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A major limitation of the traditional return to sport (RTS) decision has been the exclusion of the athlete in question.1 Recently, two frameworks have underscored the importance of involving the athlete in a multidisciplinary team (MDT) and putting them at the centre of a shared decision-making process that collectively decides RTS protocol.2 3 RTS should also be considered as a continuum that begins at the onset of injury, rather than an isolated step occurring at the end of rehabilitation.3 It should be a process that fosters athlete autonomy; this has been shown to promote personal development, improve motivation and task performance, and subsequently improve rehabilitation outcomes.4
To date, little has been published on the practicality of integrating these principles into a rehabilitation programme within a high-performance environment. The purpose of this editorial is to outline four key habits that clinicians and practitioners can focus on to improve RTS outcomes and maximise rehabilitation outputs : empowerment, engagement, feedback and being transparent. We refer to this as the ‘athlete-centred return to sport approach’ (figure 1).
Four key habits underpinning the athlete-centred RTS approach
Empower the athlete
Educate the athlete early about their injury. Take the time to describe potentially injured structures and explain the basic stages of tissue healing. Having this conversation within the first days of injury is an opportunity to empower the athlete early in taking ownership of their rehabilitation. An example of this would be educating the athlete how they can modify their nutrition to optimise recovery during the acute phase of injury. We have found that these early discussions can help establish a strong collaborative working relationships between the athlete and clinician for the journey from injury through to RTS and performance. It also reminds the athlete that RTS starts from the very moment of injury incidence.
We find a business analogy useful when educating the athlete about his/her role in RTS: the athlete is the Chief Executive Officer (CEO) of his/her company. The company has a team of executives (ie, the MDT) who are experts in their respective fields who consult with the CEO to help identify action points and reach the best decisions. Shared decisions help achieve the best outcome for the ‘company’. The athletes MDT comprises medical, physical performance, nutritional, psychology and coaching staff.
‘Round-table’ meetings are regularly held between the athlete and their MDT, the first of which is held within the first days of injury. The aim of the first meeting is for management options to be discussed and for gold-standard practice/supporting research to be presented. Potential other avenues are also discussed, with accompanying clinical reasoning as to why these may or may not be appropriate. This provides the athlete with an opportunity to make an informed decision on how to progress. A practical example here would be there athlete with long-standing FAI symptoms. Both conservative and surgical pathways may be reasonable management options , so the ‘pros and cons’ of each are presented. The opinion(s) of the orthopaedic consultant(s) would also be discussed in this scenario. The athlete is given the opportunity to then ask questions, given time to reflect and then come to an agreement on how best to proceed.
Another aim of this meeting is for the athlete to understand what is needed for a successful RTS. This is achieved through the development of a ‘return-to-performance contract’. This ‘contract’ comprises progressive short-term and long-term criteria that the athlete agrees to complete prior to RTS. This ensures that the RTS continuum follows a criteria-based (not time-based) progression. It is also a useful agreement to refer back to, if the athlete or coaching staff start to increase RTS pressures.
Before the meeting is closed, clear actions points are agreed and a follow-up meeting is scheduled.
Once a management plan has been finalised, we encourage the athlete to outline other objectives—not necessarily specific to the injury—to achieve during the RTS continuum. These could be physical, psychological or other objectives, such as:
‘Improve my upper body strength’
‘Deepen my relationship with my daughter by walking her to school three times a week’
‘Complete my UEFA ‘B’ Licence Coaching Badges’
‘Develop my online business platform so I have something to fall back on after sport’
The athlete’s objectives are incorporated in the RTS continuum to ensure adequate time is allocated to achieve them. The aim is to foster personal and professional development, parallel to athletic development. Broadening the athlete’s identity outside sport has a positive impact on motivation and psychological well-being during rehabilitation.3
The MDT educates the athlete to develop a basic understanding of the periodisation strategies and physiological principles underpinning their training. The athlete is encouraged to use this knowledge to contribute in the planning of a weekly schedule, engaging and motivating the athlete to complete the required training. For example, if the athlete should complete three aerobic conditioning sessions during the week, a ‘menu’ of training options are presented—the athlete may choose to perform two maximal aerobic speed cycling sessions and one intermittent rowing session from the available options.
Preplanned ‘rehabilitation holidays’ are encouraged, the nature of which will be dependent on the length of rehabilitation. This may be as simple as an extended weekend away with family or friends, or it might be an 2-week international training camp with an external practitioner and/or accompanying team clinician. Rehabilitation holidays provide a change of environment and break up the monotony of club-based training. In our experience, rehabilitation holidays can act as a short-term goal for the athlete to work towards, which helps maintain motivation and compliance.
Our approach provides the injured athlete with the opportunity to interact with the coach to discuss ‘work-ons’—components of the athlete’s sport that coaches feel can improve, while the athlete is not able to participate in training. In football, ‘work-ons’ may include tactical coaching or opposition analysis. Other sports may have different ‘work-ons’ such as technique visualisation and competition strategy. Discussing and planning ‘work-ons’ provide weekly points of contact with the coach(es), opportunities to improve performance and may help to minimise the feeling of isolation.
Regular ‘round table’ progress meetings should be scheduled through the various stages of the RTS continuum—this is in stark contrast to the historic approach of having a meeting near the end of the rehabilitation period to ‘decide’ RTS. The aims of these meetings are to allow the athlete and MDT to communicate effectively, to review the ‘return-to-performance contract’ and to review other goals.
In these meetings we find it helpful to:
Allow the athlete to speak first. This is to ensure the athlete’s feedback is not influenced by what the coach says, and to reinforce that the athlete is the focus of the meeting. The athlete feeds back on their positive and negative experiences of their rehabilitation to date. Positive aspects of the process should be continued, and negative ones are addressed.
Use video feedback to highlight progression of key performance indicators (eg, a video of an athlete’s squat progress after ACL reconstruction). This helps to summarise progress that at times may feel slow.
Summarise agreed action points and updates to the ‘return-to-performance contract’. Which criteria does the athlete have to meet before they can RTS?
Communication between the athlete and MDT must be frequent and honest. The development of transparent relationships helps to manage expectations regarding RTS, not only for the athlete but also for the coaching staff. The aim of this is to avoid a premature RTS.
Transparency allows for stakeholders to openly discuss the potential for setbacks in the RTS continuum. We found that this helps to protect athlete motivation and compliance levels if progress does not go to plan.
Using an athlete-centred approach, modelled on a shared decision-making framework, may help improve RTS.
The elements we recommend commits time and resources to personal development and fulfilling the psycho-social needs of the athlete through the four key habits: empowerment, engagement, feedback and transparency. In our experience, the result is a more rounded, balanced and better performing athlete (box 1).
Practical tips for implementing the four key habits of athlete-centred RTS
Empower the athlete: educate the athlete about their injury and explain what they can do to facilitate recovery at each step of the RTS continuum (eg, appropriate nutrition strategies to optimise tissue repair). Consult them on their injury, let them make the final decision on management options—they are the ‘CEO’!
Engagement: allow athletes to contribute to the planning of their rehabilitation programmes. Encourage ‘rehabilitation holidays’!
Feedback: use video feedback within progress meetings to reinforce the progress they are making.
Transparency: hold a frequent round-table progress meetings involving the athlete, coach(es) and clinicians (ie, the MDT).
CEO, Chief Executive Officer; MDT, multidisciplinary team; RTS, return to sport.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.