Clinical Journal of Sport Medicine:
Return-to-Play in Sport: A Decision-based Model
Creighton, David W MS*; Shrier, Ian MD, PhD†; Shultz, Rebecca PhD*; Meeuwisse, Willem H MD, PhD‡; Matheson, Gordon O MD, PhD*
From the *Division of Sports Medicine, Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California; †Centre for Clinical Epidemiology and Community Studies, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; and ‡Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.
Submitted for publication May 10, 2010; accepted July 22, 2010.
The authors report no conflicts of interest.
This publication represents work done by members of RAISEM (Research Alliance in Sport and Exercise Medicine). RAISEM undertakes group research projects on sport injury prevention, clinical treatment, and return to play. The members of the group include clinicians, content experts, epidemiologists, biomechanists, and physiologists, with associated members collaborating on specific projects.
Reprints: Ian Shrier, MD, PhD, Centre for Clinical Epidemiology and Community Studies, SMBD-Jewish General Hospital, 3755 Cote Ste-Catherine Rd, Montreal, QC H3T 1E2, Canada (e-mail: firstname.lastname@example.org).
Objective: Return-to-play (RTP) decisions are fundamental to the practice of sports medicine but vary greatly for the same medical condition and circumstance. Although there are published articles that identify individual components that go into these decisions, there exists neither quantitative criteria nor a model for the sequence or weighting of these components within the medical decision-making process. Our objective was to develop a decision-based model for clinical use by sports medicine practitioners.
Data Sources: English literature related to RTP decision making.
Main Results: We developed a 3-step decision-based RTP model for an injury or illness that is specific to the individual practitioner making the RTP decision: health status, participation risk, and decision modification. In Step 1, the Health Status of the athlete is assessed through the evaluation of Medical Factors related to how much healing has occurred. In Step 2, the clinician evaluates the Participation Risk associated with participation, which is informed by not only the current health status but also by the Sport Risk Modifiers (eg, ability to protect the injury with padding, athlete position). Different individuals are expected to have different thresholds for “acceptable level of risk,” and these thresholds will change based on context. In Step 3, Decision Modifiers are considered and the decision to RTP or not is made.
Conclusions: Our model helps clarify the processes that clinicians use consciously and subconsciously when making RTP decisions. Providing such a structure should decrease controversy, assist physicians, and identify important gaps in practice areas where research evidence is lacking.
Previous injury is associated with up to a 4-fold increase in the risk of reinjury,1 and the treatment of all injuries includes advice on when it is safe to resume sport participation. For this reason, return-to-play (RTP) decisions are critical to the practice of clinical sport medicine. In general, previous research related to RTP decision making has focused on conditions with serious long-term morbidity or potential mortality such as concussion,2-12 spinal cord injuries,13-17 and cardiovascular abnormalities.18-27 Even though musculoskeletal trauma represents the majority of injuries in sports medicine, there is little original RTP research for them. In the absence of clear scientific evidence, RTP decisions lack standardization28-30 and can be a source of confusion and disagreement for physicians, athletes, coaches, and administrators.31,32 More importantly, the RTP process may be open to influence by those not trained or experienced in medical decision making.33,34 Practices such as game-day injections to mask pain and deviations from the typical medical approaches to allow full healing have become commonplace in sports medicine practice, leading to questions among bioethicists,35,36 media,37,38 legal professionals,39 and medical professionals.40-44
In 2002, the American College of Sports Medicine issued a “consensus statement” on RTP to help team physicians “make an informed decision as to whether an injured or ill athlete may safely return to practice or competition.”45 Although it includes a list of the various elements involved in RTP, the consensus statement fails to describe how or why those elements influence the medical decision-making process. Indeed, the statement reflects the difficulties and complexities in RTP medical decisions:
This statement is not intended as a standard of care, and should not be interpreted as such. This statement is only a guide, and as such is of a general nature consistent with the reasonable and objective practice of the healthcare professional. Individual decisions regarding the return of an injured or ill athlete to play will depend on the specific facts and circumstances presented to the physician. Adequate insurance should be in place to help protect the athlete, the sponsoring organization, and the physician.
The purpose of this article is to synthesize the available literature concerning RTP and to propose a model for RTP decision making in sports medicine. We believe that this model helps clarify the processes that clinicians use consciously and subconsciously when making RTP decisions. Providing such a structure provides a logical rationale for the RTP process with the hope that it will decrease controversy, assist physicians, and identify important gaps in practice areas where research evidence is lacking. The model is applicable for emergent, urgent and nonurgent decisions, although the weighting of individual components will differ with the context partly because of importance and partly because it may not be possible to obtain all the information when decisions need to be made rapidly-but a decision still has to be made nonetheless.
RETURN-TO-PLAY DECISION MAKING: THE DECISION-BASED RTP MODEL
In clinical practice, RTP may refer to “full return without restrictions,” “partial return,” “allowed to practice,” and so forth. The model proposed in this article is applicable to any of these definitions, but for clarity, we will use the following RTP definition for our examples: “medical clearance of an athlete for full participation in sport without restriction (strength and conditioning, practice, and competition).”
The most common type of decision-making model is the rational decision model,46-48 in which individuals weigh the advantages and disadvantages of decision “A” (eg, allowing an athlete to compete) against the advantages and disadvantages of decision “B” (eg, restricting an athlete from participation). In the medical context of RTP, the issue is more complex because the physician is actually making a decision that affects someone else. There are additional factors and influences (medical and otherwise) that must be considered.
Figure 1 shows the decision-making model for RTP using an influence diagram.49 In an influence diagram, the states of nature elements (the circumstances under which a decision is made) are illustrated with circles. Decision elements are usually illustrated with squares (we have used a rectangle in our diagram), and arrows are used to illustrate when information from one element contributes information to another element. The model integrates and sequences the many factors mentioned in the published literature and shows how they interact and at what point they should be considered in the RTP decision-making process. We first describe the model globally and then explain each component in subsequent sections of the article.
The first step in the decision-making process is the Evaluation of Health Status of the athlete. Evaluating health status requires an assessment of the athlete's recovery from a biological, psychological, and functional standpoint and is done by considering several Medical Factors. In essence, it is an evaluation of how much healing has occurred and how close to “normal” the previously injured tissue is. This is essential because tissue that has not healed is generally weaker or less functional than it was before the injury and therefore more likely to be reinjured.
Evaluation of Health Status (Step 1) is the most important piece of information that clinicians have for the Evaluation of Participation Risk. However, there are several other factors associated with the sport or activity (Sport Risk Modifiers) that, although not directly related to the evaluation of health status, have the capacity to substantially increase or decrease the participation risk for a given health status. For example, a swimmer with a medial collateral ligament injury to the knee may have a different risk than a football player (different sports), a first baseman with rotator cuff disease may have a different risk than a pitcher (different positions), and a recreational field hockey player may have a different risk related to a stress fracture than an Olympian (different competitive levels).
Evaluation of Participation Risk (Step 2) is essential in the rational decision-making model because a high reinjury risk represents the main disadvantage of allowing RTP (Decision A). However, there are additional factors that also represent disadvantages or advantages for Decision A (or similarly for Decision B of not allowing participation). We have called these factors Decision Modifiers (Step 3) because they may change the decision that would have been made if Participation Risk had been considered alone. Although it might be argued that the health of the athlete should be the only concern, all activity is associated with risk. Therefore, the clinician's role is to help determine what is an acceptable level of risk, and this evaluation must occur within the context of the Decision Modifiers present in a given situation. There are 3 important points related to decision modifiers. First, unlike Participation Risk, these factors are not restricted to the athlete. For example, family, coaches, and even the doctor may benefit or be harmed if the athlete is allowed to RTP or is prevented from RTP. Second, some clinicians may not consider all the factors listed as appropriate (eg, a physician in a conflict of interest may risk losing employment), but the factors are included because we believe that they are currently being considered in clinical practice today. Third, Decision Modification is set aside from the other steps because Participation Risk does not contribute information about Decision Modification, and Decision Modification cannot be used to determine RTP except in the context of knowing participation risk.
The next section discusses each of the components in greater detail. The main purpose of this article is to make note of what the literature defines as the individual components that make up the RTP medical decision. The actual value of each of these components with respect to contribution and weight in the decision-making process may or may not be quantifiable, but the value of RTP guidelines lies in the consideration of all such components before making an important decision.
SPECIFIC CONSIDERATIONS FOR RTP DECISION MAKING
Evaluation of Health Status: Step 1
Although estimates of biological healing time can be considered in the Evaluation of Health Status,14,30,50-53 a complete evaluation of the health status for any particular injury or illness based on history, symptoms, signs, laboratory tests, and functional testing is preferable. We recognize that this is a developing clinical science. For example, plain radiographic or magnetic resonance findings lag behind the physiological healing of bone after a stress injury.54,55
* Patient demographics: Sex and age50,56-59 influence the health status because of hormonal and age-related factors that can affect tissue regenerative abilities.
* Symptoms: History of the present illness provides very important information in the evaluation of an athlete's health status. Pain is considered an essential factor in the evaluation by most authors,14,16,30,51,52,56-69 presumably because it is indicative of incomplete healing. Other symptoms that are often used by clinicians, such as stiffness or sensation of joint stability, are not explicitly discussed in the literature.
* Personal medical history: The literature emphasizes some aspects of the history that are related to the current injury.58,62,70 For example, authors have distinguished between first-time injuries versus recurrent injuries.13,15,50,71,72 Family history and medical history can predispose an athlete to other medical conditions or injuries, and the medical history provides the physician with a context in which to evaluate the health status.
* Signs: Like symptoms, the presence or absence of signs on physical examination have been used by some authors to propose RTP recommendations based solely on these criteria. These recommendations are summarized in Table 1. Of these signs, muscular strength and joint range of motion (ROM) are most frequently mentioned. Most authors suggest that muscular strength should be at or near preinjury levels (often measured compared with the uninvolved limb) before returning an athlete to sports.14,30,51-53,56-61,65,67,68,71,73-79 However, the acceptable range for near normal is 70%53 to 100%,58 and these recommendations seem to be based on opinion and clinical experience, most likely because of the paucity of good scientific evidence. Similar criteria have been proposed for ROM,13,14,17,30,51-53,56-61,64,65,67,68,72,73,75-80 and others have added criteria that ROM should be pain free.30,52,57,72 In addition, some authors suggest that the injury site should be functionally stable13,15,28,52,53,61,62,71,72,81 and nontender,51,66,69,82 and joints should be without swelling30,61,62,80 or effusion.30,60 Although girth has been mentioned,30 no specific criteria have been provided.
* Laboratory tests: Imaging techniques such as plain radiographs,13,15,30,63,65,66,72,82 magnetic resonance imaging,13,15,29,58-60,63,66,72 computed tomography,13,52,63,66,82 bone scan,63 and ultrasound58 can provide objective evidence of tissue healing and detect some of the structural and physiologic abnormalities that suggest incomplete healing.13,17,65,72,79 Laboratory tests are also of value in recovery from illness and some injuries.
* Functional tests: At times, an injured tissue may be healed biologically, but deficits remain that are secondary to the injury. Functional testing allows the clinician to assess the status of the athlete with respect to function by testing exercise maneuvers that simulate sport-specific actions. An appropriately designed battery of functional tests helps assess the integration of muscular strength, ROM, proprioception, endurance, and confidence,28,60,77,83 and each individual test within the battery should mimic the forces and stresses that will be experienced by that athlete in a competitive situation.14,28,30,45,52,56,57,62,68,84,85 In general, authors recommend that RTP should occur when there is no pain,30 no instability,30 normal kinematics,14,30 and near symmetrical performance compared with the contralateral limb.30,53,74
* Psychological state: Authors have recently emphasized the importance of psychological “readiness” or “confidence” before RTP.45,50,57,86,87 Apprehension, fear, and anxiety are associated with a higher risk of reinjury86 in addition to negative effects on performance.
* Potential seriousness: Finally, the health status is related to the particular tissue injured, its extent, and the propensity for healing.15,29,34,50,58,59,62 For example, the evaluation of health status is very different for a concussion versus an ankle sprain. This is an important field for further research because short-term and long-term effects of participation after injury can substantially affect health after retirement from sport.
Like symptoms, the presence or absence of signs on physical examination has been used by some authors to propose RTP recommendations based solely on these criteria, without accounting for other factors affecting risk or the decision-modifying factors.69,79 Although some authors have suggested that RTP should only be allowed after complete resolution of symptoms,17,30,69,78,79 the proposed model clearly demonstrates why these individual components cannot be considered in isolation. Although they are considered before the Evaluation of Participation Risk and Decision Modification, they remain only the first step in the RTP process. Further, the model helps us to understand why providing general recommendations without describing any of the specific symptoms is of limited value.
Evaluation of Participation Risk: Step 2
* Type of sport: Participation in collision sports (eg, football and rugby) generally poses a higher risk of acute injury compared with participation in contact sports (eg, basketball), which poses a higher risk compared with participation in noncontact sports (eg, swimming).15,30,50-52,56-60,62,64,78,82,88,89 However, high velocity sports (eg, alpine skiing) without collision or contact are also associated with high risks.15,89 Noncontact sports may not present a high risk for acute injury, but RTP decisions may need to be conservative because disabling overuse injuries do occur in some activities60 (eg, femoral stress fracture in a long-distance runner and patellar tendinopathy in a football lineman).
* Position played: Different positions within a sport are exposed to different forces and stresses and therefore different risks.30,50,56-58,90 For example, an acromioclavicular sprain in a quarterback is repeatedly stressed during the throwing motion but receives much less stress in a field goal kicker.
* Limb dominance: An athlete's hand (or foot) dominance affects whether an injury is likely to be repeatedly stressed during activity (eg, a baseball pitcher with an injury to the dominant vs nondominant shoulder).30,59
* Competitive level: In general, greater size, speed, and strength in the more competitive athlete mean that these athletes will experience greater forces and greater stresses on the body. Furthermore, competitive athletes may be more likely to push themselves beyond the levels of noncompetitive athletes in an attempt to win. Therefore, for the same health status, higher levels of competition are associated with higher health risk.50,57,58,64,66,91
* Ability to protect: For some injuries, taping, bracing, splinting, or padding may reduce the risk for the same level of tissue healing.30,45,52,61,62,81,82 A related consideration should be whether the piece of equipment poses a higher risk of reinjury to other athletes,45,88 but this is usually governed by the rules of the sport.
Decision Modification: Step 3
* Timing and season: During the off-season, there may be less benefit to the athlete to return sooner. Allowing an athlete to participate in the play-offs may carry significant benefits in the form of bonus payments, scholarships, and so forth. Furthermore, the risk of reinjury in this situation may include only short-term disability but no long-term consequences. Therefore, for the same level of risk, the balance of advantages and disadvantages changes with respect to the timing and season involved.14,17,32,50,57,58,63,66,81
* Pressure from athlete: In most jurisdictions, the clinician must make the legal decision for RTP, although disagreement does exist about the extent to which the athlete should be involved in the decision.17,29,32,41,59,73,74,92,93 In brief, the primary decision is left to the clinician because it is often difficult to determine if the athlete is in a position to provide informed consent because of the nature of the injury (eg, concussion) or if she/he is being coerced by “handlers” or “superiors” (eg, coach) or family members. Within this context, the clinician's assessment of what constitutes an acceptable risk may contradict the athlete's assessment.41,74 Although the clinician has more experience evaluating the absolute level of injury risk, the athlete may (or may not) be in a better position to evaluate other risks, such as job security, potential scholarships, contract offers, and endorsements, and any of the athlete's other goals within sport.14,16,32,41,50,81,90
* External pressure: In the context of both competitive amateur and professional sport, many different groups of people stand to benefit (in a variety of ways) from a timely return of the athlete to competition, including coaches, teammates, relatives, team administrators, agents, sponsors, league officials, fans, and media.14-16,32,34,41,50,88 Some of these groups may provide valuable additional information for the evaluation of risks and benefits, and some may provide misinformation and undue pressure related to their focused concern. Within an overall complex matrix of decision making, all the groups have the potential to influence the RTP decision. Although the immediate reaction of some clinicians may be to suggest these all be discounted, an athlete may consider the hopes and dreams of family members (or team members) as valid and important factors that need to be considered when balancing risks and benefits.
* Masking the injury: The use of cortisone injections, local anesthetics, and analgesics is very common in sport medicine34 because it can increase function and allow injured players to participate. This factor could be considered under either Evaluation of Participation Risk or Decision Modification or both. For example, if someone has an acromioclavicular sprain and is able to return to play because it was injected with lidocaine, they may be at increased risk of worsening the pathology and prolonging the disability. To keep the decision-based RTP model as simple as possible, we have chosen to include it as only a Decision Modifier because there are other contexts where masking the injury has little effect on injury risk.
* Conflict of interest: Although it is the ethical obligation of the clinician to be an advocate for the athlete,34,41 clinicians also have obligations to the team if they are paid employees. Potential conflicts of interest arise when the team's best interests and the athlete's best interests are not aligned.33,41,88,93 In this context, advocating too strongly for the athlete means that the clinician may enter into a conflict with coaches or risk losing his or her job, including all of the perks, status, and money associated with it.41 In essence, the clinician should be transparent with the athlete about dual roles and responsibilities so that the athlete is properly informed (analogous to informed consent). How often this occurs is difficult to determine because clinicians are subject to the same frailties as the general public, and it must be considered as a potential modifying factor for RTP decisions.
* Fear of litigation: This is actually a special form of conflict of interest. Physicians are typically sued for damages that may result when an athlete is injured after an RTP decision that is deemed as too early or if an athlete is deemed inappropriately restricted from returning to play with consequent financial or nonfinancial loss.93 Although this fear concerns only the clinician's welfare, the fear is based on the potential benefits and harm that the athlete may be exposed to. Furthermore, in other areas of medicine, this fear is tempered by providing informed consent. However, the concept of informed consent is weak in sport medicine. For example, although adult athletes are considered capable of making every other decision in their life including medical ones, RTP decisions have been considered the responsibility of the team physician and “informed consent” is not considered a general defense. That said, regardless of the RTP decision, clinicians need to fully inform athletes about the risk of RTP and properly document all instructions and restrictions given to the athlete should it need to be drawn on as evidence in the future.29,34,41,61,88,92,93
CONCLUSION AND RECOMMENDATIONS
We have outlined a 3-step decision-based model for RTP that provides the clinician with structure and transparency within a complex process. The model includes the major factors within the Evaluation of Health Status and Evaluation of Participation Risk, as well as factors involved in the Decision Modification.
Our hope is that each of these individual components will become topics for future research. Progress needs to be made quantifying the importance of each of the individual components of each step, and ethical constructs need to focus on the unique sports medicine environment.
The decision-based RTP model provides a foundation for research into the individual factors and components that, when integrated, provide clinicians with an evidence-based rationale for RTP decision making.
1. Fuller CW, Bahr R, Dick RW, et al. A framework for recording recurrences, reinjuries, and exacerbations in injury surveillance. Clin J Sport Med. 2007;17:197-200.
2. Cohen JS, Gioia G, Atabaki S, et al. Sports-related concussions in pediatrics. Curr Opin Pediatr. 2009;21:288-293.
3. Congeni J. Management of the adolescent concussion victim. Adolesc Med State Art Rev. 2009;20:41-56, viii.
4. Ellemberg D, Henry LC, Macciocchi SN, et al. Advances in sport concussion assessment: from behavioral to brain imaging measures. J Neurotrauma. 2009;26:2365-2382.
5. Fait P, McFadyen BJ, Swaine B, et al. Alterations to locomotor navigation in a complex environment at 7 and 30 days following a concussion in an elite athlete. Brain Inj. 2009;23:362-369.
6. Lovell M. The management of sports-related concussion: current status and future trends. Clin Sports Med. 2009;28:95-111.
7. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport, 3rd International Conference on Concussion in Sport, held in Zurich, November 2008. Clin J Sport Med. 2009;19:185-200.
8. Meehan WP III, Bachur RG. Sport-related concussion. Pediatrics. 2009;123:114-123.
9. Parsons TD, Notebaert AJ, Shields EW, et al. Application of reliable change indices to computerized neuropsychological measures of concussion. Int J Neurosci. 2009;119:492-507.
10. Purcell L. What are the most appropriate return-to-play guidelines for concussed child athletes? Br J Sports Med. 2009;43(suppl 1):i51-i55.
11. Putukian M, Aubry M, McCrory P. Return to play after sports concussion in elite and non-elite athletes? Br J Sports Med. 2009;43(suppl 1):i28-i31.
12. Randolph C, Millis S, Barr WB, et al. Concussion symptom inventory: an empirically derived scale for monitoring resolution of symptoms following sport-related concussion. Arch Clin Neuropsychol. 2009;24:219-229.
13. Jeyamohan S, Harrop JS, Vaccaro A, et al. Athletes returning to play after cervical spine or neurobrachial injury. Curr Rev Musculoskelet Med. 2008;1:175-179.
14. Krabak B, Kennedy DJ. Functional rehabilitation of lumbar spine injuries in the athlete. Sports Med Arthrosc. 2008;16:47-54.
15. Tator CH. Recognition and management of spinal cord injuries in sports and recreation. Neurol Clin. 2008;26:79-88, viii.
16. Burnett MG, Sonntag VK. Return to contact sports after spinal surgery. Neurosurg Focus. 2006;21:E5.
17. Dunn IF, Proctor MR, Day AL. Lumbar spine injuries in athletes. Neurosurg Focus. 2006;21:E4.
18. Anderson BR, Vetter VL. Return to play? Practical considerations for young athletes with cardiovascular disease. Br J Sports Med. 2009;43:690-695.
19. Baptista CA, Foronda A, Baptista Lde P. Competitive sports for children and adolescents: should an electrocardiogram be required in the pre-participation physical examination? Arq Bras Cardiol. 2009;93:188-195.
20. Link MS. Prevention of sudden cardiac death: return to sport considerations in athletes with identified cardiovascular abnormalities. Br J Sports Med. 2009;43:685-689.
21. Seggewiss H, Blank C, Pfeiffer B, et al. Hypertrophic cardiomyopathy as a cause of sudden death. Herz. 2009;34:305-314.
22. Sik EC, Batt ME, Heslop LM. Atypical chest pain in athletes. Curr Sports Med Rep. 2009;8:52-58.
23. Thiene G, Carturan E, Corrado D, et al. Prevention of sudden cardiac death in the young and in athletes: dream or reality? Cardiovasc Pathol. 2010;19:207-217.
24. Pelliccia A, Zipes DP, Maron BJ. Bethesda conference #36 and the European Society of Cardiology consensus recommendations revisited a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2008;52:1990-1996.
25. Sofi F, Capalbo A, Pucci N, et al. Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. BMJ. 2008;337:a346.
26. Basavarajaiah S, Wilson M, Whyte G, et al. Prevalence and significance of an isolated long QT interval in elite athletes. Eur Heart J. 2007;28:2944-2949.
27. Maron BJ. Hypertrophic cardiomyopathy and other causes of sudden cardiac death in young competitive athletes, with considerations for preparticipation screening and criteria for disqualification. Cardiol Clin. 2007;25:399-414, vi.
28. Lam MH, Fong DT, Yung P, et al. Knee stability assessment on anterior cruciate ligament injury: clinical and biomechanical approaches. Sports Med Arthrosc Rehabil Ther Technol. 2009;1:20.
29. Brukner P. Return to play-a personal perspective. Clin J Sport Med. 2005;15:459-460.
30. Miller MD, Arciero RA, Cooper DE, et al. Doc, when can he go back in the game? Instr Course Lect. 2009;58:437-443.
31. Clover J, Wall J. Return-to-play criteria following sports injury. Clin Sports Med. 2010;29:169-175.
32. McFarland EG. Return to play. Clin Sports Med. 2004;23:xv-xxiii.
33. Fuller CW, Walker J. Quantifying the functional rehabilitation of injured football players [discussion]. Br J Sports Med. 2006;40:151-157.
34. Verrall GM, Brukner PD, Seward HG. 6. Doctor on the sidelines. Med J Aust. 2006;184:244-248.
35. Dunn WR, George MS, Churchill L, et al. Ethics in sports medicine. Am J Sports Med. 2007;35:840-844.
36. Bernstein J, Perlis C, Bartolozzi AR. Normative ethics in sports medicine. Clin Orthop Relat Res. 2004;420:309-318.
37. Jenkins S. Not everything's clear when it comes to HGH, PRP. The Washington Post. May 20, 2010:D01.
38. Skolnick EJ. Taking shot at glory: Wade's decision to get 2 injections to play in do-or-die NBA playoff game raised questions. Chicago Tribune. June 26, 2005:Sports: 6.
39. Blackwell T, O'Connor J. Drug charges for MD to the stars. National Post. May 19, 2010:A1.
40. Dietzel DP, Hedlund EC. Injections and return to play. Curr Pain Headache Rep. 2005;9:11-16.
41. Tucker AM. Ethics and the professional team physician. Clin Sports Med. 2004;23:227-241, vi.
42. Johnson R. The unique ethics of sports medicine. Clin Sports Med. 2004;23:175-182.
43. Orchard JW. Is it safe to use local anaesthetic painkilling injections in professional football? Sports Med. 2004;34:209-219.
44. Bernstein J, Perlis C, Bartolozzi AR. Ethics in sports medicine. Clin Orthop Relat Res. 2000;378:50-60.
45. The team physician and return-to-play issues: a consensus statement. Med Sci Sports Exerc. 2002;34:1212-1214.
46. Ashby D, Smith AF. Evidence-based medicine as Bayesian decision-making. Stat Med. 2000;19:3291-3305.
47. Reyna VF, Rivers SE. Current theories of risk and rational decision making. Dev Rev. 2008;28:1-11.
48. Shakespeare TP, Gebski VJ, Veness MJ, et al. Improving interpretation of clinical studies by use of confidence levels, clinical significance curves, and risk-benefit contours. Lancet. 2001;357:1349-1353.
49. Howard RA, Matheson JE. Influence diagrams. Decis Anal. 2005;2:127-143.
50. Bauman J. Returning to play: the mind does matter. Clin J Sport Med. 2005;15:432-435.
51. Curl LA. Return to sport following elbow surgery. Clin Sports Med. 2004;23:353-366, viii.
52. Kovacic J, Bergfeld J. Return to play issues in upper extremity injuries. Clin J Sport Med. 2005;15:448-452.
53. Cascio BM, Culp L, Cosgarea AJ. Return to play after anterior cruciate ligament reconstruction. Clin Sports Med. 2004;23:395-408, ix.
54. Faber KJ, Dill JR, Amendola A, et al. Occult osteochondral lesions after anterior cruciate ligament rupture. Six-year magnetic resonance imaging follow-up study. Am J Sports Med. 1999;27:489-494.
55. Fowler PJ. Bone injuries associated with anterior cruciate ligament disruption. Arthroscopy. 1994;10:453-460.
56. Drake DF, Nadler SF, Chou LH, et al. Sports and performing arts medicine. 4. Traumatic injuries in sports. Arch Phys Med Rehabil. 2004;85:S67-S71.
57. McCarty EC, Ritchie P, Gill HS, et al. Shoulder instability: return to play. Clin Sports Med. 2004;23:335-351, vii-viii.
58. Orchard J, Best TM, Verrall GM. Return to play following muscle strains. Clin J Sport Med. 2005;15:436-441.
59. Park HB, Lin SK, Yokota A, et al. Return to play for rotator cuff injuries and superior labrum anterior posterior (SLAP) lesions. Clin Sports Med. 2004;23:321-334, vii.
60. Bowen TR, Feldmann DD, Miller MD. Return to play following surgical treatment of meniscal and chondral injuries to the knee. Clin Sports Med. 2004;23:381-393, viii-ix.
61. Saal JA. Common American football injuries. Sports Med. 1991;12:132-147.
62. Smurawa T, Congeni J. Return-to-play decisions in the adolescent athlete: how to decide. Pediatr Ann. 2007;36:746-748, 750-741.
63. Kaeding CC, Yu JR, Wright R, et al. Management and return to play of stress fractures. Clin J Sport Med. 2005;15:442-447.
64. Eck JC, Riley LH III. Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004;23:367-379, viii.
65. Cantu RC. Cervical spine injuries in the athlete. Semin Neurol. 2000;20:173-178.
66. Diehl JJ, Best TM, Kaeding CC. Classification and return-to-play considerations for stress fractures. Clin Sports Med. 2006;25:17-28, vii.
67. Dimberg EL, Burns TM. Management of common neurologic conditions in sports. Clin Sports Med. 2005;24:637-662, ix.
68. Kuhn JE. Treating the initial anterior shoulder dislocation-an evidence-based medicine approach. Sports Med Arthrosc. 2006;14:192-198.
69. Lord J, Winell JJ. Overuse injuries in pediatric athletes. Curr Opin Pediatr. 2004;16:47-50.
70. Bolin D, Goforth M. Sideline documentation and its role in return to sport. Clin J Sport Med. 2005;15:405-409.
71. Weinberg J, Rokito S, Silber JS. Etiology, treatment, and prevention of athletic “stingers.” Clin Sports Med. 2003;22:493-500, viii.
72. Cantu RV, Cantu RC. Current thinking: return to play and transient quadriplegia. Curr Sports Med Rep. 2005;4:27-32.
73. Beazell JR, Magrum EM. Rehabilitation of head and neck injuries in the athlete. Clin Sports Med. 2003;22:523-557.
74. Myer GD, Paterno MV, Ford KR, et al. Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. J Strength Cond Res. 2008;22:987-1014.
75. Larrain MV, Mauas DM, Collazo CC, et al. Arthroscopic anterior cruciate ligament distal graft rupture: a method of salvage. Arthroscopy. 2004;20:757-760.
76. Paulos L, Noyes FR, Grood E, et al. Knee rehabilitation after anterior cruciate ligament reconstruction and repair. J Orthop Sports Phys Ther. 1991;13:60-70.
77. Bizzini M, Gorelick M, Drobny T. Lateral meniscus repair in a professional ice hockey goaltender: a case report with a 5-year follow-up. J Orthop Sports Phys Ther. 2006;36:89-100.
78. Eddy D, Congeni J, Loud K. A review of spine injuries and return to play. Clin J Sport Med. 2005;15:453-458.
79. Elias I, Pahl MA, Zoga AC, et al. Recurrent burner syndrome due to presumed cervical spine osteoblastoma in a collision sport athlete-a case report. J Brachial Plex Peripher Nerve Inj. 2007;2:13.
80. Myklebust G, Bahr R. Return to play guidelines after anterior cruciate ligament surgery. Br J Sports Med. 2005;39:127-131.
81. Shelton WR, Barrett GR, Dukes A. Early season anterior cruciate ligament tears. A treatment dilemma. Am J Sports Med. 1997;25:656-658.
82. Steinberg B. Acute wrist injuries in the athlete. Orthop Clin North Am. 2002;33:535-545, vi.
83. Greenberger HB, Paterno MV. Relationship of knee extensor strength and hopping test performance in the assessment of lower extremity function. J Orthop Sports Phys Ther. 1995;22:202-206.
84. Hopper DM, Strauss GR, Boyle JJ, et al. Functional recovery after anterior cruciate ligament reconstruction: a longitudinal perspective. Arch Phys Med Rehabil. 2008;89:1535-1541.
85. Hudson Z. Rehabilitation and return to play after foot and ankle injuries in athletes. Sports Med Arthrosc. 2009;17:203-207.
86. Glazer DD. Development and preliminary validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. J Athl Train. 2009;44:185-189.
87. Langford JL, Webster KE, Feller JA. A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med. 2009;43:377-378.
88. Best TM, Brolinson PG. Return to play: the sideline dilemma. Clin J Sport Med. 2005;15:403-404.
89. Morganti C, Sweeney CA, Albanese SA, et al. Return to play after cervical spine injury. Spine (Phila Pa 1976). 2001;26:1131-1136.
90. Leach RE, Paul GR. Injury and disability in the professional athlete. Clin Orthop Relat Res. 1987:221:68-76.
91. Poulsen TD, Freund KG, Madsen F, et al. Injuries in high-skilled and low-skilled soccer: a prospective study. Br J Sports Med. 1991;25:151-153.
92. Mitten MJ, Mitten RJ. Legal considerations in treating the injured athlete. J Orthop Sports Phys Ther. 1995;21:38-43.
93. Maron BJ, Brown RW, McGrew CA, et al. Ethical, legal, and practical considerations impacting medical decision-making in competitive athletes. Med Sci Sports Exerc. 1994;26:S230-S237.
This article has been cited 8 time(s).
American Journal of Sports MedicineMatch Injuries in English Youth Academy and Schools Rugby Union An Epidemiological StudyAmerican Journal of Sports Medicine
Physical Therapy in SportCritical reflection of the advanced rehabilitation of an elite rugby league player sustaining a posterior Bankart lesionPhysical Therapy in Sport
Sports MedicineA Meta-Analysis of Injuries in Senior Men's Professional Rugby UnionSports Medicine
International Journal of Athletic Therapy & Training
A Basic Construct for Improving Outcomes in Rehabilitation
International Journal of Athletic Therapy & Training, 18(3):
Journal of Sport Rehabilitation
Return to Play in Elite Rugby Union: Application of Global Positioning System Technology in Return-to-Running Programs
Journal of Sport Rehabilitation, 22(2):
Scandinavian Journal of Medicine & Science in SportsIsokinetic rotator muscles fatigue in glenohumeral joint instability before and after Latarjet surgery A pilot prospective studyScandinavian Journal of Medicine & Science in Sports
PediatricsPediatric Providers' Self-Reported Knowledge, Practices, and Attitudes About ConcussionPediatrics
Clinical Journal of Sport MedicineThe Sociology of Return-to-Play Decision Making: A Clinical PerspectiveClinical Journal of Sport Medicine
return to play; medical decision making; sport participation; injury; preparticipation physical examination
© 2010 Lippincott Williams & Wilkins, Inc.
Highlight selected keywords in the article text.