Clinical Decision Making on Returning to Sport
Clinical Concepts
- Make progressions criteria-based rather than time-based
- Understand the nature of the sport
- Ask the right questions to gauge how important a quick return to sport is for the patient
- Be able to explain risks and benefits of early return to sport
Understanding The Big Question
As an outpatient orthopedic physical therapist in a sports setting, perhaps the most common question I get from athletes is, “When will I be able to play again.” No matter what the injury is, every athlete wants to know when they will be able to get back to doing what they love, their sport. When working with athletes, it is of utmost importance to be able to relate to them and understand what they are going through. An injury that pulls an athlete out of the game has a major impact on psychological well-being. For many athletes, their sport is a huge part of their life that has now been halted because of injury. The clinician needs to have a solid understanding of the psychological factors associated with athletic injuries in order to provide psychological support in addition to physical care.
Understanding how to safely progress athletes through rehab phases will help you in answering the big question regarding return to sport. In physical therapy school, you were exposed to many rehab protocols that had time-based progressions. These were developed based on tissue healing rates and they are great tools to understand general progression guidelines. However, there is no “one size fits all approach” in the real world. You can have two patients come in with the exact same post-operative diagnosis but they will most likely recover at different rates. Perhaps one patient will be ready to begin double-leg plyometrics two weeks before the other patient. There are many factors that influence the recovery process and it’s important that you understand how to safely progress your patients with criteria-based protocols rather than time-based protocols.
Rehab progressions should always be criteria-based instead of time-based. One exception to this rule is regarding immediate post-operative tissue. There is plenty of evidence regarding tissue healing rates that supports time-based progressions after certain orthopedic procedures. However, even in these cases after the initial 4-6 weeks of healing, progressions should be based on criteria rather than time. For example, the athlete recovering from ACL surgery wants to know when they can run. The answer to this question should never be a timeline. Instead, the answer should be based on criteria. “You can begin jogging once you can successfully perform x, y, and z.” This type of answer will save you as the clinician from giving your patient false hope. If you tell the athlete they can run at 6 months post-op but when that time comes they still have a 30% quad strength deficit from involved to uninvolved leg, they are going to be upset with you that they can’t run yet. The last thing you want as a clinician is to explain to the patient that you underestimated their recovery time. Using criteria-based progressions will help you from encountering that situation.
Examples of Criteria-based Progressions
- Transition to squats on uneven surface after patient can successfully perform 10 mini-squats on firm surface with good postural control
- Transition to double leg plyometrics on ground once patient can demonstrate good landing mechanics on leg press in gravity-reduced position
- Transition from double leg plyometrics to single leg plyometrics once patient can maintain good form with 10 repetitions of drop jumps onto 12″ box
- Transition to jogging once patient demonstrates 90% 1RM leg press on involved leg compared to uninvolved
Here is a great article from JOSPT outlining a criteria-based progression for patients after ACL reconstruction.
These are all simply examples of criteria based progressions and are by no means meant to be all-inclusive. Using criteria-based progressions provides the athlete with short term goals and milestones to reach. This will provide them with positive reinforcement and confidence in their own ability. When it comes to answering the big question, you must consider a criteria-based approach. Return to sport decision making is multifaceted and should take into account many different factors. Things that need to be considered include the nature of injury, extent of injury, tissue healing process, timeline of season, timeline of athletic career, and so on. Hopefully as a healthcare practitioner, you understand the physiological factors mentioned such as tissue healing and extent of injury. Let’s discuss the sport-related factors in a bit more detail.
Understand the Nature of the Sport
You can’t confidently release a patient back to sport unless you understand the demands of the sport. What position does the athlete play? A football defensive back with an elbow injury could be released to play sooner than a quarterback with the same injury. As the clinician, you need to gather the details of what the athlete does during their sport and the specific movements they need to be able to perform in order to succeed.
What It All Comes Down To
The patient’s goals. How much does it mean to the patient to get back to sport. What competition level are they playing at? Is it pre-season, mid-season, or playoffs? Are they a freshman in high school or a senior? All of these questions should influence your decision making process. If the athlete is in a recreational soccer league, perhaps you can take a more conservative approach and discuss the importance of sitting out for longer in order to ensure full tissue healing and decreased risk of further injury. If the patient is a high school senior in playoffs with hopes to be recruited for a college team, you are going to have to be a bit more aggressive with your rehab approach and discuss the risk/benefit analysis with the patient. If the athlete has a grade II ankle sprain with 4 weeks left in the regular season, perhaps you need to discuss the benefits of sitting out for the remainder of the season in order to be ready to play in the playoffs. These are the types of decisions you need to make when working with athletes.
Please be sure to ask your patients enough questions about their sport in order to understand exactly what they need to be able to do. Once you’ve gathered that information, come up with several criteria-based milestones for the patient to achieve in order to progress to the next phase. This approach will ensure you are meeting important rehab milestones and help the patient understand what they need to achieve in order to get back to playing.
If you have any questions about return to sport after a specific injury or would like some more examples of criteria-based progressions I use in the clinic with different athletes, feel free to contact me!