Return to Play in Sports

Original Editor - Janine Rose Top Contributors - Janine Rose, Kim Jackson, Yvonne Yap and Wanda van Niekerk

Introduction

Injuries are common amongst the athletic population. After an injury, there are various factors to consider prior to an athlete returning to sport. It has been suggested that returning to sport should be viewed as a continuum, alongside recovery and rehabilitation.

At the point of return to sport, physiological healing ought to have occurred. Parameters such as pain, swelling, range of motion and strength should be assessed and the athlete should have minimal or no deficits. Having had a previous injury predisposes an athlete to re-injury. This therefore would mean an injured athlete who returns to competition before sufficient recovery and reconditioning will be at increased risk of injury.

The decision to return to play for a professional athlete is not made in isolation, but by a variety of personnel, including the medical team, physical therapist, coach and family and friends. According to Magee, “the most difficult decision the sports medicine team makes is whether and when the athlete should be allowed to return to competition" (Magee, 2011)[1].

Defining Return to Sport

Returning to sport can be different for each individual athlete, depending on the sport and the level of participation the athlete aims to return to. It is suggested to be a continuum comprising of:

  1. Return to participation - the athlete may be participating in rehabilitation or sport but at a level lower than the desired goal, but not yet "ready" medically, physically and/or psychologically.
  2. Return to sport - the athlete has returned to sport, but not at his or her target level of performance.
  3. Return to performance - the athlete has returned to his or her sport and is performing at or better than pre-injury level.

Herring et al postulated on the various factors that must be addressed when the decision is made for an athlete to return to playing sport. These are:

  1. The safety of the player
  2. The potential risk to the safety of the other members of the team
  3. The functional capabilities of the player
  4. The functional requirements of the sport being played
  5. Regulations of varied institutions which govern the return of an injured player to sport

Brukner and Khan (2016)[2] stated that disagreements and conflicts regarding prognosis may arise. This may result in negative effects such as the following:

  1. Miscommunication
  2. Loss of trust
  3. Potential litigation
  4. Decline in sports participation rates - some persons have a fear of re-injury although the level of risk is acceptable
  5. Serious medical complications -some players return to activity while they are still at unacceptable level of risk repeated sport related injury[2]

It was thought that such conflict could be mitigated if a process was developed which could guide how decisions were made in regard to return to play. This process would aid the interaction of those who were involved in the process as it relates to an athlete returning to competition. This led to the development of the Strategic Assessment of Risk and Risk Tolerance (StARRT).

Models to guide return to sport process

There are some models that have been suggested to assist clinicians and athletes to consider the various factors that can influence RTS outcomes, as well as encourage consistency and transparency in RTS decision-making.

StaRRT

The StaRRT framework was developed to assist all involved with deciding when an athlete was ready to return to their particular sport. This framework was developed to take the guesswork out of the decision. It was hoped that StaRRt would mitigate the conflicts which could arise with an athlete returning to competition. The StaRRt framework is a 3 step model. According to Ardern et al (2016) "step 1 (tissue health) of the StARRT framework synthesises information relevant to the load (stress) the tissue can absorb before injury. Step 2 (tissue stresses) synthesises information relevant to the expected cumulative load (stress) on the tissue. Step 3 (risk tolerance modifiers) synthesises information relevant to the contextual factors that influence the RTS decision-maker's tolerance for risk"[3] According to the framework the athlete is allowed to return to play when step 1 (assessment of health risk) and step 2 (assessment of activity risk) are below the acceptable risk tolerance which step 3 (assessment of risk tolerance) alludes to[2]. Clinicians and other stakeholders are able to apply the StaRRt framework.

Sportfisio 2015 Return to play Nicola Philips[4]

References

  1. Magee DJ, Zachazewski JE, Quillen WS, Manske RC. Athletic and Sport Issues in Musculoskeletal Rehabilitation-E-Book. Elsevier Health Sciences; 2010.
  2. 2.0 2.1 2.2 Brukner P. Brukner & Khan's clinical sports medicine: McGraw-Hill; 2016.
  3. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, Gojanovic B, Griffin S, Khan KM, Moksnes H, Mutch SA. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med. 2016 Jul 1;50(14):853-64.
  4. dreicast GmbH. Sportsfisio 2015 Day 1 Nicola Philips Available from: https://www.youtube.com/watch?v=1C6k4_mpZYY [last accessed 05/05/2019]