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Return to Play

The Sideline Dilemma

Best, Thomas M MD, PhD, FACSM*; Brolinson, P Gunnar DO, FAOASM, FAAFP

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Clinical Journal of Sport Medicine: November 2005 - Volume 15 - Issue 6 - p 403-404
doi: 10.1097/01.jsm.0000187076.74606.75
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“When can I play again, Doc?” is one of the first questions posed by an athlete following an injury. In rapid succession, the same inquiry is posed by parents, teammates, coaches, and-in the case of the high-profile athlete-the media. An unfortunate consequence is that the medical staff is often judged on the basis of how quickly an athlete returns to play following an injury. To meet the expectations of the athlete, coaches, parents, and sport administrators, swift intervention and accelerated rehabilitation have assumed an even greater priority in the minds of some practitioners. Community physicians increasingly feel similar pressures. The challenge of making appropriate return to sport decisions involves competitive and recreational athletes suffering acute as well as chronic or overuse injuries.

Return to play decisions are a core responsibility of team physicians and sport medicine practitioners. Such decisions frequently present significant ethical dilemmas. Bertrand Russell once stated, “Science, by itself, cannot supply us with an ethic.” If a team physician does not fully inform an athlete of the potential danger associated with playing with a particular injury, or the risks of a proposed treatment, the athlete's decision can be viewed as uninformed.1 Office-based and sideline clinicians are typically faced with several options and little highest quality (level 1 or 2) evidence on which to make final return to play recommendations. Their dilemmas are compounded in the case of athletes participating in contact and collision sports who assume a risk of potentially serious injury each time they take the field. Team sport physicians and athletic trainers face extreme pressure to clear athletes for competition and have been noted to make decisions in “derogation of sound medical judgement”.1 An added, self-imposed pressure may emerge because of the desire of such a physician or athletic trainer to retain his/her status with the team and its perceived benefits including attendant publicity.

Despite the emphasis on ensuring safe return to play, only a limited number of studies addressing return to play strategies are available. Do we really know, for example, when an athlete is recovered from a first concussion, or from his third or fourth? This very common clinical scenario may require a physician and medical team, athlete, and family to make decisions largely based on anecdotal experience and an expert opinion level of evidence. It is difficult for athletes and coaches to recognize and appreciate that the practice of medicine is frequently an inexact science. As evidence-based decision-making assumes a greater role in medicine (and in sports medicine in particular), it is incumbent upon all of us involved with the medical care of athletes to help design and carry out research studies that will assess the validity of many of our current approaches-thereby assisting athletes and the medical staff.

Advances in surgical techniques as well as imaging technologies further muddy the waters. We are able to diagnose rapidly and to repair aggressively injuries with minimally invasive techniques; but what then? What is the natural history and long-term outcome for individuals electing these aggressive treatments?

The decision for safe and timely return of an injured or ill athlete to practice or competition is ideally the result of a thoughtful and highly informed process of evaluation, treatment, and rehabilitation. In this thematic issue of the Journal, we explore a variety of topics addressing return to play, ranging from immediate on-the-field decisions regarding acute fracture and asthma management to decisions concerning the timing of safe return following a tibial-shaft stress fracture. As you will discover, our authors have generated more questions than answers through their critical reviews of the literature coupled with their own significant, personal experience. Given the complexity of the decision-making process that can surround many return to play decisions, this is not surprising. An athlete's state of mind is frequently disregarded when providing advice concerning a safe return to sport. As pointed out by Jim Bauman, PhD, the Kubler-Ross model describing the stages of grief and loss is an interesting paradigm that may assist our understanding of why some athletes can return more quickly from injury or illness than others.2

What is the actual status of healing-anatomically and in terms of an appropriate return to function-of any injured tissue or system? How do we determine it? What is the status of recovery from acute or chronic infectious illness? What are the potential sequelae of a premature return to athletic participation? Does the returning athlete pose undue risk to the safety of other participants? Have an athlete's sport-specific skills been restored to an appropriate level? What are the psychologic issues surrounding return to play? Will bracing and/or taping be helpful? Is a decision to return an athlete to competition compliant with applicable federal, state, local, school, and governing body regulations? As sports medicine clinicians, these are only some of the questions we must attempt to answer in reaching a return to play decision.

We hope that you will find this issue to be of value in your practice. We have probably raised more questions than we have answered, but we believe that the dialogue has been started. Issues regarding return to play will continue to be an area of controversy for the foreseeable future. We appreciate the contributions of our authors and look forward to feedback from you, the reader.

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1. DiCello N. Exploiting professional athletes. Clevel State Law Rev. 2001;49:507-538.
2. Bauman J. Returning to play: the mind does matter. Clin J Sport Med. 2005;15:427-430.
© 2005 Lippincott Williams & Wilkins, Inc.