New guidance on making complex decisions about injured athlete's return to play

When is it appropriate for an injured athlete to return to competition? A new three-step framework provides team physicians and other sport medicine clinicians with guidance on making complex decisions about return to play, reported in the September Clinical Journal of Sport Medicine. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, and pharmacy.

The decision-based model "helps clarify the processes that clinicians use consciously and subconsciously when making return-to-play decisions," the researchers write. A panel of U.S. and Canadian sport medicine clinicians and researchers developed the model, based on a synthesis of previous literature. The lead author was David W. Creighton, M.S., of Stanford University School of Medicine.

Model Provides Structured Framework for Return-to-Play Decisions
The model seeks to define the many factors that can affect decisions regarding return to competition after athletic injuries. The three-step process begins with Evaluation of Health Status: how much healing has occurred and how close to "normal" the injured tissue is. The evaluation includes not only medical factors like symptoms, range of motion, or x-rays, but also the athlete's psychological state—his or her "readiness" or "confidence" to return to play. The potential seriousness of the injury is another factor. "The evaluation of health status is very different for a concussion versus an ankle sprain," the authors write.

The next step is Evaluation of Participation Risk—the risk that the athlete will be injured again if he or she returns to play too soon. Previous injury is associated with up to a 4-fold increase in the risk of reinjury. The type of sport is one key factor—contact sports like basketball carry a higher risk of acute injuries, yet athletes in noncontact sports like running have the potential for disabling overuse injuries. Other factors may include the position played, the level of competition, and the ability to protect the injury.

The third and most complex step is Decision Modification. It calls to attention the many and varied situations and circumstances that may affect the final decision on return-to-play. For example, decisions may be different if the injury occurs in the preseason before a playoff game. The athlete's desire to compete may place pressure on the physician, while coaches, the athlete's family, and even sponsors or the media may be sources of external pressure.

"Potential conflicts of interest arise when the team's best interests and the athletes' best interests are not aligned," the researchers write.

Despite its central importance in sport medicine, there is little scientific evidence to guide the process of making return-to-play decisions. The authors hope their proposed model will provide "structure and transparency" in making these often-complex decisions. They emphasize the need for more research to clarify each of the three steps in the process. Ultimately, they hope the model will lead address the need for "evidence-based rationales for return-to-play decision making."

In an accompanying editorial, Dr. Ian Shrier of McGill University, Montreal, and colleagues give a clinical perspective on the "social context" of return-to-play decision making. They believe the new model can provide a much-needed formal structure and process to minimize potential conflicts between the physician, coach, athletes, and others involved. "Given that return-to-play decisions represent a fundamental element of sport medicine practice," the authors conclude, "it is time that we learn more about how, when where, why, and by whom these decisions are made in different sport settings and how such processes can be improved."