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SPORTS & EXERCISE

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

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.
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.

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