College athletics is a multimillion-dollar industry with massive TV contracts and payouts to schools; however, historically, student-athletes have gone uncompensated and cannot profit off their name, image, or likeness via sponsorships, endorsement deals, or even merchandise sales.
In the last few years, this landscape has shifted to allow athletes to profit from their name, image, and likeness (NIL), leading to a high degree of change in the collegiate landscape. These changes to NIL and transfer rules have created unique challenges for physicians dealing with college athletes. NIL has opened doors for agents, second opinions, a tangible net worth, and questions for covering medical expenses as, unlike professional sports, injuries are not covered by Workman’s compensation laws.1
Transfer portal changes have led to questions about paying for injuries and rehabilitation once transferred, appropriate care follow-up, and sharing medical records. The lack of a standardized electronic medical record (EMR) system among all schools means that crucial medical information may not be readily available when an athlete transfers, potentially leading to delays in treatment or even misdiagnosis. This review will explore the ever-changing NIL and transfer portal landscape and discuss how these changes may affect the ability to provide the best care for these athletes.
Name, Image, and Likeness
The introduction of NIL rights represents a monumental shift in the landscape of college athletics, empowering athletes and redefining the concept of amateurism that has long been a pillar of collegiate sports. The historical backdrop of this transformation is rich with contentious debates and regulatory challenges, exemplified by the high-profile case of Reggie Bush. In the early 2000s, Bush, a standout football player at the University of Southern California (USC), found himself at the center of a National Collegiate Athletic Association (NCAA) investigation that concluded he and his family had received improper benefits from sports agents. This case resulted in severe penalties for USC, including the vacating of wins and a two-year postseason ban, and ultimately led to Bush voluntarily returning his Heisman Trophy.2 The case highlighted the growing tensions between the NCAA's amateurism rules and the evolving landscape of college sports, where the commercial exploitation of athletes' performances was at odds with their inability to profit from their fame and skills. Contrastingly, today's environment under the NIL policies sees athletes like Shedeur Sanders, who is valued at $5.8 million, and Arch Manning, valued at $3.7 million, earning substantial amounts from their NIL without the repercussions faced by athletes in previous eras.3-5 These developments reflect a dramatic shift from when athletes like Bush faced significant hardships and penalties for minor benefits.
In contrast, today's athletes can openly capitalize on their marketability without fear of NCAA reprisal.6 This essentially makes the "amateur collegiate athlete" a professional athlete, with some collegiate athletes earning at a similar or higher rate than their peers in professional athletics. This also opens the door to competing interests, such as agents, brokers, parents, and others looking to capitalize on the monetization of these athletes. However, the new system ensures fairness and transparency, providing a level playing field for all athletes.
As NIL policies have evolved, states like Missouri have taken pioneering steps by enacting legislation that allows athletes to benefit from their NIL as early as high school. Missouri's approach, mainly through House Bill 417, has significantly advanced the discourse around athlete compensation by allowing high school athletes to sign endorsement deals once they commit to a college within the state. This legislation not only aims to retain local talent by providing financial incentives but also challenges the traditional recruitment dynamics that have long favored collegiate powerhouses. It raises questions about how these policies might affect the recruitment process, with potential concerns about unfair advantages for schools in states with more lenient NIL laws.7
Missouri's Progressive NIL Legislation
Missouri's legislation is groundbreaking in its proactive approach. By allowing in-state high school athletes to engage in NIL activities upon signing letters of intent, the state is not only providing early financial benefits to athletes but also potentially increasing their loyalty to local programs. This could significantly elevate the competitive stature of Missouri's collegiate institutions. Furthermore, the legislation allows school officials and coaches to actively participate in discussions about NIL deals, ensuring that the agreements are both lucrative and compliant with broader educational and athletic objectives.7
Impact on College Athletics and Counter Perspectives
The broader adoption of NIL policies significantly influences college sports, introducing complex dynamics that affect recruitment, athlete welfare, and institutional strategies. As NIL becomes a strategic tool for colleges, it profoundly impacts recruitment and competitive balance. Institutions with robust NIL opportunities can attract top talent, potentially centralizing the talent pool and skewing competitive equity in collegiate sports. This strategic shift is a double-edged sword; while it brings talent and resources to certain schools, it may also create disparities that challenge the foundational principles of collegiate athletics. It is crucial to manage these disparities carefully to ensure the preservation of these foundational principles.8
Moreover, NIL introduces new income sources for athletes, enhancing their financial independence and offering personal and professional growth opportunities. These opportunities, however, come with the responsibility to manage complex financial, legal, and commercial arrangements, which can be daunting for student-athletes. Universities play a crucial role here, as they must integrate NIL within their existing frameworks, ensuring that commercial interests do not overshadow educational and developmental objectives.7-8 The role of universities in managing these complexities is crucial, providing a sense of reassurance about the system.
However, the introduction of NIL also brings to light significant complexities. Concerns about equity and fairness have surfaced, highlighting potential disparities within teams. Star athletes may receive substantial compensation, which could create a divide between them and their less-recognized teammates. This scenario could affect team cohesion and the overall team environment, underscoring the urgency of addressing potential disparities to maintain a harmonious team dynamic.8
Furthermore, the varying state laws and the NCAA's evolving stance on NIL create a regulatory maze that institutions must navigate carefully. Ensuring compliance while avoiding sanctions is a delicate balance that requires meticulous attention to the legal aspects of NIL agreements.8 With the NIL comes the ramifications of decisions such as school location, playing time, and potential decision to pursue or forgo medical treatment. With the introduction of monetary incentives comes increased pull from advisors, agents, or both, who often may want multiple opinions on the care of the student-athlete, especially if millions of dollars are at stake. These trends can drive athletes to seek referrals out of their university system for second or third opinions, which was previously less seen at the collegiate level. It is important for the sports medicine team physician to be aware of these dynamics and always put the athlete first while considering these complex dynamics.
Transfer Portal
In 1961, the NCAA passed a rule stating that athletes had to sit out for one year if transferred to another institution. This rule first faced challenges from graduate transfers, who argued that they had fulfilled their academic requirements, which should negate the one-year rule. Next, the rule faced challenges through lawsuits requesting a waiver for various exemption rationales. In order to minimize the legal challenges they were dealing with, the NCAA adopted a "one-time exemption" to the transfer rule in 2021, around the time NIL rules were beginning to take hold. In December of 2023, West Virginia basketball player RaeQuan Battle was granted a temporary injunction against the NCAA in his transfer waiver request that was previously denied. The lawsuit was brought on by the Attorney General (AG) from Ohio and was joined by six other AGs, thus the name of the case Ohio, et al vs NCAA. After the passage of NIL laws discussed above, the lawsuit's complaints allege that NCAA transfer rules violated antitrust laws and "unjustifiability restrains the ability of these college athletes to engage in the market for their labor as NCAA Division I college athletes." This injunction led to unlimited transfers beginning in the spring season of 2024 and became a permanent settlement soon after. Currently, the only rules around transfers center around the timing of transfers to coincide with sports seasons, thus leading to a window of time that transfers may occur based on the sport, the "transfer portal" window. Exceptional circumstances such as a coach firing or a sport being dropped by an institution lead to other transfer windows for athletes. In addition, transfers must be in appropriate academic standing.
Transfers have significantly increased with the new rules, presenting a unique challenge for physicians who care for these athletes. The lack of a standardized EMR amongst institutions makes it difficult to share medical information, unlike the NFL, where all teams have the same EMR system. Medical coverage and payments may also become an issue. If an athlete transfers after surgery, whose responsibility is to cover follow-up and physical therapy at the new institution? Who makes return-to-play decisions after surgery on an athlete who transferred? If follow-up imaging or procedures are needed, whose responsibility is that once an athlete has transferred? These issues are commonly encountered in the new transfer portal era, and without oversight or guidance at the NCAA level, will remain issues that must be addressed on a case-by-case basis. Good communication amongst institutions is key to ensuring the best care for these athletes, and our role in facilitating this communication is crucial.
NIL and transfer rule changes have created unique challenges and difficulties for physicians who treat collegiate athletes. Understanding how these rules affect the care of these athletes is important for all physicians who deal with these issues. The lack of a uniform EMR system among institutions is a pressing issue that needs to be addressed. Ideally, a uniform EMR system and medical insurance coverage would occur at some point in the future. Until then, appropriate oversight and communication will be necessary to ensure the best outcomes under the current circumstances.
Despite the shifting landscape, the role of the team physician remains crucial. The physician should always strive to provide a standard of care and enhance communication between all parties, including, first and foremost, the student-athlete, as well as family, coaches, advisors, and agents as necessary. In instances where the athlete is seeking a transfer or a second opinion, it is crucial for the team physician to provide clear communication to enhance the collaboration of the patient's care and ensure that the patient is always at the forefront of medical decision-making.
References
- Coello S. What Is NIL in College Sports? How Do Athlete Deals Work? Accessed August 29, 2024. www.espn.com/college-sports/story/_/id/41040485/what-nil-college-sports-how-do-athlete-deals-work
- Dodd D. NCAA's State-By-State War over NIL Benefits Continues with Missouri Law Bumping Right up to Pay for Play. Accessed May 17, 2023. www.cbssports.com/college-football/news/ncaas-state-by-state-war-over-nil-benefits-continues-with-missouri-law-bumping-right-up-to-pay-for-play/
- McMillen R, FirstPoint USA. Arch Manning, Shedeur Sanders, and NIL Valuations. 2024.
- On3. NIL Rights and Athlete Earnings Explained. 2023.
- Dodd D. Missouri's Progressive NIL Legislation and Its Impact. 2024. www.cbssports.com/college-football/news/missouri-state-law-universitys-progressive-nil-approach-gives-mizzou-advantage-amid-evolving-landscape/
- Ubben D, DeMeyer T. What Is NIL, How Has It Changed College Sports and Why Are Schools under Investigation? Accessed February 2, 2024. www.nytimes.com/athletic/5245564/2024/02/02/nil-explained-ncaa-name-image-likeness-investigation/
- Jones S. The Impact of NIL: New Opportunities for College Athletes and Brands. Accessed May 28, 2024. www.linkedin.com/pulse/impact-nil-new-opportunities-college-athletes-brands-stacy-jones-zxl4c/
- Patton H. NIL Deals Are Ruining College Athletics. Accessed March 25, 2024. www.thesoutherneronline.com/94997/sports/nil-is-ruining-college-athletics/
