Athletes’ readiness to participate in activity is determined through a standardized pre-participation physical examination (PPE) screening process.


For nearly four decades a number of medical organizations have formalized the pre-participation physical examination (PPE).4, 5, 6 This PPE is meant to identify areas of concern in the health of the athlete which could contribute to impaired function during participation in athletics. This formalization creates a base framework for all health care providers to work from. No matter who is performing the PPE, they should all be held to the same standard outlined by the document. The PPE should be performed early enough before participation to ensure that any areas of concern can be addressed prior to beginning participation. Pre-participation physical exams should be conducted in accordance with local and state guidelines.

  1. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations; Journal of Athletic Training 2013;48(4):546–553
  2. Advancing the Pre-participation Physical Evaluation: An ACSM and FIMS Joint Consensus Statement
  3. American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Academy of Pediatrics. PPE: Pre-participation Physical Evaluation. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
  4. BOC Guiding Principles for AT Policy and Procedures
  5. NATA Secondary School Value Model
  6. National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports; Journal of Athletic Training 2012:47(1):96-118
  7. National Athletic Trainers’ Association Position Statement: Pre-participation Physical Examinations and Disqualifying Conditions; Journal of Athletic Training 2014;49(1):102–120
  8. Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE.
  9. Screening for Sudden Cardiac Death Before Participation in High School and Collegiate Sports: American College of Preventive Medicine Position Statement on Preventive Practice
  10. Wingfield K, Matheson GO, Meeuwisse WH. Pre-participation evaluation: an evidence-based review. Clin J Sport Med. 2004;14(3):109–122.

Hill v. Slippery Rock University, 138 A.3d 673 (PA Super. Ct. 5/3/16), 332 Ed. Law Rep. 361


In September, 2011 Jack Hill, Jr. was participating in a late-night, high-intensity basketball practice for Division II Slippery Rock University when he complained of feeling ill, and collapsed to the floor, unresponsive.  Hill went into respiratory and cardiac arrest and passed away.  Hemoglobin electrophoresis disclosed Sickle Cell Trait (“SCT”).  The lawsuit alleged the negligence of Slippery Rock University, Slippery Rock University Health Center, and the nurse for not testing or requiring testing for SCT in pre-participation physical examinations.  Hill completed a pre-participation physical questionnaire, which asked if the student-athlete had Sickle Cell Anemia (“SCA”) or SCT.  Hill answered that he had neither SCA nor SCT, because he was unaware that he had SCT.


Although Division I schools required testing for SCT, Division II schools did not until 2012, and Division III schools until 2013.  Relying partly on the fact that the questionnaire asked about SCA or SCT, but did not test for the presence of either, the Superior Court of Pennsylvania stated, “the incomplete medical clearance may have led Mr. Hill to believe that he was physically fit for basketball.”  Finally, the Court held the lawsuit could proceed, as the plaintiffs sufficiently alleged that the medical and physical evaluations increased Mr. Hill’s risk of harm.


Practice, competition and athletic health care facilities as well as equipment used by athletes are safe and clean.


Those engaged in organized athletic activities deserve the opportunity to play in a safe and hazard free environment. In the event of an injury or illness while participating in athletic activities, participants should be able to be cared for in an accessible, clean and well organized facility.7 This facility should promote privacy, care without risk of infection, and care with the designated QMP. Having a defined facility and hours of operation can also improve patient compliance and ensures a clean and safe environment to provide medical care.

In Ausmus by Ausmus v. Board of Education of City of Chicago, 155 Ill.App.3d 705, 508 N.E. 2d 298 (Appellate Court of Illinois, First District, Fifth Division, 4/16/1987), the Court cited cases from various jurisdictions enunciating the legal requirement of providing safe facilities and equipment, as follows:


Gerrity v. Beatty (1978), 71 Ill.2d 47, 15 Ill.Dec. 639, 373 N.E.2d 1323 for negligence in failing to furnish safe athletic equipment fit for the purpose intended. See also Hadley v. Witt Unit School District No. 66 (1984), 123 Ill.App.3d 19, 78 Ill.Dec. 758, 462 N.E.2d 877 (where, in addition to other allegations, a complaint alleges that school district was negligent in providing hazardous equipment it should not be barred as a matter of law because the school district has a duty to provide safe equipment); Nielsen v. Community Unit School District No. 3 (1980), 90 Ill.App.3d 243, 45 Ill.Dec. 595, 412 N.E.2d 1177 (Supreme Court Rule 308 (87 Ill.2d R. 308), interlocutory appeal holding that plaintiff's complaint alleging negligence by the school district in furnishing defective and dangerous equipment in a high school science class was not barred as a matter of law); Griffis v. Board of Education District No. 122, Oak Lawn (1979), 72 Ill.App.3d 784, 29 Ill.Dec. 188, 391 N.E.2d 451 (a reversal of the dismissal of a negligence action against the school district, wherein the court stated, “[l]ike the court in Gerrity, we are not anxious to relieve school boards from liability for acts which do not clearly fall within the doctrine of educational immunity * * *”); and Thomas v. Chicago Board of Education (1978), 60 Ill.App.3d 729, 17 Ill.Dec. 865, 377 N.E.2d 55, rev'd on other grounds, 77 Ill.2d 165, 32 Ill.Dec. 308, 395 N.E.2d 538 (complaint that school board was negligent in furnishing ill-fitting and obsolete football equipment was sufficient to state a cause of action under the holding in Gerrity v. Beatty (1978), 71 Ill.2d 47, 15 Ill.Dec. 639, 373 N.E.2d 1323).


Ausmus by Ausmus v. Bd. of Educ. of City of Chicago, 155 Ill. App. 3d 705, 709–10, 508 N.E.2d 298, 300–01 (1987)


Clean Equipment

In Zaffarese v. Iona College, 63 A.D. 3d 727 (New York Supreme Court, Appellate Division, Second Department, 06/02/2009), the Court dismissed plaintiff’s allegation that athletic facilities are required to be maintained in such a manner as to be free from the MRSA bacteria.  The Court also dismissed plaintiff’s allegation that athletic training personnel have the duty to routinely screed for the presence of MRSA, holding that requiring athletic personnel to screen for the presence of MRSA “far exceed[s] any legally cognizable duty on the part of the defendant.”  However, the Court allowed plaintiff’s claim that the defendant had actual or constructive notice of the presence of MRSA and notwithstanding such notice, failed to take proper precautionary measures.  Thus, this case stands for the proposition that facilities are not required to be free of MRSA, and athletic personnel are not required to screen for MRSA, but when athletic personnel know or should be aware that MRSA actually exists in the facility, the suit may proceed.


Equipment worn by athletes is properly fitted and maintained while instructions to use safely and appropriately are provided.


Equipment used by athletes as part of any sport should conform, at minimum, to National Operating Committee Standards on Athletic Equipment (NOCSAE) and the American Society for Testing and Materials (ASTM) guidelines even if the organization or participant provides the equipment.  If the participant is allowed to use personally owned equipment it is imperative that the organization ensure the equipment complies with all standards and guidelines including recertification. Requiring standards by NOCSAE and ASTM provide assurance that equipment meets minimal safety standards.  A review of case law shows that equipment that is not well maintained or that is improperly fitted can contribute to, if not cause, injury to participants. In addition, the use of equipment that has not been approved by the appropriate certifying body exposes the athlete to injury and the sponsoring entity to liability and negligence.

  1. National Athletic Trainers’ Association Position Statement: Preventing and Managing Sport-Related Dental and Oral Injuries: Journal of Athletic Training 2016;51(10):821–839
  2. National Athletic Trainers’ Association Position Statement: Head-Down Contact and Spearing in Tackle Football; Journal of Athletic Training 2004;39(1):101–111
  3. Benson BW, Hamilton GM, Meeuwisse WH, McCrory P, Dvorak J. Is protective equipment useful in preventing concussion? A systematic review of the literature. Br. J. Sports Med. 2009;43(Suppl 1):i56-i67.    
  4. Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players; Sports Health. vol. 8 • no. 3
  5. Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities history, physical properties and injury prevention effectiveness. Sports Med. 2007;37(2):117-144.
  6. Mascarenhas AK. Mouthguards reduce orofacial injury during sport activities, but may not reduce concussion. J. Evid. Based Dent. Pract. 2012;12(2):90-91.
  7. Moyer RF, Birmingham TB, Bryant DM, al. e. Valgus Bracing for Knee Osteoarthritis: A Meta-analysis of Randomized Trials. Arthritis Care Res. 2014

In Palmer v. Mount Vernon TP. High School Dist. 201, 662 N.E.2d 1260 (Illinois Supreme Court, 1/18/86), the Illinois set the duty of school districts regarding safe equipment, as follows:


A school district has a duty to furnish reasonably necessary safety equipment to protect students from reasonably foreseeable serious injury; the school district cannot discharge this duty by simply warning the students to purchase such equipment themselves. (Lynch, 82 Ill.2d at 434–35, 45 Ill.Dec. 96, 412 N.E.2d 447.)


A school district should not be permitted to avoid its obligation to provide appropriate safety equipment by the expedient of advising students that they should purchase such equipment at their own expense. As this court stated in Lynch, a student's ability to engage in a school athletic activity while wearing the appropriate safety equipment should not be dependent upon the student's financial ability to obtain such equipment. Lynch, 82 Ill.2d at 434–35, 45 Ill.Dec. 96, 412 N.E.2d 447.


For an example of how the law varies from state to state, see e.g. Allen v. Dover Co-Recreational Softball League, 807 A.2d 1274 (Supreme Court of New Hampshire, 9/30/02) in which the Supreme Court of New Hampshire ruled that a recreational softball league had no duty to provide helmets for softball players, and no duty to protect player against risk of errant throw striking her in the head; as compared to the case of Tolar, et al. v.  The Amateur Softball Association of America, et al; No. 48,880 3rd Judicial District Court Lincoln Parish, Louisiana, a case worked by the author’s firm, in which a Louisiana Court ruled that the identical claim of a widow (errant softball throw striking her husband in the head resulting in his death) could proceed to trial on claims that the Amateur Softball Association of America had a duty to provide helmets for softball players.


Protective materials and products used to prevent athletic injuries are safely are appropriately applied.


Application of taping, wrapping, padding, splinting and bracing materials or equipment are common practices in the athletic setting and most often used prophylactically. Applying supportive materials or equipment to an athlete is used to restrict the motion of an injured joint, compress soft tissues to reduce swelling, support anatomical structures involved in the injury, serve as a splint or secure a splint, secure dressing or bandages, protect the injured joint from re-injury, or protect the injured tissues during the healing process. It is also common for a QMP to fabricate or modify prophylactic materials (e.g. foam, felt, rigid or semi-rigid plastics) and apply them safely and effectively to minimize the risk of injury or re-injury. Preventive and protective materials (e.g. athletic tape, casting, splints, felts, foams, pads) and special protective/correction equipment (e.g. braces, durable medical equipment, orthotics, mouth guards) should only be applied by a QMP that has the fundamental knowledge (e.g. anatomy, physiology, biomechanics, physics, chemistry) and skills to do so.

  1. Beam JW. Orthopedic Taping, Wrapping, Bracing, & Padding. 3rd ed. Philadelphia: FA Davis; 2017
  2. Lewis, M., Wright, Barker, S. and Deer, R. Cramer’s Comprehensive Manual of Taping, Wrapping and Protective Devices, 5th ed., 2017, Sagamore-Venture Publishing.
  3. Best, R., Mauch, F., Bohl, C., Huth, J., and Bruggerman, P. Residual Mechanical Effectiveness of External Ankle Tape Before and After Competitive Professional Soccer Performance., 2014, 24(1): 51-57.
  4. Ankle Bracing is Effective for Primary and Secondary Prevention of Acute Ankle Injuries in Athletes: A Systematic Review and Meta-Analyses. Barelds, I. Van den Broek, A, Huisstede, B, Sports Med, 2018.   
  5. Collins NJ, Barton CJ, van Middelkoop M, et al 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017 Br J Sports Med 2018;52:1170-1178.
  6. Callaghan MJ, McKie S, Richardson P, al. e. Effects of patellar taping on brain activity during knee joint proprioception tests using functional magnetic resonance imaging. PhysTher. 2012;92(6):821-830
  7. Gabriner ML, Braun BA, Houston MN, al. e. The Effectiveness of Foot Orthotics on Improving Postural Control in Individuals With Chronic Ankle Instability: A Critically Appraised Topic. J Sport Rehabil. 2015
  8. Montalvo AM, Cara EL, Myer GD. Effect of kinesiology taping on pain in individuals with musculoskeletal injuries: Systematic review and meta-analysis. PhysSportsmed. 2014;42(2):48-57.
  9. Moyer RF, Birmingham TB, Bryant DM, al. e. Valgus Bracing for Knee Osteoarthritis: A Meta-analysis of Randomized Trials. Arthritis Care Res. 2014
  10. Yeo BK, Donanno DR. The effect of foot orthoses and in-shoe wedges during cycling: a systematic review. J Foot Ankle Res. 2014;7:31


See for example section B. 2-3 below, 46 La. Admin. Code Pt XLV,  5705, as follows:


A.         The Activities of an Athletic Trainer--the practice of prevention, emergency management, and physical rehabilitation of injuries and sports-related conditions incurred by patient/athletes. In carrying out these functions, the athletic trainer shall use whatever physical modalities are prescribed by a team physician or consulting physician, or both. The results of these activities should be recorded.

B.         Practice of Prevention--shall include, but is not limited to the following:

. . . .

3.         working cooperatively with supervisors, coaches, and a team physician or consulting physician in the selection and fitting of protective athletic equipment for each athlete and constantly monitoring that equipment for safety; and



Athletic participation in a safe environment is ensured or activity is modified or canceled based on established environmental policies.


Monitoring environmental conditions and modifying and/or cancelling activity that may pose a threat to the health, and safety of the athlete is critical for the prevention of sudden death in sport. Sponsoring organizations of athletics programs have a duty to develop, adopt and implement comprehensive best-practice policies for preseason heat acclimatization, outdoor participation in both warm and cold weather, lightning and air quality18 based on accepted evidence-based techniques. To enhance implementation and promote clear lines of communication, the policies should include the designation of a representative whose responsibility it is to monitor changing environmental conditions and to suspend or resume activity when conditions are safe. To optimize communication and ensure a uniform message to the athletes, key members of the sponsoring organization must be provided with and educated on all environmental modification and cancellation policies. The organization should pay close attention to the routine preventative measures that must be put in place and be aware of the potential catastrophic injury or illness that can occur when modifications are not closely monitored and followed.

20: Grundstein AJ, Hosokawa Y, Casa DJ. Fatal Exertional Heat Stroke and American Football Players: The Need for Regional Heat-Safety Guidelines. J Athl Train. 2018;53(1):43-50.
21: Walsh KM, Bennett B, Cooper MA, Holle RL, Kithil R, Lopez RE. National Athletic Trainers' Association postion statement: Lightning safety for athletics and recreation. J Athl Train. 2000;35(4):471-477.

In Pichardo v. North Patchogue Medford Youth Athletic Association, Inc., 569 N.Y.S. 2d 186 (New York Supreme Court, Appellate Division, Second Department, 4/29/91), 172 A.D.2d 814, the New York Supreme Court dismissed the lawsuit of a participant in a summer league baseball game who was struck by lightning and killed.  The Court found that the player was not under inherent compulsion to play, and thus league officials were not negligent in allowing the game to continue when threatening weather became apparent. 


In Porter v. Grant County Board of Education, 219 W.Va. 282 (6/16/2006), 633 S.E.2d 38, the West Virginia Supreme Court ruled that the school board was not negligent in failing to cancel an athletic event due to snow and ice, despite the fact that academic classes were cancelled countywide, when the plaintiff fell on snow and ice on school grounds on the way to the athletic event.


In the author’s opinion, Pichardo and Porter reflect the efforts of national lobbying to cloak States, political subdivisions, and insurance companies with “immunity” (see e.g. Governmental Tort Claims and Insurance Reform Act) and deny individuals access to courtrooms and our justice system.  As some states have been successful in limiting the efforts of insurance companies to push their tort reform agenda through state legislatures, these case results cannot be taken to infer that schools will escape liability for failure to monitor or cancel athletic events.


Education and counseling is provided for athletes on nutrition, hydration and dietary supplementation.


Sports nutrition is a key factor in an athlete’s growth, development, and performance. Sponsoring organizations of athletic programs have a responsibility to provide a safe environment including, scientifically based information regarding nutrition, hydration, and supplements. Adolescents need education and counseling to make sound nutritional decisions in an age where fad diets and performance enhancement products are prevalent and marketed to their specific demographic. Members of the AHCT should be well versed in proper sports nutrition for the adolescent and have a basic knowledge of proper nutrition and eating habits and have access to a professional nutritionist or dietitian. Organizations should establish components of a comprehensive sports nutritional support system, based on current scientific facts, and should include specifics regarding healthy nutritional habits, appropriate hydration prior to, during, and after activity and supplement use. Lastly, athletes who participate in sports that use weight classification systems may be at higher risk for disordered eating and unsafe weight gain or loss practices. Organizations need to educate and monitor athletes in these sports using recommended practices for monitoring and aiding in weight management.

  1. American Dietetic Association, Dietitians of Canada, American College of Sports Medicine, Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand: nutrition and athletic performance. Med Sci Sports Exerc. 2009;41(3):709–731.
  2. Berning J, Manore MM, Meyer NL, eds. Nutrition and athletic performance before, during and after exercise: adapting the joint position statement into practical guidelines. Barrington, IL: Gatorade Sports Science Institute; 2010.
  3. Bonci CM, Bonci LJ, Granger LR, et al. National Athletic Trainers’ Association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train. 2008;43(1):80–108.
  6. International Olympic Committee Consensus Statement on Youth Athletic Development
  7. National Athletic Trainers' Association Position Statement: Safe Weight Loss and Maintenance Practices in Sport and Exercise; Journal of Athletic Training 2011:46(3):322-336
  8. National Athletic Trainers’ Association Position Statement: Anabolic-Androgenic Steroids; Journal of Athletic Training 2012;47(5):567–588
  9. National Athletic Trainers’ Association Position Statement: Evaluation of Dietary Supplements for Performance Nutrition; Journal of Athletic Training 2013;48(1):124–136
  10. Selected Issues for Nutrition and the Athlete: a Team Physician Consensus Statement

See for example See for example section B. 2-3 below, 46 La. Admin. Code Pt XLV,  5705, as follows:

A.         The Activities of an Athletic Trainer--the practice of prevention, emergency management, and physical rehabilitation of injuries and sports-related conditions incurred by patient/athletes. In carrying out these functions, the athletic trainer shall use whatever physical modalities are prescribed by a team physician or consulting physician, or both. The results of these activities should be recorded.

B.         Practice of Prevention--shall include, but is not limited to the following:


4.         counseling and advising supervisors, coaches, and patient/athletes on physical conditioning and training, such as diet, flexibility, rest, and reconditioning.


46 La. Admin. Code Pt XLV,  5705


Wellness programs promote a safe progression of physical fitness and improve long-term health across an athlete’s lifespan.


Participation in sports and physical activity provides the opportunity for many physical and psychosocial benefits to student athletes. In addition, it provides an opportunity for on-site qualified medical providers and others in the sports medicine community to serve as leaders in aiding adolescents to benefit from a physically active lifestyle and the benefits of sports participation. Several professional organizations have developed statements to ensure the safe development of young individuals into healthy, active adults in a manner that promotes general physical fitness and sampling in a variety of sports. To help achieve optimal wellness and sports performance, organizations should ensure they have the ability to design safe and effective training programs that include athlete monitoring. The organization should ensure whole person health care through the collection of patient-report outcomes to guide injury or illness management. Attention should be paid to behavioral health concerns, including the abuse of prescription and over the counter medications, supplements, and performing enhancing substances.

  2. AAP policy statement strength training in children:
  3. DiFiori, JP, Benjamin, HJ, Brenner, J, Gregory, A, Jayanthi, N, Landry, GL, and Luke, A. Overuse injuries and burnout in youth sports: A position statement from the American Medical Society for Sports Medicine. Clin J Sport Med 24: 3–20, 2014.
  5. Lloyd, RS, Oliver, JL, Meyers, RW, Moody, JA, and Stone, MH. Long-term athletic development and its application to youth weightlifting. Strength Cond J 34: 55–66, 2012.
  6. NATA statement dietary supplements:
  7. Oliver, JL, Brady, A, and Lloyd, RS. Well-being of youth athletes. In: Strength and Conditioning for Young Athletes: Science and Application. R.S. Lloyd and J.L. Oliver, eds. Oxon: Routledge, 2013. pp. 213–225.
  8. Position statement on youth resistance training: the 2014 International Consensus
  9. The Team Physician and Strength and Conditioning of Athletes for Sports: A Consensus Statement    (

In perhaps the most extensive opinion seen regarding the duty of an institution to care for its patient/athletes, the Commonwealth Court of Pennsylvania provided the following lengthy discussion in a lawsuit against the Pennsylvania Interscholastic Athletic Association (PIAA).  Although the case arose due to high school patients/athletes who suffered long term, severe concussion symptoms, the court requires an overarching duty of care with regard to the long-term health as highlighted:


[The] PIAA was in a superior position to know of student-athletes' concussion-injury rates and the long-term medical consequences. [The] PIAA and its members breached the duty to provide a ‘safe environment’ and by failing to provide long-term and/or complete medical or financial aid for student-athletes who suffered concussion(s) while playing PIAA sports.

[The] PIAA's conduct is particularly egregious in light of the fact that its policies and procedures—or lack thereof—leave student athletes like Plaintiffs ... inadequately protected from sustaining, monitoring, and recovering from brain injuries at a particularly early and vulnerable point in their lives. Unlike professional athletes, who at least have resources to pay for medical care necessitated by head injuries caused during their professional careers, youth athletes range in age from 12–18. For such PIAA student athletes, including Plaintiffs ... these injuries may have long-term, debilitating effects, ranging from an inability to finish their education, to loss of memory, physical impairments in hearing and sight, depression, and early-onset dementia.


[The] PIAA was aware of the health risks associated with blows producing sub-concussive and concussive results and was further aware that members of the PIAA athlete population were at significant risk of developing brain damage and cognitive decline as a result. Despite its knowledge and controlling role in governing member schools, coaches, trainers, and student player conduct, the PIAA failed to timely and adequately impose safety regulations and post-concussion protocols governing this health and safety problem.


Comprehensive athletic emergency action plan (EAP) is established and integrated with local EMS per athletic venue.


Participation in athletic activities can carry an inherent risk of serious injury. As such, members of the AHCT, along with coaches and administrators, need to be prepared for emergency situations through the development and implementation of a comprehensive Emergency Action Plan (EAP). The need for an EAP has been well documented in literature and supported in case law. The sponsoring organization should have a comprehensive EAP to ensure that the appropriate care can be provided in a timely manner, even in the absence of on-site medical providers. The development of an EAP however, requires the input of the QMPs, administrators of the sponsoring organization, legal counsel or risk managers, coaches, and facility managers, along with parents and members the local emergency response community. The EAP should be specific to each venue (practice/game), reviewed annually with all involved personnel, should have legal approval prior to implementation, and include a mechanism for a responsible adult to advocate on behalf of an injured minor in situations when parents or guardians are not present.

See, for example, in Kentucky KRS § 160.445 “Sports safety course required for high school athletics coaches; training and education on symptoms, treatment, and risks of concussion; venue-specific emergency action plans” as follows:


  1. (a) The Kentucky Board of Education or organization or agency designated by the board to manage interscholastic athletics shall require each interscholastic coach to complete a sports safety course consisting of training on how to prevent common injuries. The content of the course shall include but not be limited to emergency planning, heat and cold illnesses, emergency recognition, head injuries including concussions, neck injuries, facial injuries, and principles of first aid. The course shall also be focused on safety education and shall not include coaching principles

(b) The state board or its agency shall:


. . . .


  1. Be responsible for ensuring that an approved course is taught by qualified professionals who shall either be athletic trainers, registered nurses, physicians, or physician's assistants licensed to practice in Kentucky;

On-site prevention, recognition, evaluation and immediate care of athletic injuries and illnesses are provided with appropriate medical referrals.


On site recognition, evaluation, treatment and appropriate referral should be available, if warranted, to all participants of all activities. Each athletic injury needs to have immediate appropriate treatment and care to prevent further risk as well as promote proper healing while reducing the risk of re-injury. It is in the best interest of the athlete that the person making medical decisions be a QMP. This allows for sound medical judgment that is not based on the players importance or the significance of the contest but based on the signs and symptoms that the athlete shares and are presented to the QMP. Relationships established by a QMP with other health care professionals will assist in referral to the appropriate medical provider.

  1. Interassociation Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges.  Journal of Athletic Training .  2014;49(1):128-137
  2. National Athletic Trainers’ Association Position Statement: Prevention of Pediatric Overuse Injuries; Journal of Athletic Training 2011;46(2):206–220
  3. Osteoarthritis Action Alliance’s Consensus Opinion for Best Practice Features of Lower Limb Injury Prevention Programs
  4. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs:  Best-Practices Recommendations.  Journal of Athletic Training.  2013;48(4):546-553
  5. National Athletic Trainers’ Association Position Statement: Management of Sport Concussion; Journal of Athletic Training 2014;49(2):245–265
  6. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016
  7. Preventing Sudden Death in Sport, 2012 (pdf)
  8. Emergency Planning in Athletics, 2002 (pdf)
  9. Emergency Preparedness and Management of SCA in High School and College Programs, 2007
  10. National Athletic Trainers’ Association Position Statement: Acute Management of the Cervical Spine–Injured Athlete; Journal of Athletic Training 2009;44(3):306–331

In Williams v. Board of Supervisors of the University of Louisiana System, 135 So.3d 1352 (La. 2 Cir. 2/26/14) the Louisiana Second Circuit Court of Appeal upheld a jury verdict of nearly $2,000,000.00 to the minor child of Henry White, III a Grambling basketball player who collapsed while on an outdoor team run, and later died as a result of heat stroke complications.  No athletic trainers were present during the run.  When Mr. White collapsed, it took 15 – 20 minutes for a “trainer” to respond.  The “trainer” who finally arrived had failed her boards and was uncertified.  Expert testimony provided by Douglas Casa, Ph.D. established that Mr. White would have survived had the “trainer” been on-site, recognized the signs of heat stroke, and immersed White in an ice bath within 10 – 15 minutes.  The jury found Grambling and its staff 100% negligent, and the Louisiana Second Circuit Court of Appeals upheld the verdict. 


On-site therapeutic intervention (pre-, post-, and non-surgical conditions) outcomes are optimized by developing, evaluating and updating a plan of care for athletes.


Rehabilitation is the process to regain full function following injury and involves restoring strength, flexibility, endurance and power. It is achieved through various exercises and drills. Rehabilitation is as important as treatment following an injury. The main goal is to return an injured player to training or competition without putting the individual or others at undue risk of injury or illness. This process is criteria driven (not time driven). Certain levels of physical ability, and criteria, must be achieved before further progression through the stages. The process of rehabilitation should start as early as possible after an injury and form a continuum with other therapeutic interventions. It can also start before or immediately after surgery when an injury requires a surgical intervention. The rehabilitation plan must take into account the fact that the objective of the athlete is to return to the same activity, level of competence, and environment in which the injury occurred. Functional capacity after rehabilitation should be the same, if not better, then before injury.

Many states require physician direction/supervision of licensed athletic trainers, but not all.  Athletic Trainers and organizations should be aware of state laws and requirements and ensure compliance.  State law takes precedence over documents produced by non-regulatory organizations such as NATA and State Athletic Training Associations.


In states where state law requires physician direction see, for example N.J. Admin. Code § 13:35-10.5  “Plan of care guidelines”


 (a) Every licensed athletic trainer shall enter into a written plan of care with a supervising physician, which sets forth the practices in which a licensed athletic trainer shall engage in while providing physical treatment modalities to athletes in an interscholastic, intercollegiate, intramural or professional athletic setting and all athletic training services, including physical treatment modalities, provided outside of these settings. The plan of care shall be signed and dated by both the licensed athletic trainer and the supervising physician.

(b) A licensed athletic trainer and his or her supervising physician shall meet at least once a year to review the plan of care and revise it as necessary.

(c) A supervising physician shall be available, either in person or through voice communication, whenever a licensed athletic trainer is practicing athletic training.

(d) A licensed athletic trainer shall make a plan of care available to the Board upon request.


Comprehensive management plan for at-risk athletes with psychological concerns.


As with other medical emergencies, illness and injuries, organizations should plan and be prepare to address psychosocial conditions. These conditions include but are not limited to anxiety, depression, effects of concussion; substance, alcohol, and physical abuse; eating disorders, bullying and hazing; and effects of ADHD, teen suicide. Members of the AHCT should rehearse and be capable of identifying and appropriately referring such conditions. Organizations should identify local experts with specialty training in working with at-risk athletes who can serve as resources for referral as needed. Members with this specialty training should be included on the AHCT.

  1. Emergency Action Plan Guidelines: Mental Health Emergency in Secondary School Athletes
  2. Everly GS, Jr, Welzant V, Jacobson JM. Resistance and resilience: the final frontier in the traumatic stress management. Int J EmergMent Health. 2008;10(4):26-270.
  3. Interassociation Consensus Document: Understanding and Supporting Student-Athlete Mental Health  Best Practices
  4. Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Secondary School Level: A Consensus Statement
  5. NATA webpage Mental Health Resources
  6. National Athletic Trainers’ Association Position Statement: Preventing, Detecting, and Managing Disordered Eating in Athletes; Journal of Athletic Training 2008;43(1):80–108.
  7. Psychological Issues Related to Illness and Injury in Athletes and the Team Physician: A Consensus Statement-2016 Update.
  8. Special Issue focused on mental health: Athletic Training & Sports Health Care 2017;9(6)

At the time of publication, no case law was found on this standard.


Comprehensive athletic health care administration system is established to ensure appropriate medical care is provided.


Organizations sponsoring athletic programs for secondary school-aged individuals should establish a comprehensive athletic health care administrative system that ensures that appropriate medical care is provided for all participants. To provide appropriate medical care, organizations must create an AHCT that must function in a coherent, coordinated, and efficient manner with coaches and administrators of sponsoring organizations and must adhere to commonly accepted standards of good clinical practice. Specifically, the system should address the following: documentation, policies and procedures, job descriptions, job evaluations, job supervisory structure, supervising physician medical direction documents, and written standing orders.

While there is growing case law in this area, we would be unable to list all relevant cases.  Athletic trainers and organizations must be aware of state laws and ensure compliance.


See discussion regarding Standard 7, as cited from Hites v. Pennsylvania Interscholastic Athletic Ass'n, Inc., No. 8 C.D. 2017, 2017 WL 4507367, at *5–6 (Pa. Commw. Ct. Oct. 10, 2017).  Again, although the plaintiffs in the Hites case brought claims for inadequate care following concussions, the Court does an excellent job of stating the overarching duty of the PIAA regarding health care administration and ensuring appropriate medical care is provided.