6] In such a model, the pain physician becomes the clinician who protects the long arc, not just the next game, but the next season and sometimes the next decade of musculoskeletal health. Conclusion: The Opportunity Is Bigger Than Procedures The role of pain physicians in sports medicine is not a niche add-on. It is a strategic opportunity to improve athlete care by incorporating mechanism-based reasoning, ultrasound-guided precision, analgesic stewardship, and ethical clarity into a field that often moves faster than evidence. For JMUPM readers, the message is especially relevant: musculoskeletal ultrasound and pain medicine already share a common language—structure, function, guided intervention, and outcomes. The next step is to apply that language deliberately to sports: publishing better data, building safer pathways, and training clinicians to treat pain without losing sight of performance, identity, and long-term function. If sports medicine is the medicine of movement, pain medicine must be the medicine that keeps movement possible without turning pain relief into harm. Acknowledgment The authors acknowledge the academic environment and mentorship at Daradia: The Pain Clinic that supports scholarly work in pain medicine and musculoskeletal care. Author contributions Dr. SSK: literature synthesis, and final editing. Dr. GD: conceptualization, and original draft. Dr. SD: critical review Ethical policy and Institutional Review board statement Ethical approval was not required as this manuscript is a letter to editor and does not involve patient-specific data or interventions. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Authors: Suzen Sumeet Kaur, Gautam Das, Sushpa Das
Institution: Daradia: The Pain Clinic
Language: English
Subfield: Orthopedics and Sports Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W7128299693