L19-20: Return to Sport

Question 1

“When can I go back to [insert sport/activity here]…?”

Answer 1

Criteria based rather than issue healing timeline

Question 2

How does return to sport fit into physiotherapy management?

Answer 2

Question 3

What are the 2 minimum information required to define return to sport?

Answer 3

1. specific sport or activity goal
   
   • What position do they play in (eg. striker)
2. level of participation that the individual aims to return to

Question 4

What are 3 different patients/athletes (and other stakeholders) that will have different goals and ideas of success in return to sport?

Answer 4

1. Athlete – sustained participation in sport in the shortest time possible
2. Coach – defined relative to performance on return to sport
3. Clinician – prevention of new/recurrent injury
   
   • Prevent the negative risks of getting patient back too early

Team needs to define success collaboratively, and work towards these for each individual

Question 5

What are the 3 elements of the return to sport continuum?

Answer 5

Question 6

Who does return to sport apply to?

Answer 6

Everyone… not just competitive athletes… Most patients have an activity goal that they want to get back to Your job is to ask what these goals are – at their first appointment – and consider this at all stages of management

Question 7

Who makes decisions regarding return to sport/participation?

Answer 7

Question 8

What do we need to consider in making RTS/P decisions (2)? What are 3 steps?

Answer 8

1. Using valid and reliable measures of self-efficacy & fear of reinjury, & establishing normative values on these measures after ACLR
2. Routine assessment of self-efficacy and fear of reinjury alongside physical function throughout the rehabilitation period
3. Improve adherence to objective clearance criteria for return to sport

Question 9

What are 3 models to guide return to sport?

Answer 9

1. StARRT Framework: Strategic Assessment of Risk and Risk Tolerance
   
   1. Helps to estimate the risks of different short- and long-term outcomes associated with RTS
   2. Identify factors that may affect what should be considered an acceptable risk within a particular context
2. Biopsychosocial model:
   
   1. Considers biological, psychological and social factors that might influence treatment, outcome after injury, and return to sport
3. Optimal loading – the ‘Goldilocks’ approach:
   
   1. Acute:chronic workload (load during current training week vs. average of preceding 4 weeks)
   2. Useful to plan load progressions for return to sport

Question 10

What are 2 characteristics of the StARRT Framework: Strategic Assessment of Risk and Risk Tolerance as a model for return to sport?

Answer 10

1. Helps to estimate the risks of different short- and long-term outcomes associated with RTS
2. Identify factors that may affect what should be considered an acceptable risk within a particular context

Question 11

What is a characteristic of the Biopsychosocial model as a model for return to sport?

Answer 11

Considers biological, psychological and social factors that might influence treatment, outcome after injury, and return to sport

Question 12

What are the 2 factors of guide return to sport?

Answer 12

Question 13

What are 2 characteristics of the Optimal loading – the ‘Goldilocks’ approach as a model for return to sport?

Answer 13

1. Acute:chronic workload (load during current training week vs. average of preceding 4 weeks)
2. Useful to plan load progressions for return to sport

Question 14

How can we optimise return to sport/participation (4)?

Answer 14

1. Make return to sport goals a priority from day 1
2. Make sure that all rehabilitation goals logically lead to RTS
   
   • this will help with patient buy-in, especially with exercise adherence
3. Must maintain clear communication with your patient/athlete and all stakeholders
4. Have an understanding of the evidence for return to sport for specific injuries / patient populations

Question 15

Return to sport means different things to different people … defined by _________, and the ________ that the individual aims to return to

Answer 15

specific sport or activity goal; level of participation

Question 16

Return to sport applies to _____ , not just those involved in _____or who have_____

Answer 16

all patients; competitive sport; sustained injuries

Question 17

All ________must have an understanding of and work towards common RTS goals … _____ is key

Answer 17

key stakeholders; communication

Question 18

Why is it important for Brooke to return to football (3)?

Answer 18

1. Young, active
2. Football is her career, and part of her identity
3. Important to maintain her health (including knee)

Question 19

What are 4 things to consider about ACLR & retunr to sport?

Answer 19

1. After revision ACLR, ~85% return to sport, but only 52% return to their preinjury level, and 51% return to high-level sport
2. Psychological readiness to return to sport is one of the most important factors associated with returning to pre-injury level
3. Other variables associated with return to sport: higher quadriceps strength, less effusion, less pain, greater tibial rotation, higher activity score (Marx), higher athletic confidence, higher pre-operative knee self-efficacy, lower kinesiophobia, higher pre-operative self-motivation
4. One-third of young athletes who return to cutting/pivoting sports after ACLR will sustain another ACL tear within 2 years

Question 20

What are the 6 stages in the return to soccer after ACL reconstruction?

Answer 20

Question 21

What are the 4 rehabilitation in phase 2 (strength and neuromuscular control) in return to football after ACL reconstruction? What is the pre-requisite?

Answer 21

Needs to have:

• 0-125˚ knee ROM; minimal swelling/effusion; 0-5o quadriceps lag

Rehabilitation:

1. Single leg balance
2. Muscle strengthening (body weight → gym based)
3. Single leg squat control
4. Non-impact aerobic exercise

Question 22

What are the 4 rehabilitation in phase 3 (strength and neuromuscular control) in return to football after ACL reconstruction? What are the 5 pre-requisite?

Answer 22

Needs to have:

1. 0-125o knee ROM; no swelling/effusion
2. Good control on single leg squat
3. SL bridges, SL calf raises, side bridges, SL rise = 85% of other side
4. SL balance 43 secs EO, 9 secs EC
5. 1RM SL press & squat = 1.5x body weight

Rehabilitation:

1. Walk/run → running § Jumping
2. Hopping
3. Agility drills

Question 23

What are the 2 rehabilitation in phase 4 (return to sport) in return to football after ACL reconstruction? What are the 4 pre-requisite?

Answer 23

Needs to have:

1. SL hop, triple hop, triple cross-over hop, side hop, SEBT >95% (vs. other side)
2. SL rise >22 reps (both sides)
3. Passed dynamic balance tests
4. 1RM SL press & squat = 1.8x body weight

Rehabilitation:

1. Individual – based on Brooke’s specific sport requirements
   
   • Incorporate ball into agility drills; gradually increase kicking range; gradually progress intensity in defensive & tackling drills; match simulation drills, etc.
2. Focus on the whole person, not just the knee
   
   • Address any residual psychosocial factors – e.g. kinesiophobia, knee confidence
   • Full-body conditioning (match fitness)

Question 24

What are 3 criteria for return to football after ACL reconstruction?

Answer 24

1. Successful completion of Melbourne Return to Sport Score (>= 95)
   
   1. 6 components: clinical examination (10 points), IKDC Subjective Knee Evaluation & ACL-RSI (20 points), Tampa Scale for Kinesiophobia (hurdle criteria), functional testing (50 points); assessment of general fitness (hurdle criteria), functional testing in fatigued state (20 points)
   2. Performed over 2 sessions, 3 days apart
2. Comfortable, confident & eager to return to football
   
   1. ACL-RSI
   2. IKDC
3. ACL injury prevention program implemented
   
   1. Continuation of Brooke’s current program
   2. Structured, standardised program incorporated into team warm up (e.g. FIFA 11+)

Question 25

Why is it important for Daniel to return to running (3)?

Answer 25

1. Young, active
2. Running and sport was a big part of his life prior to his injury
3. Important to maintain his health… may have positive effects on other aspects of his recovery

Question 26

What are 8 things to consider about TBI and return to sport/participation?

Answer 26

1. Higher-level mobility skills important for participation in many activities of daily living, but often ignored in rehabilitation
2. Deficits observed in people following TBI:
   
   1. Slower self-selected running speed
   2. Higher cadence and shorter step length (when speed matched)
   3. Greater knee flexion at initial contact, greater extension at mid-stance, and greater flexion at toe-off; reduced knee power absorption in early stance
   4. Greater hip extensor power generation at initial contact
   5. Reduced ankle power generation at push off
3. People who have sustained a TBI are often diverse in their presentation
4. Self-selected walking speed (>1m/s) is predictive of ability to run after TBI
5. Factors that may affect running after TBI:
   
   1. Higher risk of falling and subsequent injury
   2. Awareness of safety / judgement due to potential cognitive deficits
   3. Associated deficits e.g. spasticity, ROM, motor control
   4. Comorbidities e.g. orthopaedic injuries, visual deficits
   5. Cardiovascular fitness
6. May need medical clearance (e.g. if haemorrhagic TBI)
7. Consider the potential for new injury – traumatic or load-related running injury
8. Running is a skill – incorporate skill acquisition and running retraining principles

Question 27

What are 5 deficits observed in people following TBI as considerations for TBI and return to sport/participation?

Answer 27

1. Slower self-selected running speed
2. Higher cadence and shorter step length (when speed matched)
3. Greater knee flexion at initial contact, greater extension at mid-stance, and greater flexion at toe-off; reduced knee power absorption in early stance
4. Greater hip extensor power generation at initial contact
5. Reduced ankle power generation at push off

Question 28

What are 5 factors that may affect running following TBI as considerations for TBI and return to sport/participation?

Answer 28

1. Higher risk of falling and subsequent injury
2. Awareness of safety / judgement due to potential cognitive deficits
3. Associated deficits e.g. spasticity, ROM, motor control
4. Comorbidities e.g. orthopaedic injuries, visual deficits
5. Cardiovascular fitness

Question 29

What are 12 items on the HiMAT from least difficulty to most difficult?

Answer 29

Question 30

What is the walk backwards as an item on the HiMAT for return to running after TBI?

Answer 30

Question 31

What is the walk over obstacle as an item on the HiMAT for return to running after TBI?

Answer 31

Question 32

What is the walk on toes as an item on the HiMAT for return to running after TBI?

Answer 32

Question 33

What is the bounding as an item on the HiMAT for return to running after TBI?

Answer 33

Question 34

What is the run as an item on the HiMAT for return to running after TBI?

Answer 34

Question 35

What is the criteria for return to running after a TBI?

Answer 35

• No published criteria
• Safety and capacity are important

Question 36

Why is it important for Michelle to return to running (3)?

Answer 36

1. Young, active
2. Running and sport is a big part of her life
3. Important to maintain her health (weight management, mental health), and set example for her family & students

Question 37

What are 6 things to consider about returning to running post-pregnancy?

Answer 37

1. Pelvic floor disorders (and rectus diastasis) are common post-partum
2. Type of delivery & recovery timeline may affect functional ability to return to exercise:
   
   1. Risk of pelvic organ prolapse and surgery
   2. Urinary & faecal incontinence
   3. Time required for complete repair of abdominal fascia after caesarean section (51-59% of original tensile strength at 6 weeks, 73-93% at 6-7 months)
   4. Pain – use as a guide
3. May need medical clearance
4. Significant cardiovascular and muscle impairments post-partum
   
   1. Can have significant muscle atrophy even after 15-30 day detraining period
   2. Requires gradual retraining
5. Elite athletes:
   
   • 77% of Norwegian elite athletes (n=40) continued to compete at the same level post-partum
6. Readiness for return to physical activity and sport is an individual decision
   
   • No data to suggest that rapid return is associated with adverse outcomes

Question 38

What are 4 characteristics of type of delivery & recovery timeline affecting functional ability to return to exercise as considerations about returning to running post-pregnancy?

Answer 38

1. Risk of pelvic organ prolapse and surgery
2. Urinary & faecal incontinence
3. Time required for complete repair of abdominal fascia after caesarean section (51-59% of original tensile strength at 6 weeks, 73-93% at 6-7 months)
4. Pain – use as a guide

Question 39

What are the 3 management for retunr to running post-partum?

Answer 39

Question 40

What is the criteria for return to running post-partum?

Answer 40

• No published criteria
• Safety and capacity are important