One of the most often discussed topics among injured athletes and parents, coaches and healthcare personnel is “When can I go back and play?” Return-to-participation (RTP) recommendations following injury can be a difficult decision for health-care professionals and athletes/parents/coaches due to the various factors that must be considered to make an educated decision.
One preventative measure to avoid all sport-related injury is to refrain from play; however, sports medicine clinicians don’t solely want to keep athletes from playing sports. A clinician wants to encourage sports participation, but in a healthy and evidence-based manner to ensure optimal performance and health sustainment (Shrier et al 2014).
The clinical decision-making process for return-to-participation following injury or disease is quite varied across different types of physically active populations. One recently developed RTP decision-making model (Creighton et al, 2010) for sport is based on a three-step process: health status of athlete, risk associated with participation and decision modifiers.
The first step in this sport RTP decision-making model is the evaluation of health status. The focus of this aspect of the RTP model is centered on traditional diagnostic factors such as patient demographics (e.g., age, weight, height), symptoms (e.g., pain, swelling), medical history (e.g., previous injury history, associated medical conditions), laboratory tests (e.g., x-rays, blood analysis) and functional tests (e.g., balance, strength). Due to the varied types of injuries that can potentially occur, a rigid battery of RTP health status tests is inappropriate to recommend, yet the factors involved in the RTP decision-making process for health status should remain similar across different types of injuries. In essence, the evaluation of health status for any injury should determine how close the athlete is to his or her baseline measures or what was previously considered normal limits.
The second step of the sport RTP model presented by Creighton et al (2010) is focused on evaluation of participation risk. Unfortunately, athletes with prior injury are at almost four times greater risk of re-injury (Fuller, 2007). Issues surrounding the type of sport (e.g., collision vs. noncontact), position played, competitive level and ability to protect the injury should be considered during the RTP decision-making process to lower the risk of re-injury. Additional research-based evidence surrounding the evaluation of participation risk is needed, yet epidemiological data does indirectly support some of the clinical perspectives for this aspect of the RTP decision-making process. (Schroeder et al 2015,)
Understanding the task demands of the individual’s sport and position should dictate the clinical decision-making process for RTP. A football quarterback with a sprained thumb on his throwing hand would be severely disabled to perform at a high level and may possibly injure himself further during participation, while a defensive lineman may be fine to RTP with appropriate protection and different positional task demands. Protection of the injury may also be restricted by specific rules governing the particular sport, thus discussion with officials and sports administrators prior to participation is important.
The third step in the RTP process, Decision Modifiers, is an ever expanding area. This step in the process is utilized to determine the overall acceptable value of risk in making a RTP considering the potential “reward” of participation. This is basically a cost-benefit analysis. The third step can only be considered when both the health status and the evaluation of potential risk have been determined to be acceptable by the clinician and athlete.
The first modifier is timing or what point in the season or year does the injury occur.(Creighton et al, 2010) The urgency to return from an injury in an off-season conditioning session or a non-traditional season practice is much less than a game in-season or post-season competition. The pressures or perception of pressure placed on the clinician by the athlete, the athlete’s parents, agent, coach, friends, fans or extended family members can influence the RTP decision. While legally the clinician may be responsible for making the RTP decision, the influence of these other groups on the athlete should not be discounted and certainly not dismissed.
There is a broad spectrum on these influences as well. Some athletes will want to “suck it up” and try and perform for their teammates, coach or their team. Others might be influenced by family members or “confidants” who believe that playing right now is not in their best interest in the long run. Transparency from the clinician is vital to providing the athlete and their handlers with education and information necessary to weigh the risks and benefits of the RTP decision.
The first duty of an appropriate health-care professional is to promote the health and well-being of the athletes in a school athletic program. There are situations where this individual reports to a coach or administrator and may feel a conflict of interest. However, the health-care professional must remember that the recovery of the athlete outweighs any potential contribution the athlete might make to the team.
In addition to the dictates of professional responsibility, there are legal considerations that may affect a health-care professional’s decision-making. There is a possibility that litigation may ensue if an athlete, who arguably may have returned to play too soon, suffers a poor outcome such as re-injury or worse. For that reason, the health-care professional involved in an RTP decision should fully inform the athlete and his or her parents of the potential risks of RTP, and appropriately document the recommendations, restrictions and instructions (Enchenmedia et al 2015, Estes 2015, Tucker et al 2004, Clover et al 2010). The RTP process may take a few minutes or several months. Regardless of the timeframe, the process should be structured collaboratively, and in a manner that will provide the athlete with the best opportunity to return with a minimum of risk.
While the duties of health-care professionals are generally consistent across the nation, there are variances from state to state in governing laws, regulations and protocols (e.g., each state has its own concussion law). Accordingly, each health-care professional involved in the RTP process must investigate the necessary steps to conform with the requirements of the jurisdiction in which he or she practices. RTP is not a simple task and the spectrum of those affected and influenced either personally or monetarily continues to broaden. Whatever the specific circumstances, the process outlined above should assist in the promotion of a favorable outcome.
Shrier I, Safai P, Charland L. Return to play following injury: whose decision should it be? Br J Sports Med. 2014 Mar;48(5):394-401.
Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return to play in sport: a decision-based model. Clin J Sport Med. 2010 Sept; 20(5):379-385.
Fuller CW. Managing the risk of injury in sport. Clin J Sport Med. 2007 May; 17(3):182-187.
Schroeder AN, Comstock RD, Collins CL, Everhart J, Flanigan D, Best TM. Epidemiology of overuse injuries among high school athletes in the United States. J Pediatr. 2015 Mar;166(3):600-606.
Echenmedia RJ, Giza CC, Kutcher JS. Developing guidelines for return to play: consensus and evidence-based approaches. Brain Inj. 2015; 29(2):185-194.
Estes KR. Skin infections in high school wrestlers: a nurse practitioner’s guide to diagnosis, treatment, and return to participation. J Am Assoc Nurse Pract. 2015 Jan;27(1):4-10.
Tucker AM. Ethics and the professional team physician. Clin Sports Med. 2004 Apr;23(2):227-241.
Clover J, Wall J. Return to play criteria following sports injury. Clin Sports Med. 2010 Jan;29(1):169-175.
James Onate, Ph.D., is an associate professor in the school of health and rehabilitation sciences at The Ohio State University. He earned his bachelor’s degree from the University of Florida and his master’s and Ph.D. from the University of North Carolina. He is a member of the NFHS Sports Medicine Advisory Committee.
John Black, J.D., joined the NFHS staff as general counsel in November 1998. In that capacity, he handles the legal matters of the NFHS and assists member state associations. Prior to joining the staff on a full-time basis, Black served as outside legal counsel for the NFHS for a number of years. In addition to serving on the NFHS staff as legal counsel, Black worked for the Kansas City law firm of Shughart, Thomsom & Kilroy for a number of years. Black earned his undergraduate degree in economics from Colorado College and his law degree from Duke University.