Return to Sport

Return-to-Play (RTP) is the decision-making process of returning an injured or ill athlete to practice or competition (Herring et al. 2012). RTP can be important to an athlete for a number of reasons with common motives including achieving personal goals, a love of playing sport, socialising with teammates and preserving athletic identity (Podlog and Eklund 2006). Returning an athlete to sport participation is a complex and often difficult decision. Within competitive sport this process often involves aggressive rehabilitation while avoiding increased risk to the athlete. RTP has not been well defined in the literature and as a result there has been little progress toward identifying systematic approaches to clinical decision making in sport (Shultz et al. 2013). A consensus statement by Herring et al. (2012) states that with regard to RTP it is essential the team physician confirm:

Restoration of sport-specific function to the injured part
Restoration of musculoskeletal, cardiopulmonary and psychological function, as well as overall health of the injured or ill athlete
Restoration of sport-specific skills
Ability to perform safely with equipment modification, bracing, and orthoses
The status of recovery from acute or chronic injury
Psychosocial readiness
The athlete poses no undue risk to themselves or the safety of other participants
Compliance with federal, state, local and governing body regulations and legislation

Unfortunately, well established RTP guidelines do not exist for the vast majority of conditions (this is the case for all three of Achilles, rotator cuff and patellar tendinopathies) and patients are greatly dependent on their clinician’s ability to take a broad spectrum of factors into account in order to reach the optimal decision. Of course, individual decisions regarding the return of an injured athlete to sport will depend on the specific facts and circumstances relating to each individual patient (Herring et al. 2012) and this perhaps has prevented the establishment of comprehensive protocols for various conditions.

With this in mind, Creighton et al. (2010) developed a 3-step decision-based RTP model for an injury or illness that is specific to the individual practitioner making the decision. They aimed to synthesize the available literature and propose a model for RTP which would help clarify the processes that clinicians use consciously and subconsciously when making these decisions. A recent study by Shrier et al. (2014) set out to validate this proposed model and concluded that by grouping the large number of factors affecting RTP decision making into specific domains the process of RTP decisions was simplified. The authors also highlighted the value of utilising this model in educating relatively inexperienced sports injury rehabilitation professionals on the RTP process.

Figure 4.6: Decision-Based RTP Model as outlined by Creighton et al. (2010) which outlines a 3 step process and illustrates the interplay between these steps.

The model incorporates three general steps in the process of RTP and the interplay of these steps is demonstrated in Figure 4.6. The 3 steps outlined include:

Step 1: Evaluation of Health Status
Step 2: Evaluation of Participation Risk
Step 3: Decision Modification

Step 1: Evaluation of Health Risk (Creighton et al. 2010)

This involves a complete evaluation of the health status for the injury in question based on a subjective examination together with functional and laboratory testing when indicated. While some research uses only this health status evaluation in the RTP decision making process, this model identifies this evaluation as simply the first step stress and the findings should not be considered in isolation. Table 4.8 outlines the rationale behind inclusion of the various medical factors involved in step 1.

Functional Tests

Even when tissue may be fully healed biologically, deficits can remain that are secondary to the injury and functional testing which simulate the sport specific actions the individual needs to RTP. Regarding tendinopathy specifically, Silbernagel et al. (2006) developed a test battery to evaluate if AT caused functional deficits on the injured side compared with the non-injured side in patients. In patellar tendinopathy given that it is more prevalent in sports involving repetitive jumping, simulation of this movement would be a rational functional test to use.

Psychological State

See psychosocial factors involved in return to sport section

Potential Seriousness

The health status is also affected by the specific tissue injured, its extent, and the subsequent potential for healing. With this in mind it is clear that the RTP decision making process would vary significantly between chronic and acute tendinopathies.

Step 2: Evaluation of Participation Risk (Creighton et al. 2010)

The main disadvantage of allowing RTP is a high risk of re-injury. A study by Hägglund et al. (2006) investigated 263 elite footballers and found that 87% of those injured in a given season would also suffer from an injury the following season compared with 48% of those who had no injury in the first season. There are a number of factors that need to be taken into consideration in evaluating the sports participation risk for each individual athlete.

Generally, the higher the degree of contact allowed in a given sport the higher the risk of injury that the participants are exposed to (Kovacic and Bergfeld 2005) and this is an important factor to consider. In addition the competitive level at which the athlete will be competing at will affect RTP as at the same health status higher levels of competition are associated with higher health risk (Orchard et al. 2005).

The specific risk factors for achilles, rotator cuff and patellar tendinopathies have been outlined in this booklet. If the athlete is returning to a sport or sporting position where the specific risk factors for their injury are present (as will often be the case as may have been cause of original injury), this will affect the RTP decision making process. For example, the RTP decision would differ between an outfield soccer player with a rotator cuff injury and a goalkeeper with the same injury.

Step 3: Decision Modification (Creighton et al. 2010)

The authors acknowledge that there are additional factors aside from health status and participation risk that may influence the RTP decision making process. These factors are termed “Decision Modifiers”. These factors are not restricted to the athlete and can involve family, teammates and coaches. As can be seen in Figure 4.6, the decision modification step is set aside from the other steps. This is because while decision modification factors cannot be used to determine RTP in isolation without the context of the previous steps, no information on decision modification is provided by these previous steps. Examples of such factors which can modify the RTP decision making process include:

Timing: If the injury occurs during the off-season for an athlete then it may be more beneficial for them to delay return to sport until it is necessary in order to maximise recovery. Conversely, in-season injuries may be affected by desire to partake in certain events due to prestige, financial gain, etc.
Pressure from Athlete or Others: Although the sports injury rehabilitation professional may be inclined to discount pressure from these types of sources, in certain instances those other than the clinician may be in a better position to evaluate other factors such as job security, family and personal situations etc.

KEY POINTS

Return-to-Play (RTP) is the decision-making process of returning an injured or ill athlete to practice or competition (Herring et al. 2012)

Unfortunately, well established RTP guidelines do not exist for the vast majority of conditions and patients are greatly dependent on their clinician’s ability to take a broad spectrum of factors into account in order to reach the optimal decision (Herring et al. 2012)

Creighton et al. (2010) developed a 3-step decision based RTP model for an injury or illness that is specific to the individual practitioner making the decision which incorporates three steps:

Evaluation of Health Status

Factors involved: patient demographics, symptoms, personal medical history, signs, laboratory tests, functional tests, psychological tests, potential seriousness.

Evaluation of Participation Risk

This involves considering the specific risks that each individual athlete will be exposed to on return to pay and how this affects the RTP decsion making process

Decsion Modification

There are additional factors that can occasionally influence the process such as timing of injury be it in-season or during the off-season or or pressure from others such as teammates, family etc.

Key References

Creighton, D. W., Shrier, I., Shultz, R., Meeuwisse, W. H. and Matheson, G. O. (2010) 'Return-to-play in sport: a decision-based model', Clinical Journal of Sport Medicine, 20(5), 379-385.

Herring, S. A., Kibler, W. B. and Putukian, M. (2012) 'The team physician and the return-to-play decision: a consensus statement-2012 update', Medicine and science in sports and exercise, 44(12), 2446-2448.

Shrier, I., Matheson, G., Boudier-Reveret, M. and Steele, R. (2014) 'Validating the 3-step return to play decision making model', British journal of sports medicine, 48(7), 661-661.