The Team Physician and the Return-to-Play Decision

A Consensus Statement—2012 Update

DEFINITION

Return-to-play (RTP) is the decision-making process of returning an injured or ill athlete to practice or competition. This ultimately leads to medical clearance of an athlete for full participation in sport. This consensus statement will focus on the process that addresses non–game-day RTP decisions.

GOAL

The goal is to return an injured or ill athlete to practice or competition without putting the individual at undue risk for injury or illness. The team physician’s duty is to protect the health and welfare of the athlete. To accomplish this goal, the team physician should have knowledge of and be involved with:

• Establishing an RTP process.
• Evaluating injured or ill athletes.
• Treatment and rehabilitation of injured or ill athletes.
• Returning an injured or ill athlete to play.

INTRODUCTION

The objective of this consensus statement is to provide physicians who are responsible for the health care of teams with a decision process for determining when to return an injured or ill athlete to practice or competition. 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 health care 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. This statement was developed by the collaborative effort of six major professional associations: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine.

PRIMARY AUTHORS

Stanley A. Herring, M.D., Chair, Seattle, WA

W. Ben Kibler, M.D., Lexington, KY

Margot Putukian, M.D., Princeton, NJ

EXPERT PANEL

John A. Bergfeld, M.D., Cleveland, OH

Lori Boyajian-O’Neill, D.O., Overland Park, KS

Rob Franks, D.O., Marlton, NJ

Peter Indelicato, M.D., Gainesville, FL

Rebecca Jaffe, M.D., Wilmington, DE

Walter Lowe, M.D., Houston, TX

Craig C. Young, M.D., Milwaukee, WI

ESTABLISHING AN RTP PROCESS

Establishing a process for returning an athlete to play is the essential first step in deciding when an injured or ill athlete may safely return to practice or competition. This process should include evaluation of the athlete’s health status, participation risk, and extrinsic factors (³). The final RTP decision is made by the team physician.

It is essential the team physician:

• Understand the RTP process should be established during the off season.
• Coordinate a chain of command regarding decisions to return an injured or ill athlete to practice or competition.
• Evaluate the athlete’s health status.

• ○ Medical factors including history, symptoms, signs, and additional tests.
• ○ Psychological factors, including readiness and coping mechanisms (⁵).
• ○ Functional testing to evaluate readiness to RTP.
• ○ Nature of the illness/injury including mechanism of injury, natural history, and known risks of participating after illness/injury.

• Evaluate the athlete’s participation risk.

• ○ Demands of the athlete’s sport, including the position and competitive level of play.
• ○ Role of taping, bracing, or orthoses to protect the athlete.
• ○ Role of medical interventions that allow an athlete to play (e.g., analgesics/injections, inhalers, and intravenous fluids).
• ○ RTP may affect other athletes (e.g., bracing, casting, and disease transmission).
• Understand extrinsic factors that may modify the acceptable level of risk (risk/gain ratio) for the individual athlete (e.g., pressure from parents, team and/or coaches, conflicts of interest and other ethical considerations, fear of litigation, point in athlete’s season, or career).
• Communicate the RTP process to players, families, certified athletic trainers, coaches, administrators, and other health care providers.
• Confirm a system for medical documentation is in place.
• Establish protocols within disclosure regulations for the release of information regarding an athlete’s ability to return to practice or competition after an injury or illness.
• Understand certain sports have governing body rules and regulations regarding participation that affect the RTP decision (e.g., no knee brace in rugby and skin infection in wrestling).
• Understand federal, state, and local regulations and legislation related to returning an injured or ill athlete to practice or competition.

It is desirable the team physician:

• Work with the athletic care network to educate athletes, parents, and coaches about the RTP process.
• Prepare a letter of understanding between the team physician and the administration that defines the authority, responsibilities, and RTP decisions (⁶).

EVALUATING INJURED OR ILL ATHLETES

Evaluation of an injured or ill athlete is the key step in establishing a diagnosis and directing treatment and is the basis for deciding when an athlete may safely return to practice or competition. Repeated evaluations throughout the continuum of injury or illness management optimize medical care and aids in the RTP decision.

It is essential that evaluation of an injured or ill athlete include:

• A condition-specific medical history.
• A condition-specific physical examination and functional testing.
• Medical and radiological tests and consultations as indicated.
• Psychosocial assessment (⁵).
• Documentation.
• Communication with the player, family, certified athletic trainer, coaches, and other health care providers within disclosure regulations.

It is desirable the team physician:

• Coordinate evaluation of the injured or ill athlete.

TREATMENT AND REHABILITATION OF INJURED OR ILL ATHLETES

Comprehensive treatment includes complete rehabilitation of an injured or ill athlete, thus optimizing the safe and timely return to practice or competition.

It is essential that the treatment and rehabilitation plan of the injured or ill athlete:

• Begin in a timely manner (⁶).
• Address short- and long-term needs for the athlete.
• Are individualized and may include consultations and referrals.
• Include rehabilitation components that:

• ○ Provide sport-specific assessment, treatment, and training to restore function of the injured part.
• ○ Restore musculoskeletal, cardiopulmonary, and psychological function, as well as overall health of the injured or ill athlete.
• ○ Serve as a basis for sport-specific conditioning (⁷).

• Include equipment modification, bracing, and orthoses as necessary.
• Address psychosocial issues.
• Provide a realistic prognosis regarding a safe and timely return to practice or competition.
• Include continued communication with the player, family, certified athletic trainer, coaches, and other health care providers.
• Include documentation.

It is desirable the team physician coordinate:

• The initial and ongoing treatment for the injured or ill athlete.
• A rehabilitation team including certified athletic trainers, physical therapists, medical specialists, and other health care providers.

RETURNING AN INJURED OR ILL ATHLETE TO PLAY

The decision for safe and timely return of an injured or ill athlete to practice or competition is the desired result of the process of evaluation, treatment, and rehabilitation.

The RTP decision can be a complex process, involving the health status of the individual and participation and extrinsic factors, and may require obtaining and interpreting information from multiple sources. The responsibility of the team physician is to take these factors into consideration to make the RTP decision and communicate and document its implications and risks with the athlete and parent(s) or guardian(s) if the athlete is a minor.

It is essential the team physician confirm:

• Restoration of sport-specific function to the injured part.
• Restoration of musculoskeletal, cardiopulmonary, and psychological function, as well as overall health of the injured or ill athlete.
• Restoration of sport-specific skills.
• Ability to perform safely with equipment modification, bracing, and orthoses.
• The status of recovery from acute or chronic illness and associated sequelae.
• Psychosocial readiness.
• The athlete poses no undue risk to themselves or the safety of other participants.
• Compliance with federal, state, local, and governing body regulations and legislation.

It is desirable the team physician:

• Discuss RTP decision of the athlete with parents/guardians, certified and licensed athletic trainers, coaches, school officials, and others within disclosure regulations.

SUMMARY

Understanding the RTP decision-making process is important for the team physician. Although it is desirable that the team physician coordinate the RTP process, it is essential that the team physician ultimately be responsible for the RTP decision. Individual decisions regarding return of an injured or ill athlete to play may be complex and will depend on the specific facts and circumstances presented to the team physician.

FIGURE