Return To Sport: Are We Really Asking A Novel Question

Return to sport is a hot topic in the fields of sports medicine and human performance.  Implicit in “return to sport” is an injury that prohibited an athlete from participating in competition.  Return to sport guidelines typically warrant the most scrutiny following a surgical procedure like an anterior cruciate or ulnar collateral ligament reconstruction.  Essentially, the greater the number of games missed to a particular injury, the more medical and performance professionals fixate on what constitutes physical readiness for specific sporting demands.

What is it about surgery in particular that warrants this additional scrutiny?  In actuality, post surgical return to sport readiness criteria should be no different than preparatory criteria for any athlete all other things being equal.  Preparation is preparation.  The return to sport question is probably so unnerving because most sports have yet to determine what constitutes adequate physical preparation in the first place.  Surgery forces performance professionals to pay careful attention to what athletes do prior to returning to the field or court.  Athletes with unremarkable medical histories are often not held accountable for their physical preparation because they are assumed to be healthy.

The absence of injury, however, is not synonymous with preparation or even health.  When one regards rehabilitation and performance as a fluid continuum and not as distinct disciplines, the return to sport question is not so unique.  In the early stages of rehabilitation, tissue healing and pain interfere with joint position and motor control.  Ultimately, qualities like special endurance, work capacity, and technical/tactical execution are contingent upon foundational joint position and motor control.  Consequently, a surgical procedure need not alter a systematic, process-oriented preparatory framework.  Post-operative tissue repair (assuming a successful surgery) merely prolongs the development of the positional and motor control baseline necessary for higher-level tasks.  That the return to sport question isn’t novel within an integrated conceptual model doesn’t mean the answer is easy.  As always, and perhaps unsatisfactorily, the answer is: it depends.  Nevertheless, a reasonable answer is contingent upon reasonable questions.  The following questions provide some basis for further discussion:

  1. Should medical providers, who typically view problems through a patient-centric and structural lens, determine return to sport criteria in a professional vacuum?  In other words, is return to sport strictly a medical question or a multi-disciplinary one?
  2. Assuming the answer to question 1 is the latter, how does the organizational culture ensure seamless communication and egoless professional discourse among the various disciplines, including the front office and coaching staff?
  3. Has a needs analysis been conducted to determine what constitutes an athlete’s physical readiness in the context of position, relative importance to the team, and technical/tactical considerations?
  4. What global strategies exist to maximize training load and systemic physiological adaptations that do not compromise tissue healing, post operative guidelines, and pain sensitization?
  5. How do medical and performance staffs  “do no harm” without resorting to excessive risk aversion and in turn, inadequate preparation?
  6. What is the contingency plan when an athlete decides to rehabilitate an injury with his/her people and not with the team?
  7. Are political and economic factors confounding the medical decisions?
  8. Assuming robust return to sport guidelines have been established, when is it permissible to deviate from them?  In other words, what degree of risk is acceptable when a player’s compromised readiness still benefits the team (e.g. a star player returning from injury for a playoff game)?
  9. How do organizations most effectively hold athletes accountable for their return to sport and foster an environment that promotes the behavioral modifications necessary to apply medical and scientific knowledge?
  10. What psychological return to sport parameters, if any, should exist when somebody whose identity is predicated on physicality and athleticism must confront his/her fragility?

Return to sport can be as much an ethical, political, or economic decision as it as a medical one.   Medicine is becoming increasingly characterized by specialization and the pursuit of data.  In the context of return to sport, lack of information and specialized knowledge may be less of an obstacle than applying what we already know, inducing behavioral changes, modifying organizational hierarchies, and navigating the connections among disparate, but relevant fields.

Rotator cuff manual muscle testing within normal limits and favorable follow up MRI ≠ HAHO jump readiness...

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