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Return to play: the challenge of balancing research and practice
  1. Alan McCall1,2,
  2. Colin Lewin1,
  3. Gary O'Driscoll1,
  4. Erik Witvrouw3,
  5. Clare Ardern4,5,6
  1. 1Research & Development Department, Arsenal Football Club, London, UK
  2. 2Research & Development Department, Edinburgh Napier University, Edinburgh, UK
  3. 3Faculty of Medicine & Health Sciences, Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
  4. 4Aspetar Orthopaedic & Sports Medicine Hospital, Doha, Qatar
  5. 5Division of Physiotherapy, Linköping University, Linköping, Sweden
  6. 6School of Allied Health, La Trobe University, Melbourne, Australia
  1. Correspondence to Dr Alan McCall, Arsenal Football Club, Bell Ln, London Colney, Hertfordshire AL2 1DR, UK; alan_mccall{at}

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Life is full of risky decisions, from mundane ones, to matters of life and death.1 In professional football, risk is everywhere: For the club—the risk of having a poor season and loss of income by not qualifying for an important competition. For the manager—overseeing a bad run of results, potentially jeopardising his position. For the player—poor performance and, of course, injury. For the medical/science team—bringing a player back too early from musculoskeletal injury, and he/she suffering a reinjury. The dilemma is that, usually, riskier options promise higher returns.1

In football, the decision to progress or delay a player's return to play (RTP) after musculoskeletal injury could be the difference between having a key player back two games earlier (giving the best chance to earn six points) contrasted with keeping the player out for two extra games, lowering his/her reinjury risk, but potentially ending up with fewer points. Which risk is more important? Do we aim for a reinjury rate of 0%? Or might we settle for 10% recurrence, where every injured player is back one game earlier?

RTP has been prominent in 2016—the focus of conferences and topic of an expert consensus statement.2 In this editorial we aimed to highlight the real-world challenge of taking the best available research evidence and expert consensus, and applying it in the practical world of professional football. We (1) highlight how research and practice can present conflicting views regarding when a player should RTP after musculoskeletal injury and (2) emphasise that while research helps us guide this process, it is only with skills and experience, combined with knowledge of the injury, the sport, and the individual player that high-quality RTP decisions can be made.

Research versus practice

We examine the RTP challenge through the lens of hamstring injury—the most common musculoskeletal injury in professional football.3

The argument for delaying RTP: research

RTP should only occur when the risk for reinjury is the same as the risk for primary injury (ie, the previously injured player should have the same risk of injury as his/her previously uninjured peers).

To support a recommendation to delay RTP, we look to the research evidence: the majority of players who will sustain a hamstring reinjury do so in the first 50 days after injury.4 Why might this be? Many players have residual strength deficits at the time they are cleared to RTP,5 and reduced sprint performance.6 These deficits might have implications for on-field performance and reinjury risk. The time required for full biological healing after hamstring injury is unknown, although players returning after 2 weeks are likely to have immature scar tissue.7

The argument for not delaying RTP: practice

If we hold all players with an acute hamstring injury back from the pitch for at least 50 days, we do not reduce the injury burden. Instead, by being overly cautious, the burden of injury increases.

We must assess each case on individual merit. A player may be given the extra week as the risk of reinjury is evaluated as unacceptable by the key decision-makers (manager, player and medical/science team). However, what if the ‘next best’ player was of far inferior skill level or injured too? What about a developing, promising 17-year-old player? This player might be afforded longer as it might be an unacceptable risk to return him/her to competition earlier. The practitioner's career in elite sport would be short lived if every injured player was kept out until reinjury risk was reduced to ‘the lowest level’. The RTP decision is so multifactorial it cannot simply be read from a ‘research recipe book’. The challenge is to practise good sports medicine and science while balancing the interests of the player and the team.

Arriving at a decision

Arriving at a shared decision regarding whether the player is ready to RTP or not is complex and dynamic, involving a combination of injury characteristics, sociodemographic factors, physical, functional and psychological aspects as well as the surrounding context (many of which are beyond the scope of this editorial).2

The practitioner's role in this shared decision is to provide a realistic and accurate evaluation of the player's ability, not only to compete, but to compete well and to compete safely (ie, lowest accepted reinjury risk). The practitioner is in the best position to judge the player's physical readiness to RTP. A strategic model integrating both research and practice has been developed that provides practitioners with a coherent approach to estimating the risk in the RTP decision.8

Relationships are also key. The relationship between the manager, player and medical team must be one of trust and belief, following one agreed upon RTP plan. Mutual understanding of the decision faced is vital. Mixed messages are almost always damaging and doubt inducing.

Final word

RTP in practice is a constant learning process: refined by experience, and reflection on how we combined the best quality research and clinical evidence in a given RTP decision. After reinjury, as a sports medicine/science team, we try to understand why the reinjury occurred. We learn from this so that if (and when) faced with a similar set of recognisable circumstances again, we can improve our evaluation of risk and ultimately have more confidence in our final recommendation to the manager/coach and player.



  • Twitter Follow Alan McCall @Alan_McCall_, Clare Ardern @clare_ardern

  • Contributors CL proposed the idea for this editorial. AM and CA wrote the first draft. All authors revised the manuscript for important intellectual content and approved the final version. AM is the guarantor. AM and CL are co-first authors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.