Athletics: Sports Medicine – Guidelines

The goal of the athletic training staff at St. Mary’s University is to provide quality medical care for student athletes. Each member of the athletic training team works to help provide education, prevent injury, evaluate injuries, provide care and assistance for athletes with injuries, and rehabilitate those injuries. Along with taking care of student athletes injuries, they also have leadership, professional and administrative duties such as insurance responsibilities, record keeping and documentation. 

Objectives

The following are some of the objectives of the Sports Medicine Staff:

• To ensure that first year student-athletes are physically prepared to participate at the intercollegiate level through a pre-participation physical examination.
• To anticipate and prevent injuries or illnesses that could endanger participation in practice, competition or the pursuit of a healthy lifestyle when athletic participation concludes.
• To rehabilitate injuries and manage illnesses in a manner that promotes a healthy return to practice and competition.

Athletic Training Room Policies

The athletic training room rules are accessible in the StMU Student-Athlete Handbook that each student-athlete is required to read and sign off that they reviewed. Student-athletes unable to adhere to these policies and procedures will lose athletic training room privileges and are responsible for the consequences that result from the inability to utilize the athletic training room, including loss of student-athlete status.

Responsibilities of Student-Athletes

Report any injury or illness to the Sports Medicine Staff member(s) assigned to your sport or the Team Physician as soon as possible. Inform the Sports Medicine Staff member(s) of any potential issues that may affect the physical wellness of teammates.

Medical Services and Care

Participation in varsity athletics carries with it a risk of injury. The following areas describe the coverage provided to student-athletes injured while participating in a required athletically related activity – injuries outside athletically related participation in a varsity sport (e.g. intramural injuries) are not covered by the athletic department sports medicine insurance policy although these injuries must be reported to the athletic training staff for participation clearance

Athletics Insurance Coverage

Claims will follow three standard insurances in the event a student-athlete suffers an injury while directly participating in an intercollegiate activity. These insurances will be billed in the following order: student-athlete’s primary insurance policy, St. Mary’s Athletic Department’s secondary/excess insurance policy, NCAA’s Catastrophic Insurance Plan

Student-Athletes Primary Insurance Policy

Any individual participating in intercollegiate athletics MUST provide proof of medical insurance coverage. They will NOT be allowed to participate in any St. Mary’s sponsored activities until this is done. .Student-athletes may be covered under their parent’s policy or the St. Mary’s University Student Health Care Plan (offered through St. Mary’s University and may be purchased by the student-athlete). In the event of an injury, medical expenses will be processed FIRST through the student­ athlete’s primary insurance policy. Proof of primary insurance payment must be established before the secondary insurance policy will provide payment.

A student’s primary insurance may require a co-payment. These are predetermined amounts, established by the insurance company’s policy that is paid at the time any medical service is rendered.  All co-payments will be the responsibility of the athlete.

Insurance companies also have a predetermined amount that is required to be paid out of pocket by the covered individual out of pocket prior to the insurance company covering any payments. Student-athletes are responsible for meeting their deductible set by their primary insurance.

St. Mary’s University will NEVER receive any bills or Explanation of Benefits associated with any medical treatment. It is the responsibility of the student-athlete to mail or email any statements, explanations of benefits (EOB), or any communication from the provider or primary insurance company directly to BMI Claim Services (the Claim Service Company which processes claims for the Athletic Department’s Secondary/Excess Insurance Policy).

Student-athletes will have 120 days, from primary insurance company payment date, to provide BMI with any billing statements. After this 120-day period, they will assume the cost of any medical expenses incurred as a result of their injury. If these matters are not taken care of in a timely manner, the charge may be shown on their personal credit report.

The student-athlete’s primary insurance may require additional information prior to submitting payments to a provider. It is the responsibility of the student-athlete and/or parent to answer these requests. Not doing so may result in the primary insurance refusing to provide payment.

It is the SOLE RESPONSIBILITY of the student-athlete to show proof of medical health insurance for the academic year. Provide information regarding changes in primary insurance coverage ASAP to the Head Athletic Trainer. If proper notification is not received, St. Mary’s University will not be responsible for any medical expenses that may incur due to any injury.

Student-athletes must check with their insurance company about the following:

• Regarding out of area/network coverage while they are away at school.
• Regarding coverage for “athletic injuries”. Some insurance programs will not cover athletic-type injuries.
• Regarding dental injuries/coverage. There is an inherent risk of injury to every athlete’s teeth. It is recommended that student athletes have dental coverage. If the student-athlete suffers a dental injury and is not covered by a dental plan, they will assume all costs associated with the injury, following St. Mary’s Secondary Insurance coverage.
• To see if a referral is required from the Primary Care Physician (PCP). Health Maintenance Organizations (HMO) and some other plans may require you to travel outside of San Antonio to see their PCP for any medical coverage. It is advised to change PCP to our team physician. If this is not feasible, the athlete must enroll in the Student Health Care Plan.  Otherwise, they are personally liable for all medical debts incurred.
• Communicate with the insurance company if additional information is requested as quickly as possible.

Bring all statements, EOBs, or information from providers/insurances to the Head Athletic Trainer ASAP.

ALL INTERNATIONAL STUDENT-ATHLETES AND STUDENT-ATHLETES RESIDING ON CAMPUS WILL AUTOMATICALLY BE ENROLLED IN THE STUDENT HEALTH CARE PLAN OFFERED THROUGH ST. MARY’S UNIVERSITY.

• The student-athlete’s school account will be charged for the insurance, unless they can show adequate insurance coverage by completing the online waiver.

HEALTH CARE EXCHANGES/GOVERNMENT BASED INSURANCES

• Due to the limitations on coverage areas, physician participation and other aspects to healthcare coverage purchased on the healthcare exchanges, St. Mary’s University Athletic Department and team physicians WILL NOT accept insurance plans provided through health care exchanges or other government-based insurance.
• Student-athletes who are covered by a healthcare exchange insurance plan MUST purchase the student health plan.

NCAA’s Catastrophic Insurance Plan

The NCAA sponsors a catastrophic injury insurance program that covers a student-athlete who is catastrophically injured while participating in a covered intercollegiate athletic activity. The policy details are below:

• The policy has a $90,000 deductible and provides benefits in excess of any other valid and collectible insurance.
• The policy will pay $25,000 if an insured person dies as a result of a covered accident or sustains injury due to a covered accident which, independent of all other causes, results directly in the death of the insured person within twelve (12) months after the date of such injury.
• Both catastrophic injuries and sudden deaths should be reported to the NCAA national office insurance staff.

Insurance Information

St. Mary’s University student-athletes will be AUTOMATICALLY enrolled in two (2) different insurance programs. The first is the Student Health Care Plan that is also available for other students on campus. The second is the Athletic Department’s Secondary/Excess Insurance Program. The following information is in regards to these two insurances.

Student Health Insurance Plan

The Student Health Insurance Plan is provided through St. Mary’s University and covers physicians, medical clinics, surgical centers and specialists in the area. For complete information regarding the Student Health Insurance Plan coverage, deductible, co-pay, and waiver please visit the Academic Health Plans website at www.ahpcare.com/stmarytx.

Open Enrollment: All student-athletes will need to go online to accept or waive the student insurance plan. A link to this website can be found on GATEWAY.

Payment: All individuals that are enrolled in the plan during the Open Enrollment period will be billed the premium on their student tuition bill each semester unless they enroll after the Open Enrollment period. If registration is not done during the open enrollment period, the student-athlete will need to contact Academic Health Plans and pay for the insurance directly. If the student-athlete’s tuition bill does not show this charge and they are supposed to be enrolled in the insurance, please have them see the Head Athletic Trainer as soon as possible.

Waiver. If the student-athlete does not wish to participate in the Student Health Insurance Plan, they MUST submit an online waiver. In order to waive the insurance, they MUST show proof of comparable coverage. Proof is shown by uploading pictures of the front/back of their insurance card.

The waiver must be completed during the open enrollment period.

If they do not complete the waiver before the end of the open enrollment period, there is no removing the bill from their account for that semester. They will have to wait until the following semester for the waiver to take effect.

• If they are beginning school in the Fall: Submit a waiver ONLY ONCE for that academic year of August-May (you will not need to submit another waiver in the spring).
• If they are beginning school in the Spring: You will need to submit a waiver by the end of the Open Enrollment period for the Spring semester AND again in the Open Enrollment period for the following Fall semester.
• Have student-athlete print off confirmation and keep for their records in case they are charged for the student health plan.

All International (F,J. and H visa types) students must be enrolled in the Student Health Insurance Plan.  International/travel insurance plans will not be accepted.

Any changes that are made MUST be brought to the attention of the Head Athletic Trainer as soon as possible. Changes include but are not limited to:

• Dropped from primary and need to enroll in the Student Health Insurance Plan.
• Wish to no longer have the Student Health Insurance Plan.
• The primary policy holder changes jobs and is changing insurance plans

St. Mary’s Athletics Department’s Secondary/Excess Insurance Policy

The St. Mary’s University Athletic Department holds a secondary insurance to help cover any remaining monies due following initial primary insurance payments. Students may not waive this insurance, it is free and provided by the school.

Sports Covered: St. Mary’s secondary insurance will cover the following activities: baseball, basketball, golf, soccer, softball, tennis, and volleyball.

Sports Covered Activities: The secondary insurance will cover any loss only if the athlete is partaking in one of the following activities:

1. Regularly-scheduled practice or training,
2. Regularly-scheduled competition or exhibition game,
3. A scheduled tryout, workout session, or team meeting,
4. A supervised and sponsored sports activity, or
5. Covered sports travel {includes travel, only within the contiguous United States, including Alaska and Hawaii and only directly and without interruption): Between home and the premises of St. Mary’s University, or another site designated by St. Mary’s University.
6. Regularly-scheduled competition or exhibition game,
7. A scheduled tryout, workout session, or team meeting,
8. A supervised and sponsored sports activity, or
9. Covered sports travel {includes travel, only within the contiguous United States, including Alaska and Hawaii and only directly and without interruption):Between home and the premises of St. Mary’s University, or another site designated by St. Mary’s University.

COMMON EXCLUSIONS: The secondary insurance ONLY covers sport related injuries. Common exclusions are listed above.

REFERRAL NOTICE: Student-athletes that suffer an injury MUST be seen by and evaluated by their Athletic Trainer before seeking further medical assistance. All injuries needing further medical attention MUST be referred by the one of the University’s athletic trainers at the direction of one of the team doctors. Even if the treatment is directly related to an injury, if a student-athlete seeks additional treatment on their own, without the consent of the Athletic Training Staff, they will be responsible for any expenses that incur.

Student-athletes with a referral will be given a claims form that must be given to any provider seen for that injury. Student-athletes are responsible for getting the claims form to any provider.  If no claim form was given to a student-athlete OR if they do not give the claim information form to the provider, the student-athlete will be SOLELY RESPONSIBLE FOR ANY AND ALL COSTS THAT INCUR.

Secondary insurance payments: The secondary insurance payments will occur once proof of primary insurance payment/denial of service has been established. This is usually done with an E.O.B. (Explanation of Benefits) from the primary insurance. The secondary insurance must also receive a provider’s itemized bill. It is the responsibility of the student-athlete to request these to be sent from the provider to the secondary insurance. Payments from the secondary insurance may take up to 60-120 days to be processed. St. Mary’s University cannot uarantee payment of 100% of all related billing occurrences. Charges may incur which are not covered by the secondary insurance because they are above and beyond usual and customary insurance pricing. Once the secondary insurance pays their portion of the bill, ANY REMAINING BALANCE IS THE SOLE RESPONSIBILITY OF THE STUDENT-ATHLETE. Payments WILL NOT be issued if the primary insurance provisions are not followed.          

TRICARE Members

There are many different forms of TRICARE. The majority of student-athletes have either TRICARE Standard or TRICARE Prime.

TRICARE Standard: This plan allows the flexibility to see any TRICARE- authorized provider. Referrals are not needed to receive care; however, some services may require prior authorization.

TRICARE Prime: This plan is more restrictive and we strongly recommend switching plans or purchasing the Student Health Plan. Under this plan, a student-athlete will be assigned a Primary Care Manager (PCM) who they must see prior to seeking medical care. This typically delays care and prevents quick access to our team physicians and other diagnostic tools.  If the student-athlete is not from the San Antonio area and they wish to keep this plan, they MUST change their PCM to a local physician. If they are unable to do so, they will be required to purchase the Student Health Plan.

Insurance Compliance

Due to Health Insurance Portability and Accountability Act (HIPAA), insurance companies will NOT give any insurance information to the St. Mary’s University Athletic Training or Medical Staff. It is the student-athletes and his/her parent(s)/guardian(s) responsibility to understand the conditions that apply to their policy and comply with any requests for information, proof of full-time student status, etc. from the primary insurance company. Any delinquent bills resulting in bad credit due to non-compliance with insurance company requests will be the responsibility of the student-athlete and/or his/her parent(s) / guardian(s).

Medical Bills

In the event that a student-athlete should receive a bill/statement/EOB for an injury or illness that occurred as a direct result of participation in intercollegiate athletics at St. Mary’s University, the student-athlete must submit the bill/statement/EOB directly to NAHGA Claim Services within 30 business days of receipt.

BILLS RECEIVED AFTER 30 BUSINESS DAYS WILL BE THE SOLE RESPONSIBILITY OF THE STUDENT­ ATHLETE AND/ OR THE STUDENT-ATHLETE’S PARENT(S)/ GUARDIAN(S).

Concussion Management

Pre-Participation Requirements:

Student-athletes at St. Mary’s University are required to sign the Student-Athlete Acknowledgement of the Concussion Management Plan prior to participating in intercollegiate sports at St. Mary’s University. By signing this form, each student-athlete is accepting the responsibility to report any possible concussions to their Athletic Trainer and to follow the protocol set forth by the Concussion Management Plan. The Concussion Management Plan will be made available to all student-athletes. Student-athletes will also have available to them, other resources of educational materials, such as the NCAA Concussion video and handouts. These may be found on the GATEWAY website and within the Athletics Department.

St. Mary’s University’s Athletic Training Department will conduct a baseline assessment on all new student-athletes (incoming freshmen and transfer student-athletes). Baseline testing will consist of the Sport Concussion Assessment Tool version 3 (SCAT3) and lmPACT. The SCAT3 is a tool used for evaluating athletes suspected of receiving a concussion and consists of a symptoms check-list, cognitive (orientation , lmPACT is a computerized neurocognitive assessment tool that uses normative data to assess cognitive function. These baseline assessments will be used to establish when the return-to-play protocol may commence and to gain a full clearance for return to sport participation. In the event a student-athlete suffers a concussion, they will be required to retake both the SCAT3 and lmPACT assessments the following year to obtain a new baseline score. immediate/delayed memory and concentration) assessments, and balance and coordination assessments.

Prevention Strategies for Concussions:

The Athletic Training Department recognizes that many concussions cannot be completely prevented; however, best practices principles may help decrease the number of concussion injuries. The following are strategies that may help prevent some concussion injuries:

1. Educate student-athletes on current rules regarding purposeful or flagrant head or neck contact in any sport.
2. For sports that require headgear, a coach or appropriate designate should check that all headgear is NOCSAE (National Operating Committee on Standards for Athletic Equipment) certified, that the headgear fits the individual and the air bladders work and are appropriately filled. Padding should be checked to make sure they are in proper working condition.
3. Mouth guards should fit and be used at all times for individuals who have previously sustained multiple concussions.
4. Assess safety of playing surfaces/fields, making sure that potential hazards are remedied or removed (ie. cracks in flooring that an athlete can trip on, defective fences around fields that an athlete can run into).

Assessment of a Concussion:

In any circumstance where a concussion is suspected or a student-athlete exhibits any signs or symptoms of a

concussion, they must be removed from further participation and immediately evaluated by a health care professional (team physician or Athletic Trainer). An initial sideline assessment will establish the presence of a concussion. The assessment should include the following assessments:

1. ABCs (Airway, Breathing, and Circulation);
2. Cervical spine and skull for associated injury;
3. Symptoms;
4. Cognitive Assessment:
   • Orientation: Date, day of the week, month, location of athlete, etc.
   • Immediate/delayed memory: Series of words immediately and delayed recalling
   • Concentration: Months in reverse, series of numbers repeated backwards
5. Balance and Coordination: BESS assessment or other postural assessment test and upper extremity coordination;
6. Cranial Nerve Assessment (CN I-XII);
7. Timeline of Signs/Symptoms: Record duration of retro-/anterograde amnesia, confusion.

Immediate Management of Concussion:

Once a student-athlete has been diagnosed with a concussion, they must be removed from competition or practice for the remainder of that day and the Concussion Management Plan will be activated. Every concussion scenario will be managed in the same manner (with an exception of concussions with a prolonged loss of consciousness).

Immediate Management of Concussion without Loss of Consciousness:

1. The student-athlete must be immediately removed from participation.
2.  SCAT3 will be performed as soon as possible.
3. The student-athlete will be monitored every 5 minutes for the first 30 minutes and then every 15 minutes for one (1) hour.
   • A timeline of signs/symptoms should be recorded at each 15 minute monitored  interval.
   • If athlete’s condition continues to deteriorate, immediately refer to emergency center for conventional imaging (CT scan or MRI) to rule out intracranial hemorrhaging.
   • A deterioration of state includes worsening signs/symptoms and:
     • Increased intracranial pressure;
     • Difficulty speaking or understanding speech;
     • Seizures;
     • Loss of fine motor skills or coordination;
     • Increased blood pressure;
     • Unequal pupil size;
     • Decreased Cranial Nerve (CN I-XII) function.
   • A member of the St. Mary’s University Athletics Department will accompany the student-athlete to the emergency room. This may include: an athletic trainer, coach, Director of Athletics or Associate Director of Athletics
   • The staff Athletic Trainer must not leave a home event if there is no other Certified Athletic Trainer available to cover in their absence. However, they will accompany the student-athlete during away matches.
4. If the student-athlete’s condition stabilizes within an hour with no deterioration of state, they may be released home and reassessed within 24-48 hours.
   • Follow-up care and instructions should be given to the student-athlete and a responsible individual to help monitor the student-athlete’s condition.
     • Give the athlete/responsible individual the NCAA Concussion Facts Sheet for Student-Athletes
     • Set up reassessment time with athlete, write appointment down for them.
     • Explain to student-athlete:
       • If they experience a deterioration of state, call 9-1-1 or have someone take them to the emergency room immediately; avoid alcohol or other substances that will impair cognitive function; avoid aspirin and other medications that can increase their risk of bleeding; and replenish fluids and eat a meal as soon as possible.
         
         If possible, explain these instructions with a roommate, teammate, or guardian or someone who can follow these instructions. Have roommate, teammate, or guardian monitor athlete at home for at least 3 hours.

Immediate Management of Concussions with Prolonged Loss of Consciousness:

1. If the student-athlete has a loss of consciousness that lasts less than (<) 1 minute, they are to be referred to the team physician or another physician within 24 hours.
   • If the team physician is unavailable due to team travel, weekends, or other circumstances, the athlete must be sent to the emergency room to be evaluated by a physician and undergo conventional imaging (X-ray, CT scan or MRI) to rule out cervical fracture and intracranial hemorrhaging.
   • Referral to a neurologist must be made as soon as possible for evaluation.
2. If the student-athlete has a loss of consciousness that lasts more than (>) 1 minute, they will undergo cervical spine immobilization and be transported by EMS to the nearest emergency room (following Emergency Action Plan protocol).
   • A member of the St. Mary’s University Athletics Department will accompany the student-athlete to the emergency room. This may include:
     • A staff member of the Athletic Training Department (pending availability);
     • A coach of the student-athlete’ s sport;
     • The Director of Athletics or Associate Director of Athletics.
   • The staff Athletic Trainer must not leave a home event if there is no other Certified Athletic Trainer available to cover in their absence. However, they will accompany the student-athlete during away matches.
   • Referral to team physician or neurologist will be made as soon as possible for a follow-up evaluation.

Follow-up Care and Management

Student-athletes will receive serial monitoring of deterioration of state every 24 hours after immediate management care of a concussion. They will continue to complete the SCAT3 at each follow­ up appointment. The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve, followed by a supervised stepwise program.

Academic/Cognitive Management:

Minimizing cognitive stress and demands on a student-athlete during the post­ concussion symptomatic period will allow for a better-balanced brain energy demand that will facilitate recovery from a concussion. If the athlete develops increased symptoms with cognitive stress, they may require academic accommodations such as reduced workloads, extended test-taking time, days off or a shortened school day.

If needed, the Athletic Training Department may provide the student-athlete with a written letter to the athlete’s professors, explaining the aspects of a concussion (such as mechanism or injury, needed cognitive and physical rest, etc). The Athletic Training Department may also contact the Disability Support Services to request academic accommodations. The Athletic Training Department will provide the Disability Support Services with the proper documentation. Below are the guidelines for academic management.

Removal from Academic Stressors:

• This includes class time, reading/writing, computer work, etc
  • Symptom Severity Score more than (>) 10 Reduced Academic Workload:
  • Once Symptom Severity Score reaches less than (<) 10
  • May return to a reduced academic workload (limit stressors that exacerbate symptoms)
  • May request assistance with the Disability Support Services for academic accommodations

Full Return to Academic Workload:

• Full return to academic workload once symptoms do not increase with such loads

Physical Management:

Once a concussion has been diagnosed, the student-athlete must be removed from any competition or physical activities for the remainder of that day. The student-athlete must be asymptomatic for a 24-hour period prior to beginning the Graduated Return-to Play Protocol.

Once the 24-hour asymptomatic period has been reached, the student-athlete will complete an ImPACT post -concussion exam. If this test increases their symptoms or they do not score a satisfactory score, they will be required to rest another 24 hours and retake the ImPACT again. This will be done until the test can be successfully completed with no returning of any symptoms.

It is important to remember that physical activity may exacerbate clinical signs or symptoms; therefore, student-athletes that suffer from a concussion must be monitored by a clinician or healthcare provider (i.e . Certified/Licensed Athletic Trainer) during the Graduated Return-to-Play Protocol. Below (Table 2) are the Graduated Return-to-Play Protocol guidelines as outlined by the 2013 International Conference on Concussion in Sport, Zurich, Switzerland.

The Gradual Return-to-Play Protocol is a stepwise progression. Student-athletes must complete each stage without exacerbating symptoms prior to proceeding to the next stage.  In the event that symptoms return or worsen, the student-athlete will revert to the previously completed stage until they are able to proceed. There are no universally accepted guidelines for how quickly to move from one exercise stage to the next; however, it is recommended that each rehabilitation stage take 24 hours before progressing o the next state. However, each concussion management plan will be individualized, based on the SCAB, lmPACT results and clinical symptoms, and will be handled on a case-by-case basis. In some cases, the athlete may progress from no activity to sport-specific exercises in the same day; only if clinical symptoms are not exacerbated.

Graduated Return-to-Play Protocol

Rehabilitation State	Functional Exercise at Each Stage of Rehabilitation	Objective of Each Stage
Stage 1: No Activity	Symptom-limited physical and cognitive rest	Recovery
Stage 2: Light Aerobic Exercise	minutes of:Walking (keeping intensity between 50-70% maximum permitted heart rate) No resistance training	Increase heart rate
Stage 3: Sport-Specific Exercise	No head-impact activities. Ball Dribbling/Shooting/Passing, Running, etc.	Add movement
Stage 4: Non-contact Training Drills	Progression to more complex training drills. May start progressive resistance training.	Exercise, coordination and cognitive load
Stage 5: Full-Contact Practice	Following medical clearance, participate in normal training activities.	Restore confidence and assess functional skills by coaching staff
Stage 6: Return-to-Play	Normal game play

Return-to-Play:

Once athletes complete all five (5) stages of the Graduated Return-to-Play Protocol, they will complete a final ImPACT post-concussion assessment. In order for the student-athlete to be able to obtain full clearance for sport participation, they must complete each section with a satisfactory passing score. This satisfactory score will be based off their most recent baseline scoring.

Physician’s Referral:

In some cases, a student-athlete will be referred to a neurologist for further care. Any student-athlete who experiences a concussion associated with any loss of consciousness will be referred to a physician for follow-up care. Student-athletes will also be referred to a neurologist if any of the following occurs:

1. Worsening Signs or Symptoms within 24-48 hours.
2. Residual or Returning Post-Concussive Signs or Symptoms:
   • If symptoms persist more than 10 days.
   • If an athlete has been cleared to return-to-play status but signs or symptoms return.
   • Signs or symptoms may return up to several weeks post initial injury.
3. Second Concussion:
   • If the student-athlete has returned to full participation and receives a second concussion within the same playing season.
   • This includes championship and non-championship playing terms.