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Return to play (RTP) is an important issue in sports medicine; it is the other ‘bookend’ to effective prevention strategies for sports injury. Both share common goals and challenges and are critical to the multiple stakeholders in elite sports. RTP decisions are made in classical injuries such as sports concussion or ACL reconstruction, and are also made in infectious disease such as mononucleosis (splenic involvement) or frequently underdiagnosed myocarditis, and in less well-defined conditions such as disordered eating. Overuse injuries also present a challenge for RTP, whether in adolescents (apophyseal injuries) or adults (tendinopathies). While some of these conditions have clear diagnostic criteria, others do not and pose a greater problem with regard to readiness to play. Creighton et al1 have described a remarkable three-step model (medical factors, sport risk and decision modifiers) to facilitate decision-making.
The rational framework
A RTP decision requires accurate diagnosis, precise assessment protocols and tools, and, ultimately, capacity to correctly interpret these elements. A scientific algorithmic approach (multicomponent and sports specific) is paramount to integrate all elements. Quality control by following up on RTP decisions is essential, which means monitoring to ascertain that RTP is occurring without excessive risk, and also comparison to preinjury levels, if available, to account for baseline “normal” individual data. The latter is not easy as experience with tools such as neurocognitive testing shows.2
The emotional framework
Two elements form this framework. First, the athlete's psychological readiness and confidence is increasingly being recognised as a key factor, with positive responses linked to safer and more successful RTP.3 This mostly applies to injuries resulting in longer absence from the field (ACL). Second, the context of elite sports calls for emotions before rationality. There is pressure from media, fans, coaching staff, management, sponsors and athletes themselves. Education matters, but when the heat is on, it comes down to managing communication adequately; expectations can best be channelled when information is shared in a relevant and understandable format.
Riding the pachyderm
Behavioural science teaches us about the complex nature of decision-making. In Jonathan Haidt's Happiness hypothesis, where he applied the metaphor of the rider and the elephant to decision-making processes,4 he argues that our emotional brain (Daniel Kahneman's System 1) is like that of an elephant, which the rider, our rational brain (System 2), tries to steer with great effort. The fallacy of decision-making is that one can rationally steer the elephant without it making its own decisions at some point. In Switch, the Heath brothers help us understand how this battle within our brain leads to exhaustion and inefficiency.5 They suggest that the best way to achieve behavioural change is through a combination of efforts, to direct the rider, motivate the elephant, and shape the path that the pair must follow (BJSM6 with Dan Heath). Now what does this have to do with RTP? Consider what happened in the World Cup in Brazil, whether you look at the likes of Pereira (Uruguay), Mascherano (Argentina) or Kramer (Germany), they all suffered clear concussions and continued playing. This is a clear-cut case of inability of the rider (the doctor) to impose rational decisions on the elephant (compound powerhouse of coaches, management, public pressure, national pride, player motivation).
Pitch-side decisions are a good example where the concept of the path to be shaped is relevant: if you must make a decision in this environment, the likelihood that the elephant will take over is high. Changing the environment to create a better path is critical. The authors put it this way: “What looks like a people problem is often a situation problem”. Rugby's new 5 min concussion assessment rule, with standardised evaluation in the medical room, has defined a clearer path for the best possible decision.7 Key messages from the Heath brothers are to: (1) tweak the environment (setting, rules), (2) build habits for better decisions (education/information for stakeholders) and (3) rally the herd to harvest the power of peer-pressure (spread experiences and successes, it is contagious).
A RTP framework based on Swiss values
Quality, precision, timing and shared decision-making are core Swiss values, and they should drive the rational aspect of RTP. The culture of collaboration between entities (sports medicine, physiotherapy and sciences) must be at the forefront to address emotional aspects and shape the path. We also need to work towards a common language with coaches, athletes and managers. In Lausanne, under the auspices of the highest educational institutions and the IOC, the AISTS (Académie Internationale des Sciences et Technologies du Sport, aists.org) hosts a masters in sports administration, in which future managers learn about sports medicine and RTP, helping to shape that path.
With these reflections, I hope we will be able to develop and apply a framework for RTP processes based on acknowledged societal and cultural values that Switzerland is renowned for. This requires joint efforts of all stakeholders (clinical, coaching and managerial sector), as well as targeted athlete education to have the best chances for success.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.