Abstract
Background:
The rise of Name, Image, and Likeness (NIL) rights has transformed amateur athletics, blurring the lines between high school, collegiate, and professional sports. NIL has introduced unprecedented commercial pressures that extend into sports medicine, where physicians must now navigate new challenges in clinical care, ethics, and liability.
Purpose:
To review current concepts related to the impact of NIL on sports medicine and to highlight the evolving risks, responsibilities, and roles of physicians caring for athletes in this new landscape.
Study Design:
Narrative review.
Methods:
We reviewed newly published articles and analyzed data collected from publicly available databases addressing NIL policy changes, athlete health, and physician practice.
Results:
NIL has created an environment in which high school and collegiate athletes face pressure to play through injury, pursue premature or unnecessary interventions, and seek multiple medical opinions influenced by commercial interests. Physicians, in turn, face escalating risks, including exposure to litigation for lost athlete earnings, erosion of clinical autonomy, and growing pressure to align care with financial rather than medical priorities.
Conclusion:
The NIL era requires a redefinition of the physician's role in sports medicine. Providers must balance athlete advocacy with self-protection in a system where clinical decisions now carry increased ethical, legal, and professional consequences.
Keywords
The passage of Name, Image, and Likeness (NIL) law has transformed the landscape of amateur athletics. NIL is the legal right of an amateur athlete to profit from one's personal brand, specifically through commercial ventures by the player or the school. These activities can range anywhere from endorsements and sponsorships, social media monetization, autograph signings, and public appearances to jersey and merchandise sales. It is presumed the intent of NIL law was to allow for amateur athletes to be able to be compensated for their NIL, similar to what is seen in professional sports. However, the outcome at the amateur level has been very different. The result in college sports has been an increase in collegiate collective funds and the use of “loopholes” to pay athletes directly to bypass the National Collegiate Athletic Association (NCAA) rules and avoid consequences. 5 The NCAA has found itself in a position of uncertainty without a clear understanding of how to enforce regulations. As shown in Figure 1, the mean NIL contract value per NCAA Division I football team in 2025 decreases sharply with lower national rankings, demonstrating that elite programs consistently offer higher compensation. This trend reveals a new reality: to remain competitive, programs must invest heavily in NIL deals to attract and retain top talent. These values represent publicly reported On3 estimates and should be interpreted as illustrative of relative market trends rather than definitive contractual figures.
Mean team Name, Image, and Likeness (NIL) contract value versus national ranking among the top 25 college football programs in 2025. A clear negative correlation is observed, with higher-ranked teams offering substantially greater athlete compensation. Data from On3 rankings. 8
To date, the highest-paid collegiate athlete is earning an estimated $6.7 million. 1 While individual contracts like this attract headlines, year-over-year data reveal broader trends and disparities in NIL earnings. Figure 2 and Table 1 depict the mean NIL deal value for the top 25 NCAA Division I college football programs from 2019 to 2026, along with the range between the highest- and lowest-spending teams each year. Initially, there were typically only 1 or 2 NIL programs with exceptionally high means. With policy and legal changes, spending increased and, over the past few years, has appeared to level off.
Mean Name, Image, and Likeness (NIL) deal value for the top 25 college football teams from 2019 to 2026, with shaded area representing the range between the highest- and lowest-spending teams in each year. Data from On3 rankings. 8
Mean, Minimum, and Maximum Mean NIL Deal Values for Top 25 College Football Teams, 2019-2026 a
All data are expressed in US dollars. NIL, Name, Image, and Likeness.
While NIL initially emerged within the collegiate arena, its reach quickly expanded to include high school and even youth athletes. In several states, high school athletes are now legally permitted to sign NIL deals, with some securing 6-figure endorsements. Unlike collegiate NIL policy, high school NIL governance varies widely by state and was not addressed in the House v NCAA settlement, resulting in a fragmented regulatory landscape. Recently, a 9-year-old football player from Los Angeles, California, signed an undisclosed 6-figure contract with Family 4 Life. The same company also sponsors players from National Football League (NFL) teams, such as the New England Patriots and San Francisco 49ers. 3 This shift has redefined the identity of young athletes, placing marketability on par with athletic capability. While NIL has brought positive changes by allowing players to participate in profit sharing, it has also introduced new complexities.
The emergence of NIL has introduced significant changes in sports medicine. The pressures surrounding injury management and treatment decisions have intensified. Young athletes financially tied to their performance and public image may face increased pressure when it comes to injury management. Possible negative consequences include increased health care expenditure from excessive use of second opinions and advanced imaging for common sports injuries. Additionally, this shift can lead to a paradox in care, with some high-value athletes playing through injuries or, conversely, pursuing early or even unnecessary treatments to protect their earning potential. These decisions can be influenced by agents, family members, and sponsors. Although these relationships were present before the existence of NIL, the financial implications of health care decision-making have added further strain to the patient-physician relationship. These trends are rapidly changing the role of collegiate and high school team physicians. In this evolving environment, understanding NIL frameworks is important. Team physicians must effectively communicate and advocate for their patients’ health while respecting the commercial realities that shape their decisions. All while delivering ethical, evidence-based care in a high-stakes, high-visibility setting.
Our aim is to explore how NIL is affecting the practice of sports medicine physicians, not to fully assess the value or justification of NIL policies. We will examine NIL's implications for injury management, legal liability, clinical research ethics, and health equity, while also addressing the evolving role of sports medicine providers as advocates, communicators, and stewards of athlete well-being in a constantly evolving, commercialized era.
Historical Timeline
Pre-2021: The Era of Strict Amateurism
Before 2021, the NCAA kept a rigid amateurism model that strictly prohibited student-athletes from receiving any form of compensation related to their identity. Under this framework, athletes were barred from profiting from their NIL, and any attempt to do so could result in suspension or loss of eligibility. This included income from any activities, even those outside of NCAA athletics. The NCAA justified this stance by claiming they preserved the integrity of collegiate athletics and kept a clear distinction between amateur and professional sports. This ultimately resulted in the concept of the “student-athlete.”
However, this model came under increasing scrutiny as universities and the NCAA generated billions of dollars in revenue, often using athletes’ likeness in promotional material, video games, and merchandise without consent or compensation. Critics argued that this system exploited athletes, particularly in high-revenue sports like football and basketball, while denying them the basic rights to control and profit from their own identities.
June 2021: The NCAA's Interim NIL Policy
On June 30, 2021, the NCAA implemented a groundbreaking shift in its approach to athlete compensation by adopting interim NIL rules. The decision came in response to legal challenges, public criticism, and a growing number of state laws that undermined the NCAA's authority. For the first time, student-athletes could profit from their NIL while keeping collegiate eligibility.
Under the interim policy, athletes could engage in a wide range of activities, including endorsements, social media promotions, autograph signings, and personal appearances. The athletes were still required to comply with their state's specific NIL legislation. In states without NIL laws, athletes were still permitted to participate under the NCAA's general guidelines. The decentralization approach created a complex regulatory environment, but it marked the departure from the NCAA's amateurism model.
The policy also allowed athletes to hire marketing managers to help manage their NIL portfolio, further professionalizing the collegiate athletic experience. Importantly, the NCAA acknowledged the right of publicity, which is a league principle that protects individuals from unauthorized commercial use of their identity.
Alongside the rollout of NIL, the NCAA transfer portal, which was introduced in 2018, dramatically increased the ability of athletes to change institutions. This mobility quickly became tied to NIL, as athletes began using the transfer portal as a means to pursue better financial opportunities year to year. The combination of NIL compensation and free movement reshaped the framework of recruiting and decision-making across college sports.
June 2025: House v NCAA
On June 6, a federal judge granted final approval to a $2.8 billion antitrust settlement in the case of House v NCAA. This class-action lawsuit, brought by former and current college athletes, challenged the NCAA and Power Five conferences over longstanding restrictions on athlete compensation. The court's decision marked a historic shift in the legal and financial structure of collegiate athletics.
Under the terms of the settlement,
Schools are now permitted to directly compensate athletes for the use of their NIL.
These payments are subject to an annual cap, calculated as a percentage of each institution's athletic department's revenue.
Compensation will be distributed to current and former athletes who were previously denied NIL money in the past 10 years.
The settlement has redefined the boundaries of collegiate amateurism, acknowledging that athletes contribute significant commercial value to their institutions. It also introduces new financial obligations for schools, which must now allocate a portion of their revenue to the athletes. For sports medicine professionals, the implications will be profound. As athletes become financial stakeholders, the intersection of medical care, legal accountability, and commercial interests becomes increasingly complex. Decisions about injury management, treatment timelines, and return-to-play protocols may carry not only clinical consequences but also financial and legal ramifications. Even with new policy and national legislation, boosters look for ways to circumvent the NCAA limits on NIL to gain an advantage through the creation of organizations and clubs.
Athlete Health and Development in the NIL Era
High school and college were a time once defined by combined academic and athletic pursuits. The term “student-athlete” was commonplace, as most amateur athletes did not continue their athletic careers at the professional level and often benefited equally from their academic pursuits. The increase in commercialization in amateur athletics due to NIL law has allowed “student-athletes” to profit from their athletic careers earlier. While the financial benefits for athletes are undeniable, they come with growing concerns about both physical health and psychological well-being. The pressures of brand building and public scrutiny pose real risks to the holistic development of young athletes. Sports medicine physicians must be aware of this already established trend and start to look for ways to help these athletes stay healthy and competitive within the NIL environment.
NIL Physical Health Implications
The effects of NIL are being seen early in amateur athletics. In several states, high school athletes are permitted to sign NIL deals. To date, the highest-paid high school athlete has had earnings estimated at $7.5 million. 12 This level of early commercialization encourages professional behaviors and expectations before full physical or emotional maturity. Due to increased financial incentives, athletes may feel pressure to hide injury to protect sponsorships or public image. The growing incentive for young athletes to profit could in turn accelerate the necessity for them to become highly developed. Young athletes may be forced to push their immature bodies and train like professionals when they are biologically incapable of doing so. Additional concerns exist whether this will erode childhood play, creativity, and intrinsic motivation. An outcome of early monetization could result in early sports specialization, year-round play, and playing through fatigue.
Early sports specialization resulting in year-round play and playing through fatigue have been shown to increase injury risk in young athletes. We believe this concern to be legitimate. Even prior to NIL policy, there was a documented increased incidence of ulnar collateral ligament (UCL) injuries in 15- to 19-year-old baseball players from 2007 to 2011. Within this age group, UCL reconstructions increased at a mean rate of 9.12% per year. 2 Additionally, it has been shown that injury risk increases 5-fold when a pitcher throws >8 months per year, 4-fold when they throw >80 pitches per game, and 2.58-fold when throwing a fastball >85 mph. 6 With the competitive expectation pushing young baseball pitchers far beyond these thresholds already, the competitive nature of the new NIL landscape may force younger athletes even further. Young athletes may feel obligated to pitch through fatigue, increasing their risk of injury by 36-fold. 6 Although NIL deals in sports outside of football and basketball are less known and not as large, their existence is undeniable. Additionally, increased revenue-sharing opportunities and the continued growth of amateur athletics deals in sports outside of football and basketball are inevitable.
NIL Mental Health Implications
Mental health and physical well-being are now inseparable from the discussion of athlete care in the NIL era. The monetization of athletic identity imposes an unprecedented psychological burden. Athletes must now manage public image, brand obligations, and financial expectations in addition to their academic and athletic pursuits. For adolescents and young adults, this environment can lead to heightened anxiety, burnout, and identity issues. At this age, young athletes are more prone to engage in riskier behaviors, which could have a profound impact on future NIL earnings.
The opposite effect can also be true. As of 2012, data from the NCAA revealed that 31% of male athletes and 48% of female athletes reported experiencing mental health challenges such as anxiety and depression. 3 Substance use is also a growing concern, with approximately 30% of female athletes and 40% of male athletes engaging in binge drinking. These numbers have increased by 1.5 to 2 times following the COVID-19 era. 4 With nearly half of female athletes already experiencing significant mental distress, it is expected that NIL-related pressure could amplify this burden. Research is needed to examine if NIL earnings paradoxically coexist with elevated levels of loneliness and anxiety among athletes and whether financial upside can ever offset the emotional cost of relentless public scrutiny.
Clinical Judgment, Risk, and Liability
In the NIL era, sports medicine providers face an evolving landscape of liability, external influence, and ethical complexity. Physicians working with professional sports organizations have been grappling with these issues for years. Now, physicians working with collegiate and high school athletes in the NIL era should expect similar, if not greater, challenges. Physicians must treat athletes whose physical condition is tied to commercial contracts and sponsorships. A delayed recovery or missed return-to-play deadline can jeopardize NIL earnings, possibly exposing providers to litigation for perceived financial loss. To date there are no medical malpractice lawsuits seeking lost future earnings at the college or high school level. Many physicians in collegiate sport believe it is only a matter of time before this happens. 7 The historical precedent for this concern occurred recently in 2023 at the professional level. A jury ordered the surgeon and team-affiliated orthopaedics practice of a former NFL player to pay $43.5 million for the loss of future earnings and the pain he suffered after a knee injury. The group subsequently ended their partnership with the Eagles secondary to the risk of future litigation. 7
Team physicians are commonly navigating complex medical decision-making scenarios where multiple treatment options may be available for clinical problems. There is significant variability in the treatment of the same pathology. Management typically depends on the athlete's age, position, and individual aspirations in the setting of team dynamics and expected return to play timelines. In sports medicine, physicians often discuss treatment options and their risks in the context of time to return to play and prior performance. Surgical repair of an injury may be more beneficial in terms of joint preservation but results in a longer recovery timeline, potentially resulting in significant financial impact. Physicians practicing at state institutions may be shielded from this increased liability, but those in private practice face heightened risk if their care is perceived to have affected an athlete's NIL value.
This concern is already surfacing in professional sports, where surgeons caring for elite athletes may lack sufficient malpractice coverage to protect against the financial risks tied to career-altering medical outcomes. To treat 95% of NFL, Major League Baseball, and National Hockey League players, liability policies of US$52.6 million, $108.1 million, and $64.1 million are required, respectively, based on an analysis of physician liability exposure. 9 Although this issue has primarily been raised in the context of professional athletes, it underscores a widening liability gap that is becoming increasingly relevant as collegiate and high school athletes enter similarly monetized landscapes under NIL. Without tailored policies, physicians may quickly find themselves navigating uncharted legal terrain while treating amateur athletes with multimillion-dollar valuations without adequate liability protection. Insufficient malpractice coverage will now place many physicians and surgeons at significant legal risk.
While the athlete's health is our main concern, it is important to consider our own exposure. To navigate this legal complexity, providers must consider reviewing malpractice coverage limits, incorporating supplemental NIL-specific consent forms, and maintaining meticulous documentation. Every return-to-play decision must be supported by evidence-based standards and thorough communication with all stakeholders. Attorney Brian D. Anderson adds, “It does not change the underlying diagnosis… but it is more about appreciating the stakes and the pressures that are involved.” 11 This context forces physicians to evaluate their decision-making considering possible future income loss lawsuits, even in amateur settings.
Second Opinions in NIL
As collegiate athletes have attained higher earning potential, questions regarding medical care have increased. In many ways, this is positive for athletes, as complex injuries deserve the attention of experts in their respective fields regardless of location. However, the decision around second opinions, advanced imaging, and treatment timelines are in some instances shaped by those who have a peripheral financial stake in the player's performance. Differing medical opinions, additional imaging, inflated medical costs, and lost time could all contribute to confusion and suboptimal treatment plans.
Our medical decision-making should always be centered around what is best for the athlete. Differing opinions on diagnosis and treatment can ultimately lead to confusion and suboptimal care. This may put medical providers, teams, and athletes in difficult positions. The authors are supportive of second opinions; however, it is critical that both opinions originate from medical providers who have expertise in both the athlete's sport and the specific injury. For the benefit of the athlete, the primary and second opinion providers should communicate with each other, working as a team, to present a uniform balanced approach to the treatment plan even if a difference of opinion exists. The NIL environment is only further complicating these issues in younger athletes where medical care and resources may not be as easy to navigate for the most optimal care models. In fact, the psychological toll of this process can be significant, especially when future earnings and career opportunities are at stake. These dynamics form part of a broader cascade in the NIL era, beginning with policy changes and ultimately challenging the delivery of streamlined, athlete-centered care (Figure 3).
Cascade of NIL-era influences on athlete health care. NIL, Name, Image, and Likeness.
The Effect of NIL: Contrasting Models of the Team Physician Role
As NIL accelerates the professionalization and commercialization of US collegiate athletics, international frameworks offer both cautionary lessons and potential models for adaptation. In many international professional soccer leagues, as well as some US professional teams, team physicians are directly employed by the club rather than operating as independent practitioners. There are both pros and cons to this model. This arrangement can enhance continuity of care, facilitate rapid access to medical services, and streamline communication between the athlete, coaching staff, and medical team. It shields the provider from the elevated risk of malpractice and shifts this onto the team. On the other hand, it also introduces ethical challenges. Physicians may feel implicit or explicit pressure to align medical decisions with the club's competitive or financial objectives, potentially at odds with the athlete's long-term health. In such environments, physician loyalty may become skewed toward the employer, complicating trust dynamics among athletes, agents, and medical professionals.
The alternative model is what is currently seen across the United States with physicians serving in a consultant role. This is commonly seen at the high school level with there being no reimbursement for game coverage. This model allows the physician autonomy in medical decisions while also absorbing more medical liability. This increased liability has recently become a larger issue in US professional sports organizations with malpractice lawsuits related to return to sport becoming more common. 7 As collegiate athletic departments and donor-driven collectives begin to resemble professional organizations in structure and financial stakes, similar challenges could emerge. How NIL and the elevated risk of litigation affect the team physician model of employment is yet to be seen.
Agent and Adviser Relationships in the NIL Era
Agents and advisers have always played a crucial role in professional athletes' careers, protecting athlete contracts, coordinating marketing deals, and overseeing health maintenance and specialty care. Team physicians for professional organizations have long understood the important role that they play in athlete decision-making, and because of this, communication between agents and physicians has become the cornerstone of athlete well-being in professional athletics. As the NIL ecosystem matures, agent and adviser positions are becoming more common at the collegiate and high school levels. This shift is now rapidly expanding the influence of agent and adviser decision-making to amateur athletics. Sports medicine physicians taking care of high school and collegiate athletes, who once had full autonomy of care, will be forced to adapt to this changing landscape. It will be important to anticipate challenges such as increased clinical burden, to provide the highest level of athlete-centered care. This evolution will introduce new complexities to clinical decision-making. As physicians, we must navigate this shifting landscape with intention.
As collegiate team physicians learn to partner with these agents and advisers, it is critical for us to help consolidate and optimize the medical care model to make sure we are all able to build confidence in our athlete-driven care. What was once limited to athletes, families, and athletic programs has now expanded into an evolving network of advisers and marketing organizations, all of whom play a role in shaping an athlete's success and long-term prosperity, drawing further parallels to the professional athletic framework.
As NIL continues to reshape college and high school athletics, the role of the sports medicine physician may begin to parallel that of the professional team physician. With a combination of liability and outside parties influencing decision-making, some physicians may find that it is not worth navigating the increased risks. Sports medicine physicians must consider ways to navigate the future athlete medical care environment.
Privacy, Data Ethics, and Confidentiality
In the NIL era, an athlete's medical record is no longer just a health document, it is a commercial asset. Recovery timelines, injury history, and biometric data all influence sponsorships, draft positions, and perceived marketability. This has elevated the importance of data confidentiality and heightened the risks of unauthorized disclosures.
Physicians must now interpret HIPAA (Health Insurance Portability and Accountability Act) protections through a new lens. Even well-intentioned updates shared with family members, agents, or performance staff can result in reputational damage and financial loss if not properly consented to by the athlete and/or parents/guardians. A single data leak could cost an amateur athlete not only his or her privacy but significant value in NIL revenue. The risk of inadvertent exposure is amplified by social media and the speed of information. To address these risks, providers should consider using NIL-specific consent forms and implement rigorous documentation protocols for all information shared beyond the care team.
But deeper questions remain: In principle, who owns an athlete's biometric or motion data? If a wearable device reveals a deficiency, those data may not belong to the athlete but instead to the sponsor, data collection company, or school. As performance analytics and injury risk profiles become currency in the NIL economy, it's unclear whether consent today protects athletes from commercial exploitation tomorrow.
Research Integrity and NIL
The NIL era introduces new tensions into clinical research. While performance data can enhance injury prevention and return-to-play protocols, athletes and their representatives may hesitate to participate in studies that could reveal weaknesses or reduce marketability. This is especially true when data from force plates, wearable devices, or motion capture labs can be traced to specific deficiencies in strength, symmetry, or recovery. Even when anonymized, such insights could dissuade future sponsors or be interpreted as a liability. Several factors related to research viability, including informed consent and data ownership, present potential barriers that allow for increased innovation, research, and education to improved outcomes related to injury prevention and optimization. Informed consent becomes more complex with tension between risk and benefits. Athletes may feel pressured by organizations, hospitals, and providers who seek to make a positive impact in the sports medicine and performance space. Meanwhile, physicians who serve as both clinician and principal investigator risk the perception of conflicting roles, which could be perceived by athletes, agents, and family members as jeopardizing legal and ethical boundaries. Ownership of data is another gray area. If data collected during injury rehabilitation later support a publication or device patent, will the athlete benefit from that? Commercial incentives around NIL data may one day spark disputes over intellectual property in sports science.
These dilemmas raise a broader question about whether athletes will be willing to share data for science that puts their value at risk. Finding unskewed, publicly available biometric data for professional athletes is nearly impossible, as teams safeguard and manipulate the data to allow for greater competitive advantage. The same will now apply to amateur athletics. With monetary value associated with the athlete's “intangibles,” any perceived risk associated with disclosing those data will force the athletes and their agents to hide it from anyone who could cost them money. The changing NIL environment creates a complicated dilemma. There is a need for increased research into preventative training and development for athletes, as well as better return-to-play protocols, but with data becoming monetized and a potential risk for athlete value, research may become more difficult to push forward.
Access to Care in a Market-Driven System
NIL has not only introduced economic opportunity, but it has also widened the disparity between large and small universities. NCAA Division I athletes at major programs often receive access to elite sports medicine teams, cutting-edge diagnostics, and concierge-style rehabilitation. The possibility of a workers’ compensation framework has even been discussed. After the 2025 House v NCAA court ruling, direct revenue sharing opens the door for courts to begin viewing student-athletes as employees of the university or affiliated booster club. A student-athlete on workers’ compensation would be entitled to complete medical coverage as well as wage replacement for loss of potential earnings. 10 On the other hand, high school athletes and college athletes from Division II and III schools may lack basic support such as consistent athletic training coverage and/or timely advanced imaging and orthopaedic referrals. Athletes with high earnings may be able to pay out-of-pocket for private and/or concierge care: magnetic resonance imaging within 24 hours, regenerative therapies, or personalized biomechanical training. These disparities in access to quality and timely care extend to injury outcomes and long-term performance development. Delays in care can result in complications or lost competitive opportunities, especially for athletes without institutional or financial backing. An unanticipated consequence of the NIL economy may worsen an already existing medical inequality. The more marketable the athlete is, the more care he or she is able to receive. If this trend continues, we may see insurance policies that underwrite an athlete's NIL value. This could lead a school to quietly discourage participation in high-risk sports for athletes with low earning potential.
Opportunities and Policy Recommendations
Physician Advocacy and Ethical Leadership
Amid competing interests, physicians must remain grounded in the singular mission of student-athlete welfare. This means pushing back against pressures that compromise care, regardless of the source. Sports medicine providers should advocate not only within the clinic but within the broader NIL policy dialogue.
Structured NIL Education for Athletes
Athletes need tools and not just contracts. Universities should offer structured education on injury risk, overtraining, informed consent, and health care navigation. Seminars on emotional resilience, physical longevity, and ethical decision making should become core curriculum. Teaching athletes how to evaluate medical advice and assert autonomy is critical. This education should not only be targeted toward the athlete but also the environmental resources in which the athlete operates, including agents, advisers, teams, and organizations.
Standardized Institutional Guidelines
Every institution should develop NIL-specific care guidelines that outline liability related to the complexities of the health care environment and what documentation is required to maximize transparency, informed consent, communication, and care optimization. This structure protects physicians and student-athletes alike. National organizations and team physician associations, such as the NCAA, American Academy of Orthopaedic Surgeons, AOSSM, and American Medical Society for Sports Medicine, should continue to collaborate on collective recommendations addressing the problems noted above. Advocating nationally for policy change to address physician liability in the sports medicine arena is critical for continued physician engagement at the local level, especially in high school athletics. Lobbying from the AOSSM led to federal legislation allowing team physicians to care for their players across state lines. This is an example of the effect our national organizations can have in shaping the landscape. The opportunity for the creation of organizational multidisciplinary committees and expert panels including physicians, coaches, administrators, ethicists, agents, and attorneys would allow for national representation and improved bargaining. These new committees could improve communication between providers involved in an amateur athlete's care, whether it be for athletes entering the transfer portal or second opinion consultations
Conclusion
The NIL era has rewritten the playbook of amateur athletics and is changing the practice of sports medicine physicians. This review makes no attempt to dispute NIL or contest an amateur athlete's entrepreneurship, but rather to highlight the new challenges present for both sports medicine team physicians and the athletes they treat. As athletes across all levels become financially tethered to performance and public image, clinical decisions increasingly carry significant consequences. This new environment challenges the traditional physician–athlete relationship at the amateur level, which has resulted in heightened pressures on clinical judgment, increased liability, and amplified disparities in access to physical/mental health care. Sports medicine physicians must now also carry the responsibility of learning from past legal decisions and anticipating the trajectory of future national policy. The role and responsibilities of the team physician have expanded and will continue to do so. The future of sports medicine depends on physician engagement and how our community works to safeguard both athlete welfare and physician autonomy. Sports medicine providers must adapt by working to help shape national policy, strengthen communication frameworks, and advocate for ethical and evidence-based standards that address the unique demands of an increasingly commercialized amateur athletic landscape.
