When is an Athlete Ready to Return to Play? (Care of the Young Athlete)

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One of the first questions an athlete will ask
following injury or illness is, “When can I play again?” The
answer is rarely quick or simple. Return-to-play decisions can be controversial
and a source of conflict between health care providers and others.
Return-to-play decisions that are too strict, too lenient, or too arbitrary can
lead to unhealthy and unsatisfactory outcomes.

For some medical conditions and some sports, there
are specific policies in place that help guide return-to-play decisions.
However, most return-to-play decisions involve unique circumstances that cannot
be fully addressed by generic statements.

The following is information from the American
Academy of Pediatrics (AAP) providing guidance on when an athlete can return to
play after an injury and can be used in situations where general guidance is not
sufficient. The answers to many of these questions require input from a doctor.
However, understanding the process helps athletes and families work with their
doctor in return-to-play decisions and better understand the reasons behind
return-to-play decisions.

Question Explanation or Comment
1. What is the diagnosis? An accurate diagnosis is crucial in addressing the cause of the
symptoms, the best treatment options, time frame for recovery,
and expected level of recovery. General labels such as
“knee sprain” or “back spasm” do not
provide enough information to make a treatment plan or determine
how long recovery will take.
2. How does the condition affect performance? Will the condition get in the way of the athlete’s
ability to practice and play the sport? For example, does the
condition adversely affect endurance, flexibility, strength, or
coordination?
3. What is the risk of the condition getting worse from
playing?
Injuries occur to vulnerable structures. As a result of injury,
the injured structure may become even more vulnerable. If an
athlete returns to play before a full recovery, the injury will
predictably get worse. Mild sprains can become severe sprains. A
stress fracture can become a complete fracture. A mild
concussion can increase the risk of a second brain injury or
even death.
4. What is the risk of secondary injury? When athletes favor or try to protect an injured area, they may
expose other body parts to injury and become
“secondarily” injured. If an injured football
player can’t execute a block properly, his teammates may
become secondarily injured. Secondary injuries can also occur if
there is a communicable disease that can spread through contact
with other teammates or competitors.
5. What has been the effect of treatment? Is there treatment available for the condition? Has treatment
been carried out? How effective is the treatment? Are there any
negative effects of treatment? Has the treatment been completed?
Have the deficits from injury/illness been restored?
6. Can the sport or level of participation be modified to be
safer?
Can the athlete temporarily play another position or cut back on
specific activities without jeopardizing recovery? Can the hours
of practice or number of teams be reduced during recovery? Can
the technique or equipment used for the sport be modified to
allow the athlete to continue to play?
7. Are there published guidelines that address the
return-to-play decision?
The AAP publishes guidelines that address many playability
issues (www.aap.org/sections/sportsmedicine/policy.htm).
Because the guidelines may be incomplete, controversial, or
unclear as they pertain to your specific return-to-play
question, talking with your doctor is an important element of
fully understanding the implications of published guidelines on
your return-to-play decision.
8. Is there a disproportionately high risk for further
injury?
All sports have some risk of injury. The risk is higher for
contact and collision sports. Serious and long-term injury can
also occur from noncontact and endurance sports. These risks
should be understood and accepted by the athlete and family
before playing any sport. However, if injury or illness
increases the risk even more, it may be ill advised to play.
When the risk for further injury is disproportionately high,
doctors have a responsibility to identify these situations and
recommend changes or restrictions of participation.
9. Is there informed consent? Playing sports may seem to have nothing in common with
scheduling a surgical procedure, but both activities require
informed consent. The previous questions help define the risk of
further injury or other complications associated with return to
play. In some cases, the true risk is not known. In other cases,
the risk is elevated or unacceptable. Whatever the case, return
to play should not take place until all risks are understood and
considered to be acceptable by the athlete, family, and
doctor.
10. Does the athlete want to play? Most young athletes who enjoy sports want to return after an
injury or illness. If athletes do not want to return, they
should not be cleared to participate. There are a variety of
reasons why an athlete may not want to return to play. It may be
fear of further injury; concern that their injury does not allow
them to play as well; loss of interest; burnout; or pressure by
coaches, parents, or others. Whatever the reason, athletes who
do not want to play should not be pressured to
return—even if the injury has resolved.