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Questions
“When will I be able to play again?” is usually the reflex thought when an athlete suffers an injury. When making return to play decisions, clinicians (including physiotherapists, athletic trainers and physicians) and athletes might engage in a risk–benefit analysis of sorts, consciously or unconsciously weighing up the risks associated with participation and the extent to which those risks can be tolerated.1 ,2 There are a number of questions to contemplate: How does the clinician determine when the athlete is ready to return to play? Is physical recovery alone enough for return to play? What is successful return to play? What are the sports medicine clinician's responsibilities within the team, and to the athlete? Should athletes even return to play?
But what evidence can be used to answer these questions? We highlight some of the complexities in making the return to play decision, and key areas that need to be addressed.
Answers?
How does the clinician determine when the athlete is ready to return to play?
In the traditional evidence-based practice model,3 the clinician integrates the best available evidence from research with individual clinical experience and the patient's preferences when making decisions. In the search for the best evidence, considering an ankle sprain, the clinician might consult a textbook, where the evidence says that the athlete should have no pain or swelling, full strength and range of motion, and a healed ligament before returning to full competition.4 The time taken for pain and swelling to subside and full range of motion to return might vary from a couple of weeks to a couple of months; it may take a year for ligament healing.5 But in real life the athlete may return to play within 1 or 2 weeks of an ankle sprain, or even the next day in exceptional circumstances, and have residual symptoms on returning. The clinician who waits for tissue healing before clearing the athlete to return to play will probably find a short-lived career with a sporting team.6 So, why is there a paradox between the evidence and clinical practice regarding when the athlete should return to play?
Return to play criteria must depend on the type of injury, demands of sports and the affected body region. Ideally, a battery of accepted clinical criteria are used to guide safe return to play decisions.7 But these are physical assessments based on clinical dogma, with little empirical evidence to support their use, and little consensus regarding what the best criteria are. This highlights the need for evidence to address this knowledge gap—ideally rigorous studies—but a good first step is to have consensus.
Is physical recovery alone enough for return to play?
Recovery of sufficient physical capabilities to cope with the demands of playing sport is necessary to maximise performance and avoid reinjury. However, after serious injury, returning to play is not simply a matter of ‘getting back up on the horse’. For example, being under 25 years of age, male, and psychologically ready to return increases the likelihood of returning to the preinjury level sport after ACL reconstruction by up to 50%.8 ,9
Psychological readiness to return to play is also important in making the return to play transition. Many athletes say fear of reinjury hinders their return to the preinjury level.10 ,11 However, the current focus of rehabilitation is on restoration of physical function, and often physical and psychological readiness states do not coincide. There is no standard method of assessing an athlete's psychological readiness to return to play; at least four scales have research evidence suggesting that they might be appropriate. Therefore, consensus could help decide which (if any) is best to use.
What is successful return to play?
The definition of success might depend on whether you ask the athlete or the clinician. From the athlete's perspective, performing at the desired level in the desired sport is important. From the clinician's perspective, a safe return—without re-injury or long-term complications such as osteoarthritis—is important. In some situations, these perspectives may be at odds, and balancing these sometimes-competing interests may be a challenge.
Can we consider the return to play a success on the basis of one match? What is the minimum time duration the athlete needs to participate before the return can be labelled ‘successful’? What if the athlete returns for a single championship-winning match and has a best-on-ground performance? Is it a success if the athlete returns to play at the desired level but still experiences symptoms for months after returning to play—or suffers a reinjury a week later?
What are the sports medicine clinician's responsibilities within the team, and to the athlete?
Who comes first—the athlete or the team? While clinicians have an over-riding duty of care to the athlete,12 it is important to recognise that working for a sports team may represent an inherent conflict of interest.12 In many situations, what is in the athlete's best interests is also best for the team. Yet there are situations where the clinician may perceive pressure to make a decision that benefits the short-term interests of the team but could be detrimental to the athlete in the long term.12 The challenge is to practice good sports medicine while balancing the interests of the athlete and the team.
Should the athlete even return to play?
Role transparency is crucial to return to play decisions. Pressure from the athlete, coaches or family members, financial implications of scholarships or endorsements, and legal ramifications of restricting or permitting return to play may influence the athlete's and clinician's decisions.1
What advice do you give the 18-year-old athlete with a large chondral lesion who wants to return to playing competitive football after ACL reconstruction? This athlete is at high risk for post-traumatic osteoarthritis13 and at very high risk for a second ACL injury.14 Who has the final decision on return to play—the athlete or the clinician? How do we balance the autonomy of the athlete with the principles of practising good sports medicine?
Next steps
Return to play is complex and influenced by a range of factors. Research is necessary to answer many of these questions. However, in the absence of research evidence, consensus can help provide guidance for clinical practice and identify research gaps.15
The ankle sprain case is an elegant example of Sackett et al's3 assertion that “…excellent clinical evidence may be inapplicable or inappropriate for an individual patient…” (p.72). Being a slave to external evidence—waiting a year for ankle ligament healing—without tempering it with the best individual clinical experience and accounting for the patient's preferences may not be an effective approach to return to play. This does not mean evidence should be ignored, rather that its use must be judicious.3
But none of this is simple. Shrier's1 StARRT (risk) model (figure 1) is a biopsychosocial framework that captures and discusses key elements to be considered in the return to play decision; although the decision itself is not solved within this model. For optimal return to play decisions the clinician and athlete share decision-making. We propose that the StARRT (risk) model sits perfectly at the intersection of the three evidence-based practice pillars (figure 2).
Viewing the return to play decision1 through an evidence-based practice lens. The StARRT model1 described three steps in assessing risk in return to play decision-making: (1) assessment of health risk, (2) assessment of activity risk and (3) assessment of risk tolerance. The tissue health, tissue stresses and risk tolerance modifiers described in the StARRT1 model are arranged according to the three circles of evidence-based practice.3
Return to play is a key issue of the current phase in the development of the discipline of sports medicine. Reflecting this, the International Federation of Sports Physical Therapy, the Swiss Sport Physiotherapy Association and BJSM hosted the first international Return to Play Conference (http://www.rtp2015.com) in Bern, Switzerland (20–21 November 2015).
References
Footnotes
Correction notice This paper has been significantly amended since it was published Online First. New reference 2 has been inserted. Figure 1 has been updated and the captions for figures 1 and 2 have been changed. Reference 1 has also been updated to use the StAARt reference.
Twitter Follow Clare Ardern at @clare_ardern
Contributors CLA wrote the first draft and is the guarantor. All authors contributed to the conception of this editorial; revised the manuscript for important intellectual content and approved the final version.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.