When is an Athlete Ready to Return to Action After an Injury?

Returning to Competition

One of the more difficult problems that the performance team faces is determining when an athlete is ready to return to action after injury. The athlete can be placed under enormous pressure from the owner, coach, fans and media to get out on the track, field or floor in record time. It is vital that we remove the guesswork, because if we get it wrong, the athlete may be spending even longer on the treatment couch. Although we cannot perfectly guarantee that an injury will not recur when the player steps out onto the pitch, there are a number of factors that, if taken into consideration when determining return to competition (RTC), can help determine whether the risk of playing is acceptable.

We can divide the assessment criteria into physiological and functional categories. Physiological assessment examines the health of the athlete and the state of repair of the injury. It looks to determine the safety of the athlete. Functional assessment examines the ability of the athlete to perform the tasks demanded by the sport. This assessment seeks to determine the answers to the following questions.

Is the Athlete Fit to Play?

The foremost consideration must be the health of the athlete. In other words, is the state of the injury sufficiently healed and stable that allowing the athlete to return to action is safe? This can be a tricky minefield because it is often a grey area. If the athlete is obviously not ready, this decision usually is self-evident. It is helpful to have a clear understanding about the grounds on which this decision is to be made, so that guesswork is removed, and the decision can be communicated effectively and with authority to the coaching staff.

Pain is an obvious variable to be considered. Clearly, if the athlete is in significant distress, he or she is unlikely to be in a sound state of mind or body to perform. The absence of pain does not equal the absence of a problem; this is where assessment of the state of the injury on grounds of pain alone is always problematic. Sometimes pain (or, indeed, lack of pain) is not a good indicator of the state of repair of an injury. In some instances, the athlete may feel better than he or she actually is. For example, most people are not in pain 3 months after an anterior cruciate ligament reconstruction, yet in most instances the state of repair is not mature enough to consider a return to the playing field. To be able to answer these physiological questions with any degree of confidence, we must know healing and recovery times for the various tissues that may have been affected by the original injury. This is where a team approach with careful guidance from and communication with the medical team is critical.

Several other aspects need to be assessed, including local muscular function; ligament laxity; muscular strength, power and endurance; joint range of motion (ROM); and bony healing. The question is what is the best way to judge these parameters? Ideally, we would have an idea of what the athlete was like before the injury. We must also place a greater value on the functional use of the injured tissue rather than any one isolated muscular strength test.

Has the Athlete Returned to Baseline Measures?

The aim of rehabilitation is to return an athlete to a level of physical health and functional performance equal to or even exceeding the preinjury status. To determine whether the athlete has returned to this level, a full assessment of the injury, the kinetic chain and the entire person is required. The aim of assessing every aspect of an athlete is unrealistic, though, and is not supported by research. The field of tests that could be applied is too vast, many of which would be irrelevant to the athlete being tested. A strategic approach is required, one that relies on the gathering of intelligence as a method of sifting through all the possible things that could go wrong in order to hone in on those things that are most likely to.

The variables of interest depend on the nature of the injury and the nature of the sport. The screening tool should seek to examine the integrity of

• the injured structure;
• structures identified as commonly injured in the particular sport (e.g., the injuries seen in ice hockey are markedly different to those seen in triathlon, so it is vital to understand the sport and the risk profile associated with it); and
• structures identified as high risk according to the risk profile of the individual, based on age, past history and gender.

Commonly employed tests include isolated or multijoint ROM, localised tests of muscular strength and capacity and functional tests of kinetic chain capacity. In the case of an injury to a limb, a comparison to the noninjured side is made, but this is only appropriate when we are confident that we have a noninjured side to act as a control and when the musculoskeletal parameters in question are normally symmetrical. It is infinitely better to have a tool with which we can compare the athlete before and after injury, which provides a cogent argument for the employment of musculoskeletal screening.

Does the Athlete Have to Be 100 Per Cent Fit?

Those working in professional sport will testify to the fact that it is often unrealistic to expect each athlete to be perfectly fit for every event or game. There is a level of acceptance that, even though the athlete may not be 100 per cent fit, he or she may be fit enough to play. This decision needs to be made by the medical staff in conjunction with the athlete. At all times, we must keep the athlete's best interests in mind and weigh up short-term gain versus long-term health. We need to be especially careful when we are trying to get an athlete back to competition before full recovery.

The decision about when an athlete returns to action ultimately is determined by the athlete. Members of the coaching and support teams must fully inform the athlete about his or her state of health. All athletes have the right to make up their own minds, but they should be fully informed of the risks of playing when, in our judgment, they may not be fit enough to do so. There are several reported cases of legal proceedings brought against healthcare professionals by athletes who have aggravated an injury or been permanently disabled after an early RTC when the athlete claimed he or she was not fully informed of the risks. Indeed, it may be advisable to ask the athlete sign a document stating that he or she has been fully informed of the risks of a return to play and that the athlete is playing against medical advice.

Is the Athlete Fit to Perform?

There is a significant distinction to make between the terms fit to play and fit to perform. Medical clearance to return to elite sport (fit to play) that exists in isolation without consideration of the athlete's function and overall performance status (fit to perform) is flawed and risks injury recurrence or poor performance. We must ensure that returning athletes are optimally conditioned to perform in the sport. Hence, an RTC decision must not be based solely on healing parameters but on functional ones as well.

Functional assessment of an athlete seeks to determine whether he or she will be able to perform tasks effectively and safely on the track or pitch. It is much more difficult for this to be a black-and-white assessment because so much is determined by the exact nature of the sport, the position played and the level of competition. This assessment should be carefully designed to specifically test every component of the game or event and should look to stress the injury site to determine if it is robust enough to withstand the rigours of competition. Muscular injuries are more likely to occur when muscles are fatigued, and thus if we want to be thorough, we need to test the athlete's strength and function under fatigue.

Several tests have been validated as ways of providing objective measures of functional performance. In order to have a complete picture of an athlete's physical preparedness, we should examine recovery from a number of physiological and functional standpoints. It is impossible to provide an exhaustive list of all the tests that could be employed, and much will depend on both the injury and the demands of the sport, but table 7.2 provides some examples.

Some of the tests described in table 7.2 require equipment or technology not available to all coaches or therapists. There are other ways of determining fitness to perform. Look more at qualitative measures such as those listed in table 7.3. This list is by no means exhaustive, and there will be other factors that should be assessed, depending on the demands of the sport. The type of sport that the athlete is returning to makes a difference when assessing risk of reinjury. It may be possible to get a taekwondo fighter back to competition after a shoulder injury earlier than a rugby player, for example, due to the reduced demand on arm function in this form of martial art. This is where a knowledge of the sport is necessary, or at least, effective communication with the player or coach.

Ideally, the athlete should be able to demonstrate all the factors outlined in the fit-to-play column with none from the unfit-to-play column. Where possible, one or more members of the performance team should witness training in the competitive environment to determine proficiency in these functional tasks.

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