Return to Play: Who Makes the Decision?

By Brian Robinson, MS, ATC on March 16, 2016 hst Print

Recently, the NCAA ruled that athletic trainers and team physicians should have the final decision with regard to medical management and return-to-play (RTP) decisions related to student-athletes following injury or illness. This ruling governing NCAA member schools specifies that a coach cannot dismiss or override the decisions of the team physician or athletic trainer. It also creates a foundation of administrative structure within the athletic department where the sports medicine program is free from the influence of the coach, thus protecting the student-athlete and the athletic health-care provider when making RTP decisions.

At the high school level, conflicts arise among coaches, parents, students and health-care providers as to the readiness of a student-athlete to return to activity. Since most of these students are minors, the decision regarding their readiness to return to play lies in the hands of many individuals.

It is quite common that five or more individuals will have a role in this decision-making process. Obviously, the parents of the student-athlete play a key role. The student-athlete’s personal physician and team physician, if available, share responsibility for this decision. The athletic trainer, if one is employed by the school, has an integral part to play as well. The coach obviously wants the player back as quickly as possible if he or she is healthy. And, finally, the player certainly has a role in the RTP decision.

The responsibility for risk minimization within the interscholastic athletic program can be influenced by many individuals, situations and protocols. So, who should have the final say when it comes to RTP decisions?

There was a time when athletic directors would support a coach over the opinions of the athletic trainer or team physician because “the coach knew the player better” than either the athletic trainer or team physician since the coach had daily contact with that player. There was a belief that the coach was in a better position to judge the abilities of the player to “safely” participate based on this daily contact.

Obviously, high school administrators now understand the error in allowing non-medically qualified personnel to make medical RTP decisions. By allowing non-medical personnel to make medical decisions, schools were unintentionally exposing themselves to a legal quagmire.

Certainly parents want the best for their children. There are many emotional and sometimes financial components such as a scholarship that influence their viewpoints when it pertains to high school athletics. Quite often, however, parents may not understand the severity of the injury or the potential consequences of continuing to play or returning to activity before sufficient healing of the injury or illness occurs. On the other hand, a parent may be reluctant to allow his or her child to resume activity for fear of further injury despite assurances from health-care professionals that such risk is minimal.

Coaches are in a tenuous position. They may be caught between wanting the athlete to return to activity for many reasons, including the leadership role the player may fill, the fact that the player thrives within this activity or the success of the team and wanting to be sure that any resumption of activity will not lead to further injury. Coaches are in an excellent position to aid in the RTP decision by evaluating the ability of the returning player to execute the movements and skills necessary to not only be successful but to reduce further incidents of injury.

In most cases, the student-athlete is eager to return to the activity but most have questions as to whether they can compete at their previous performance level. It is not uncommon to hear the following questions: “What are the chances of this happening again?” or “Will I be able to run, jump, hit or swing without it hurting?”

It is important that the student-athlete takes an active role in the RTP decision, being allowed to voice opinions as well as to have questions answered. The student-athlete’s fears and desires must also be taken into consideration. It should be noted that the “warrior mentality” of many student-athletes may influence them to “suck it up,” masking their symptoms or compensations for fear of disappointing or letting down their teammates, coaches or parents.

The health-care team comprised of the personal physician, team physician and athletic trainer must openly communicate during the recovery process not only with each other but with all the individuals involved in the decision. The athletic trainer is in the position to test the quality of functional movement exhibited by the athlete not only to return successfully but with minimal risk of further injury.

In the November 2015 issue of High School Today, James A. Onate, Ph.D., ATC, and John Black, J.D. discuss many of the legal issues to consider including the duties and professional responsibilities of the “appropriate health-care professionals.” The authors also discuss the risk vs. reward aspects of the decision process. It is important that the health-care team document all clinical as well as functional evaluations related to the recovery and readiness of the student.

Administrators should develop a protocol that not only includes but encourages open communication among all the individuals involved in the process. If any individual involved in the RTP decision process does not believe the student is ready to return to activity, the athlete should be withheld until additional recovery has been accommodated. If the health-care team does not believe the student-athlete can return without risk of further injury or re-injury, then the student-athlete should continue treatment. The same can be said for the parent, even if the health-care team is confident that the student is healthy enough to return. Based on the ability of the player to execute the skills needed to return successfully and with minimal risk, the coach may decide that the player has not recovered adequately to contribute to the success of the team.

Lastly and possibly most importantly, what is the opinion of the student-athlete? There are many factors – physical and emotional – that students face when preparing to return to their activity. Despite the positive opinions of all those individuals mentioned previously, if the student-athlete does not feel adequately prepared to return to play, that opinion must be respected by all.

On examining the role of each of the individuals involved in the RTP decision process, it is important to keep the overriding commonality first and foremost: the ultimate health and safety of the student-athlete.