Return to Sport

Original Editor - Wanda van Niekerk based on the course by Ian Gatt

Top Contributors - Wanda van Niekerk, Kim Jackson and Jess Bell  

What Does Return to Sport Mean?

There are a variety of definitions of return to sport available in the literature. Some studies refer to the athlete being able to compete in competitive play, whilst other studies include return to training and clearly defined competition levels and objectives. Return to sport can be different for each individual athlete, depending on the sport and depending on the level of participation and this needs to be considered in informed return to sport decision-making.

Return to sport is considered as a “continuum paralleled with recovery and rehabilitation” and not just a decision made at the end of a recovery or rehabilitation process. The three elements of return to sport are:

• Return to participation
  • Athlete may be:
    • Participating in rehabilitation
    • Participating in modified or unrestricted training
    • Participating in sport
  • However, all of the above is at a lower level than the athlete’s return to sport goal
  • Physically active athlete, but not ready to return to sport
  • Readiness can refer to medical, physical and/or psychological readiness

• Return to sport
  • Athlete has returned to their specific sport, but not yet at the desired performance level
  • For some athletes return to sport (even though not at the desired performance level) will be enough and this can constitute a successful return to sport for the individual athlete

• Return to performance
  • Extends return to sport
  • Athlete has returned to sport, is performing at pre-injury levels or above
  • Athletes often achieve personal best performances in this stage or experience personal growth as it relates to performance expectations

In some sports, return to performance may be easier, but in open-skill sports like boxing this is not easily achieved. Performance analysis with the help of technology is often required and the experienced coach can provide insight into an athlete’s performance levels.

Climb Every Return to Sport Mountain…

Return to Sport Mountain

Della Villa et al. investigated ACL injuries in football and applied a five step approach in their aim to reach the maximum functional recovery possible.

• Stage 1 - Resolution of pain, swelling and inflammation
• Stage 2 - Recovery of range of motion and flexibility
• Stage 3 - Recovery of strength and muscular endurance
• Stage 4 - Retraining of coordination and motor skills
• Stage 5 - Recovery of specific technical movements and return to play

Valid and reliable criteria is necessary for an athlete to move from one stage into the next.

Contextual Effects to Consider in Return to Sport

Creighton et al. developed a three-step decision-based return to play model – this was specifically aimed at individual clinicians having to make return to sport decisions. The steps are:

• Evaluation of health status
  • This involves medical factors such as:
    • Patient demographics e.g., age
    • Symptoms
    • Personal medical history
    • Signs in physical examination e.g., weakness
    • Laboratory tests e.g., x-rays, MRI
    • Functional tests
    • Psychological state
    • Potential seriousness of injury e.g., concussion

• Evaluation of participation risk
  • This involves sport risk modifiers such as:
    • Type of sport e.g., collision vs non-contact
    • Position played
    • Limb dominance
    • Competitive level
    • Ability to protect e.g., padding or protective gear

• Decision modification
  • This includes decision modifiers such as:
    • Timing and season
    • Pressure from the athlete
    • External pressure e.g., coaches, family
    • Masking the injury
    • Conflict of interest
    • Fear of litigation

Read the full article here: Return-to-play in sport: a decision-based model. Please take note of figure 1 showing the decision-making model for return to play using an influence diagram.

Optimising Return to Sport

Truong et al. investigated psychological, social and contextual factors across recovery stages in athletes with a sport-related knee injury. They reported the following:

• Psychological, social and contextual factors influence and play a crucial role in recovery after injury. Clinicians should acknowledge this and see the value of a holistic approach.
• During all stages of recovery, athletes encounter barriers to “progress beyond fear”
• Autonomy and an athlete-centered approach is important and valuable for athletes.
  • “Strategies to develop a strong therapeutic alliance and engaging athletes in their care while considering how broader environmental and social factors impact decision-making should be vital components of recovery.”
• Psychological, social and contextual factors change over time and all of these should be assessed early in the rehabilitation process and throughout all recovery stages.
• Evidence-based management of sport-related knee injuries should include individual consideration of psychological, social and contextual factors for each individual.
• “Focus on the individual.”
• Insight into these factors can enhance and optimise injury management, promote return to sport and improve long-term quality of life.

Read the full article here: Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review.

The Meaning of Success in Return to Sport

Success has different meanings for different people. It may be dependent on the context of the specific situation or it may be dependent on the outcome. Specifically related to sports, success may be based on the following:

• Goal focus – defining success as the return to sustained participation in sport in the shortest possible time
• Performance focus – coach or athlete defining success relative to the athlete’s performance on return to sport
• Outcome focus – clinician defining success as the prevention of new (or recurring) associated injuries

Using an athlete-centred approach, the multidisciplinary team and athlete should collaboratively decide what success will be defined as. This should also be decided as soon as possible after injury.

Multidisciplinary Team and Return to Sport

Feigenbaum et al. reports on a case where the multidisciplinary team consisted of a physiotherapist and a nutrionist. The application of the meaning of success in this athlete’s case can be summarised as follows:

• Performance focus success
  • Athlete recovered and returned to his sport and playing position and subsequently was drafted by an NFL franchise
• Goal focus
  • Athlete successfully completed rehabilitation
  • Achieved a high-level of mobility and levels returned to above pre-injury values
  • Athlete’s self-reported function improved
  • Body fat percentages and fat mass decreased

Read the full case report here: A multidisciplinary approach to the rehabilitation of a collegiate football player following ankle fracture: a case report.

Roberts et al. advocate for clinicians wanting to improve return to sport outcomes following injury to focus on these four key habits:

• Empower the athlete
  • Gledhill et al. suggests these three strategies for clinicians to empower athletes during return to sport:
    • Educate the athlete about the injury and return to sport protocols
    • Involve the athlete in rehabilitation and return to sport decisions
    • Adopt collaborative, non-controlling forms of communication and interaction
    • Read the complete article here: Educate, involve and collaborate: three strategies for clinicians to empower athletes during return to sport.

• Engagement
  • Allow athletes to contribute to the planning of their return to sport plan

• Provide feedback
  • Regularly between the multidisciplinary team (MDT)

• Transparency
  • Frequent and honest communication between the athlete and MDT

See this infographic: 4 key habits of athlete-centred return to sport

Return to Sport versus Removal from Sport

Situations arise when a “return to sport decision may be reversed to a removal from sport decision.” For example:

• With injuries where symptoms are gradually increasing over time, the MDT using a shared decision making process may decide that a reduction in load is necessary (i.e. modifying training or competition) or if complete load reduction is necessary (no participation at all).
• The idea behind removal from sport is not necessarily that the athlete stops all participation, but rather focuses on modifying training/competition load. These decisions need to be taken in a collaborative manner, with clinicians, athletes and coaches working together.
  • Using boxing as an example:
    • Considering a boxer with a carpometacarpal (CMC) injury:
      • Can the boxer continue in their approach and preparation for competition?
      • Complete start with the return to sport continuum or a reversal of return to sport?
      • For these decisions, sufficiently clear, honest and pragmatic information is necessary and to be provided to everyone involved, especially around player safety parameters.

See information on player adherence here: Adherence to Rehabilitation in Sport

Objectivity in Goal Setting

• Gatt et al. reported that the Takei handheld dynamometer is an effective clinical outcome measure tool for hand and wrist function in boxing. For example, using the tool to provide information on the severity of a carpometacarpal (CMC) injury. This provides insight into decision-making and management of the injury. Read more about the results of this study here: Takei handheld dynamometer: An effective clinical outcome measure tool for hand and wrist function in boxing. or as summarised here: Injury Type and Classification in Sport - Structure vs Function.

• Feedback on an athlete’s performance levels provided by the strength and conditioning coach is also helpful and forms part of objectivity in goal setting and the return to sport continuum.
• Parry et al. showed that using performance tests to investigate the type of loading at the hand and wrist, as well as the upper limb in boxers, is a reliable measure of upper limb power performance.
  • These objective measures will be valuable when applying a stepwise rehabilitation approach within the return to sport continuum.
  • Read the complete article here: The test–retest reliability of bilateral and unilateral force plate–derived parameters of the countermovement push-up in elite boxers.

Surgical Considerations and Return to Sport

Following surgery, it is important to have a plan for management and return to sport. This can be done in different phases. These phases can vary depending on the type of injury and surgery and may include phases such as an immobility phase, an initial loading phase, progressive loading phases and full training phases. Strengthening is a key consideration, so that the injured structure is exposed to load, and having a good sequential approach with progressive loading is important.

Progressive Loading in Return to Sport

Gabbett et al. emphasise the importance of understanding the interplay between sport-specific and local tissue capacity.

Sport-specific capacity = “the athlete’s ability to perform (and withstand) the demands of training and competition”

Local tissue capacity = “a specific structure’s ability to withstand tissue-specific cumulative load”

The key points to remember when introducing progressing training loads are:

• Progressive loading using patient-reported feedback is best practice
• Include a session-RPE or visual analogue pain scale in combination with external loads to address local tissue loads and safe and efficient progression of exercises
• Effective programmes do use local tissue loading to maintain local tissue capacity
• Local tissue AND sport-specific loading are necessary to for an athlete’s safe and efficient return to sport

Read the complete article here: When progressing training loads, what are the considerations for healthy and injured athletes?

Watch this video from Tim Gabbett where he summarises this paper on loading considerations for healthy and injured athletes:

Return to Sport After Concussion

The Berlin Consensus statement on concussion in sport (2017) by McCrory et al. includes a graded return to sport (RTS) strategy. Table 2 is adapted from the Consensus statement.

Table 2: Graduated return to sport strategy after a concussion

Stage	Aim	Activity	Goal of each stage
1	Symptom-limited activity	ADLs that do not provoke symptoms	Gradual reintroduction of work/school activities
2	Light aerobic exercise	Walking Stationary cycling Slow to medium pace No resistance training	Increase heart rate
3	Sport-specific exercise	Running drills Skating drills No head impact activities allowed	Add movement
4	Non-contact training drills	More difficult and intense training drills Progressive resistance training can be commenced	Exercise, coordination and increased thinking
5	Full contact practice	Medical clearance necessary Participate in normal training activities	Restore confidence Assess functional skills by coaching staff
6	Return to sport	Normal game play

• Normal graduated return to sport can take between 10 -14 days, but this can be longer in athletes who experience prolonged symptoms
• An initial rest period (24 – 48 hours) is recommended
• After this, symptom limited activity can begin – athlete must stay below a cognitive and physical exacerbation threshold (stage 1)
• Athlete can proceed to the next level once concussion-related symptoms have resolved and if the athlete meets the required criteria (heart rate, activity, duration of exercise)
• Each step takes 24 hours and athletes would take a minimum of 1 week (7 days) to complete the full rehabilitation protocol, once they are symptom free at rest
• This timeframe may vary with player age, history, level of sport and individualised management is crucial
• It is possible that athletes may experience prolonged symptoms and each step in the rehabilitation protocol may therefore take longer than 24 hours
• Should an athlete experience any concussion-related symptoms during any stage of the rehabilitation protocol, the athlete should drop back to the previous asymptomatic stage and only attempt progression to the next stage after being concussion-related symptom free for a further 24 hour period at the lower stage

Read the full consensus statement here: Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.

See this infographic: Consensus Statement on Concussion in Sport - Graduated Return to Sport Strategy

Clinical Judgment in Return to Sport

• Clinical judgement is defined as: “the application of information based on actual observation of a patient combined with objective and subjective data that lead to a conclusion."
• There remains lacking and poor evidence for return to play and more research is necessary to inform change.
• Clinical judgement is devalued and undervalued. However, it remains the key decision-making process of when an athlete is ready to return to sport.
• Clinicians should be careful of diminishing “clinical judgement in place of poor scientifically validate investigations or tools.”
• “Treat the athlete, not the scan.”

Attributes of Clinical Judgement

Characteristic features of professional expertise are:

• Tacit knowledge (implicit knowledge)
  • Knowledge that is difficult to express and therefore more difficult to transfer to others either through writing it down or verbalising it
  • Includes personal wisdom, experience, insight, intuition

• Reflection in action
  • Relevant when a clinician is confronted with an uncertain situation or conflicting values
  • When dealing with issues for which direct guidelines or tacit knowledge are insufficient
  • Trying to find a solution through “reflective conversation with the situation”
  • Allows for the clinician to be open to discover new approaches and insight
  • Tacit understandings that have evolved around repetitive observations and guidelines are also challenged through reflection and can be applied as a corrective strategy to overlearning

• Gestalt cognition
  • “Assesses the wholeness of a pattern that is irreducible to its parts and conceivable independent from its particulars”
  • Gestalt cognition assesses patterns
  • Personal experience can change into Gestalt cognition and this in turn can be transformed into tacit knowledge and reflection in action
  • Gestalt cognition allows an expert to “swiftly interpret situations and to exhibit outstanding performances”

Seasoned or experienced clinicians have had many learning processes over time and can recognise certain patterns and interpret situations swiftly. However, clinicians need to be wary of not falling into a trap of assuming that the specific pattern that they are seeing is exactly that. Clinical judgement can be open to bias.

Read more here: Clinical judgement and the medical profession.

Return to Sport: Science or Art?

Batty highlights the following:

• Accept clinical judgement with return to sport decision-making – the decision is almost entirely clinical
• Scientific scrutiny and research are needed to support clinical judgement
• Clinicians associated with professional sports clubs are at risk of “employer bias”
• The clinician’s duty is first and foremost to the athlete. However, clinical judgement is open to error and mistakes can be made.
• The athlete should always be informed of any medical management and rehabilitation goals and should be actively involved in all decisions
• Read the recently published framework for clinicians to improve the decision-making process in return to sport here: A framework for clinicians to improve the decision-making process in return to sport.

Return to Sport = Athlete-Centred Approach

General Guidelines

• Define success with the athlete (and team)
• Micro and macro planning (objectivity and loading)
• Consider the return to sport continuum and return to sport reversal
• Consider the biopsychosocial model in relation to contextual effects and the multidisciplinary team
• Return to sport: science or art?
  • Perhaps a bit of both?
• Underlying science and knowledge are needed but it is also important to consider how the clinician as a person approaches situations (clinical judgement)
• Evidence-based practice is vital
• Ethos of the clinician – honesty, clarity and pragmatic in approaches

Resources

• The return-to-sport clearance continuum is a novel approach toward return to sport and performance for the professional Athlete.