Planning for Return to Play After Time-Loss Injury

When a student-athlete sustains an injury that results in lost time from sport participation, it is frustrating for all involved including the athlete, their parents, their coach and many others. The student-athlete spends a large amount of time preparing for the competitive sport season and, naturally, has high hopes for success.

Student-athletes prepare for their season in phases, ramping up over time to peak conditioning. Following injury, this process must be replicated as ignoring or speeding through re-conditioning can place the student-athlete at risk for re-injury, overuse conditions and adversely affect performance. In the unfortunate case of a student-athlete having a time-loss injury upon return to full activity, the athlete may be re-entering participation in the competition phase and engaging with athletes who have not been injured and are at their full abilities. Returning athletes must be able to protect themselves at that level.

The first component of return to play is obtaining medical clearance, which is different from the preseason physical exam. A pre-participation physical is completed and readiness to participate is determined when a student is healthy. Once an injury occurs, clearance must be granted by a qualified medical practitioner, as determined by local statute, the respective state high school association or the local school district. Not all health professionals are qualified to make return-to-play determination. Physicians (MDs, DOs), physician assistants, nurse practitioners and athletic trainers can grant return to play in most instances. Key factors of post-injury medical clearance:

• Once a student seeks care from a physician, ideally clearance must be granted by the same physician.

• Clearance should be in writing, referring to the injury, and specifying a return to competitive sports.

• It should be clear that the person providing clearance is aware of the injury history. Ideally, the health-care provider (HCP) that medically disqualified the athlete should be the one who clears the athlete.

• If any limitations are indicated, they must be followed. This may include protective padding or bracing.

Medical clearance following an injury should be taken as a starting point for the return-to-play process, not readiness for immediate full re-entry.

If the school has athletic training services, and the staff athletic trainer can coordinate supervised rehabilitation, that is how the return to play should be handled. If an athletic trainer is not available, then communication with the HCP from the time of injury is critical, and the HCP should provide guidance throughout the process. Engaging the student in rehabilitation exercises under the direction of the athletic trainer or HCP can reduce conditioning losses and speed the return to full participation. Staying active supports the athlete’s mental health, motivation, cardiovascular conditioning and endurance efforts. Appropriate goals for the athlete’s limitations can and should be incorporated.

Once the athlete is allowed to begin the return to play, activity should be ramped up as tolerated. Successful completion of each step increases the chances of success in the next step. If the student- athlete has pain, swelling, stiffness or loss of function, these are some signs that indicate the need to slow down in the process and the athlete is not physically ready to resume full activity. It is important to begin with simple exercises and progress to more complex activities so that the athlete can build up strength and stamina as well as being assured mentally of full recovery.

Initial efforts in the return-to-play process should focus on range of motion through stretching. It is important the athlete understands that overstretching can lead to muscle strains and a setback in recovery. The next phase in the process is the rebuilding of strength, and attention to the core should accompany site-specific exercises. A strong core supports limb strength and helps protect the athlete from reinjury. Flexibility and strength are key components of performance and resistance to injury. Neither should be forced beyond the athlete’s limits, and the goal is to achieve symmetry with the non-involved side. It also should be noted that there is not a specific amount of time that a student-athlete should spend in each phase. The athletic trainer or HCP should use judgment and progress the athlete when they believe the athlete is ready for the next phase.

The next phase in the process is balance and sport-specific training. Activities that allow the athlete to control the body during movement support a successful return to full participation. The body’s sensors that allow athletes to know where they are in space must be retrained. This is also called proprioception. These activities allow athletes to develop confidence and trust in their ability to do what they need to do to play their chosen sport. It is important to start with controlled movements and progress to full-speed complex movements.

It is also important to remember that conditioning and endurance training should be infused throughout all phases. The return-to-play process should complement the rehabilitation process and match the re-entry point. An athlete who is under-conditioned but trying to keep up with teammates is at risk of re-injury and will not perform as well as desired. It is important to remember that any pain and swelling that the student-athlete has are indicators that the process may be moving too fast.

Competition readiness can be assessed during practice. Game day is not the time to test the success of the rehabilitation process. The student-athlete should go into the game knowing that he or she is fully recovered and can perform at the necessary level to be successful as well as not become re-injured. If the athlete is participating in practice without regression, then the student can return to full activity and game play. Once all efforts to prevent a recurrence have been made, the athlete has regained confidence, and now it is GAME DAY.