Return to Sport

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Introduction

What Does Return to Sport Mean?

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. 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. British journal of sports medicine. 2016 Jul 1;50(14):853-64.

Link to full article: https://bjsm.bmj.com/content/bjsports/50/14/853.full.pdf

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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

All of this however 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 is necessary to provide insight into an athlete’s performance levels. Ian Gatt reference

Climb every 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. Della Villa S, Boldrini L, Ricci M, Danelon F, Snyder-Mackler L, Nanni G, Roi GS. Clinical outcomes and return-to-sports participation of 50 soccer players after anterior cruciate ligament reconstruction through a sport-specific rehabilitation protocol. Sports health. 2012 Jan;4(1):17-24. Please check with Ian if this is the correct article that he refers to. Add image created by Lenie

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. (Ian Gatt)

Contextual Effects to Consider in Return to Sport

Link to Creighton et al: https://journals.lww.com/cjsportsmed/FullText/2010/09000/Return_to_Play_in_Sport__A_Decision_based_Model.12.aspx

Creighton et al developed a 3-step decision-based return to play model – this was specifically aimed at individual clinicians having to make return to sport decisions. Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO. Return-to-play in sport: a decision-based model. Clinical Journal of Sport Medicine. 2010 Sep 1;20(5):379-85. 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 test

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 and take note of figure 1 showing the decision-making model for return to play using an influence diagram: https://journals.lww.com/cjsportsmed/FullText/2010/09000/Return_to_Play_in_Sport__A_Decision_based_Model.12.aspx

Optimising Return to Sport

Truong et al [Truong LK, Mosewich AD, Holt CJ, Le CY, Miciak M, Whittaker JL. Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review. British Journal of Sports Medicine. 2020 Oct 1;54(19):1149-56.] 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-centred 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. (ref)

Read the full article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7513260/pdf/bjsports-2019-101206.pdf

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 for athletes success may be: Ardern et al 2016

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.(Ardern et al, 2016)

Multidisciplinary Team and Return to Sport

Feigenbaum et al [Feigenbaum LA, Kaplan LD, Musto T, Gaunaurd IA, Gailey RS, Kelley WP, Alemi TJ, Espinosa B, Mandler E, Scavo VA, West DC. A multidisciplinary approach to the rehabilitation of a collegiate football player following ankle fracture: a case report. International journal of sports physical therapy. 2016 Jun;11(3):436.] reports on a case where the multidisciplinary team consisted out of the physiotherapist and the nutrionist. With the application the meaning of success in this athlete’s case can be summarised as follow:

Performance focus success

Athlete recovered and returned to his sport and playing position and subsequently was drafted by a 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: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886811/pdf/ijspt-11-436.pdf

Roberts et al [King J, Roberts C, Hard S, Ardern CL. Want to improve return to sport outcomes following injury? Empower, engage, provide feedback and be transparent: 4 habits!. British journal of sports medicine. 2019 May 1;53(9):526-7.] advocates 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: Gledhill A, Forsdyke D, Goom T, Podlog LW. Educate, involve and collaborate: three strategies for clinicians to empower athletes during return to sport. British Journal of Sports Medicine. 2022 Mar 1;56(5):241-2.

Educate the athlete about the injury and return to sport protocols

Involve athlete in rehabilitation and return to sport decisions

Adopt collaborative, non-controlling forms of communication and interaction

Read the complete article here: https://eprints.leedsbeckett.ac.uk/id/eprint/7929/1/EducateInvolveAndCollaborateThreeStrategiesForCliniciansToEmpowerAthletesDuringReturnToSportAM-GLEDHILL.pdf

Engagement – allow athletes to contribute to the planning of their return to sport plan

Provide Feedback – regularly between MDT

Transparency – frequent and honest communication between athlete and MDT

Return to Sport versus Removal from Sport

Situations arise when a “return to sport decision may be reversed to a removal from sport decision.” (Ardern et al)

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 focus 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 CMC injury:

Can boxer continue in approach and preparation for competition?

Complete start with the return to sport continuum or a reversal of return to sport

For these decisions sufficient clear, honest and pragmatic information is necessary and to be provided to everyone involved, especially around player safety parameters.

See info on player adherence here: Rehabilitation in Sport

Objectivity in Goal Setting

Gatt et al Gatt I, Smith-Moore S, Steggles C, Loosemore M. The Takei handheld dynamometer: An effective clinical outcome measure tool for hand and wrist function in boxing. Hand. 2018 May;13(3):319-24.] 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 an CMC injury. This provides insight into decision-making and management of the injury.

The 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. (Ian Gatt, course)

Parry et al [Parry GN, Herrington LC, Horsley IG, Gatt I. The test–retest reliability of bilateral and unilateral force plate–derived parameters of the countermovement push-up in elite boxers. Journal of Sport Rehabilitation. 2021 Feb 24;1(aop):1-5.] 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. (Gatt)

Read the article here: https://www.researchgate.net/publication/349573876_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. (Gatt)

Progressive loading

Gabbett et al [Gabbett T, Sancho I, Dingenen B, Willy RW. When progressing training loads, what are the considerations for healthy and injured athletes?. British Journal of Sports Medicine. 2021 Sep 1;55(17):947-8.] emphasises 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 progressing training loads are: Gabbett et al

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 programs 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: https://www.researchgate.net/publication/350775020_When_progressing_training_loads_what_are_the_considerations_for_healthy_and_injured_athletes

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

https://www.youtube.com/watch?v=Xkfi42NuXXM RESEARCH VLOG #1: Progressing training loads in healthy and injured athletes

Return to Sport After Concussion

The Berlin Consensus statement on concussion in sport (2017) by McCrory et al. [McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, Cantu RC, Cassidy D, Echemendia RJ, Castellani RJ, Davis GA. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine. 2017 Jun 1;51(11):838-47.] includes a graded return to sport (RTS) strategy.

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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 (7days) to complete the full rehabilitation protocol, once they are symptom free at rest. T

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: https://bjsm.bmj.com/content/bjsports/early/2017/04/28/bjsports-2017-097699.full.pdf

Add video: https://www.youtube.com/watch?v=sPyMv-LLZy4

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