Return to Play- Sports Medicine

Original Editor - Janine Rose Top Contributors - Janine Rose and Kim Jackson


Injuries are very common among the athletic population. After an injury long, before the athlete is ready to return to competing factors that affect return to play must be considered. There are various protocols governing return to play that depend on the type of injury suffered by the athlete. There are factors that will influence return to play which are independent of the type of injury suffered. At the point of return to play the athlete ought to be fully or almost fully reconditioned. Physiological healing ought to have occurred. Parameters such as pain, swelling, range of motion and strength ought to be gauged and the athlete should 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 made by a variety of personnel. According to Magee, “the most difficult decision the sports medicine team makes is whether and when and when the athlete should be allowed to return to competition (Magee, 2011)[1]. The decision may be influenced by the medical doctor, physical therapist and coach. Family and friends may also influence the athlete in regard to returning to competition. The views of the athlete himself will also greatly influence when they return to play. Brukner and Khan (2016) 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]

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

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).


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]


  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 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: [last accessed 05/05/2019]