After the occurence of a sports injury, the first question asked by the most athletes and coaches is "When can I (the athlete) compete again?". The answer to this question is rarely straightforward and is influenced by many factors. However, in most cases, the goals of the injured athlete and the medical team are the same - to facilitate a quick and safe RTS.
Definition of RTS
To make an informed RTS decision, the definition of each RTS process should, at minimum, align with the sport practiced and the level of participation to which the athlete intends to return (e.g., English Premier League or local recreational league, among others) (1).
Success of RTS
Success means different things to different people and depends on the context and outcome. For the athlete, sucess may be defined by a return to sustained participation in sports in the shortest time possible (goal-focused). For the coach (and also many athletes), sucess may be defined in relation to the athlete's performance in RTS (performance-focused). For the medical team, sucess may be defined by the prevention of new (or recurrent) associated injuries. The decision-making team should collaboratively decide how sucess will be defined (1).
Contextual Consideration
Contextual factors influence expectations and risk tolerance for RTS. This includes the type of injury or illness (e.g., acute vs chronic), athlete's age (or career stage), type of sport played, physical demand of the sport, level of participation, importance of future participation opportunities (e.g., Champions League Final or pre-season practice) and social and financial costs (1).
Progression and Documentation
RTS can be viewed as a continuum parallel to recovery and rehabilitation - not simply a decision made in isolation at the end of the recovery and rehabilitation process (1).
Documentation should incorporate (but not be limited to):
Definition of the sport
Relevant contextual factors
RTS goals
Performance in clinical and functional tests relevant to provide information that can be used to guide decision-making
Define and document the roles, responsabilities and actions of each member of the RTS decision-making team
In a RTS continuum, we define three elements, emphasizing a gradual, criterion-based progression that is applicable to any sport and aligned with RTS objectives.
Models to understand and guide the RTS process
Theoretical models can assist healthcare professionals in comprehending the myriad of factors that influence RTS outcomes and promote consistency and transparency in RTS decision-making. In this section, three models are described that can aid athletes and medical teams in planning, decision-making and transitioning through the RTS process.
Strategic Assessment of Risk and Risk Tolerance Framework (StARRT): Guiding RTS decision
The StARRT model (2) is a three-step model that helps estimate the risk of different short and long-term outcomes associated with RTS, considering factors that may affect what should be deemed an acceptable risk within a specific context.
Step 1 (Tissue Health - Assessment of health risk): Synthesizes relevant information regarding the stress that the tissue can withstand before injury.
Step 2 (Tissue loads - Assessment of activity risk): Synthesizes relevant information regarding the expected cumulative load (strain) on the tissue.
Step 3 (Risk tolerance modifiers - Assessment of risk tolerance): Synthesizes information relevant to contextual factors that influence the RTS decision-maker's tolerance to risk.
Biopsychosocial Model - Adressing Athlete's Best Interests
In the context of sports injury, the clinical team should provide all RTS participants with a framework to consider the biological, psychological and social factors that may influence tratment and outcomes after a sport injury and may be important in the RTS decision-making (1).
Optimal loading - The Goldilocks Approach
Optimal loading, often referred to as "The Goldilocks Approach", is a crucial aspect of rehabilitation and RTS decision-making. Achieving and maintaining the ideal load (3) are important clinical considerations. Monitoring training load during the current training week (chronic) provides an acute-to-chronic workload ratio (4).
This ratio can be a valuable tool in planning load progressions in RTS, especially when the athlete is transitioning from return to participation to RTS and from RTS to return to performance on the RTS continuum.
Condidering the biological, psychilogical and social factors that influence the decision and transition of RTS can assist the clinical team in contributing to shared RTS decision-making.
Assessment of Readiness for RTS
Most functional testing procedures are based on "closed" skills (e.g., single hop or triple hop, T-test, among others), but sports also require "open" skills. The latter involve a reactive element to perform the motor task, often in a fatigued state. Therefore, relying solely on closed tasks to determine readiness for RTS is not ideal.
The gradual and sequential introduction of sport-specific training can be used as functional tests that include a reactive decision-making element (5 - 7).
Historically, physical tests receive more attention in RTS decisions, but psychological readiness is also a crucial element for optimal RTS. Emotions, including fear of re-injury, and cognitive factors, such as self-efficacy and motivation, influence RTS (8 - 11).
Control-chaos Continuum
An early reintegration into training and competition following an injury increases the risk of injury recurrence. However, having key players available for competition benefits the team. Medical departments must balance these two components in the RTS process, combining evidence with clinical experience to estimate the risk and adapt the RTS plan (12).
As physiotherapists, we should focus on both the quantitative aspects of the running load progression and the qualitative characteristics of the movements required in competition. This includes high variability, spontaneity and anticipation of movements (the "chaos" condition), reflecting the natural unpredictability of sports (13).
Taberner et al. (13) propose a "control-chaos continuum" that links GPS variables while progressively incorporating more challenging neurocognitive, perceptual and reactive demands (14, 15). This framework moves from high control to high chaos (13).
Bibliographic References
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10. Brazier J, et al. Lower extremity stiffness: considerations for testing, performance enhancement, and injury risk. J Strength Cond Res. 2019;33(4):1156–66.
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12. van der Horst N, Backx F, Goedhart EA, Huisstede BM; HIPS-Delphi Group. Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making. Br J Sports Med. 2017 Nov;51(22):1583-1591.
13. Taberner M, Allen T, Cohen DD. Progressing rehabilitation after injury: consider the ‘control-chaos continuum’. British Journal of Sports Medicine 2019;53:1132-1136.
14. Taberner M, Cohen DD. Physical preparation of the football player with an intramuscular hamstring tendon tear: clinical perspective with video demonstrations. Br J Sports Med 2018;52:1275–8.
15. Grooms DR, Myer GD. Upgraded hardware─What about the software? Brain updates for return to play following ACL reconstruction. Br J Sports Med 2017;51:418–9.
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