Return to Play Decision-Making Flashcards
General:
Running Progression
Agility/Plyometrics
Running Progression:
Running > Sprinting
Running: Begin with controlled, straight-line jogging. Gradually increase speed and distance over several sessions, focusing on maintaining proper form and endurance.
Sprinting: Once comfortable with jogging, introduce sprints. Start with shorter distances and controlled acceleration, progressing to longer sprints and full-speed running. Incorporate varying speeds and distances.
Agility/Plyometrics:
Cutting/pivoting
Jumping/landing
Cutting/Pivoting:
Begin with controlled lateral movements such as side shuffles and gradually introduce sharper changes in direction.
Progress to sport-specific drills like cutting at 45- and 90-degree angles, focusing on proper mechanics to reduce injury risk.
Pivoting drills, such as 180-degree turns, can be integrated as reaction-based movements to simulate game scenarios.
Jumping/Landing:
Start with vertical jumps and focus on controlled landings, emphasizing soft knees and proper alignment to avoid valgus collapse.
Progress to more dynamic plyometrics such as box jumps, depth jumps, and lateral hops, ensuring good form is maintained throughout.
Multi-directional jumping and landing can be introduced later, incorporating forward, backward, and lateral movements to simulate game scenarios.
Sport specific:
Sport specific progression
What do they need to do?
Practice Drills?
Incorporate ball/defender
Unanticipated movement
What Do They Need to Do?
Develop Specific Skills: Athletes should focus on skills directly related to their sport, including technique, agility, speed, and endurance.
Simulate Game Conditions: Create scenarios that mimic competitive situations, including the physical and mental demands of the sport.
Practice Drills:
Technical Drills: Focus on skills essential for the sport, such as dribbling in basketball, passing in soccer, or swinging in tennis.
Agility and Conditioning Drills: Incorporate drills that enhance footwork, acceleration, and deceleration, such as ladder drills, cone drills, or shuttle runs.
Endurance Workouts: Increase aerobic capacity through interval training or longer sessions that build stamina, reflecting game duration.
Incorporate Ball/Defender:
Ball Handling: For sports like basketball or soccer, integrate ball skills into drills (e.g., dribbling under pressure, passing with movement).
Defender Interaction: Introduce a defender during drills to simulate real-game pressure and decision-making (e.g., one-on-one scenarios, small-sided games).
Team Play: Gradually incorporate team drills to foster communication and coordination among players, reflecting the dynamics of a game.
Unanticipated Movement:
Reaction Drills: Include drills that require athletes to respond to unpredictable stimuli (e.g., a coach’s command, a moving defender).
Change of Direction: Practice quick cuts, pivots, and changes in speed/direction without pre-planned movements to enhance adaptability.
Game-like Situations: Use scrimmages or small-sided games to create an environment where athletes must react to various scenarios and opponents.
LE return to sport testing:
85% of studies for RTS testing were for knee injury (82% were ACL)
6.2% studies looked at RTS after hip
2 studies looked at RTS after ankle sprain
Research Gap: The data reveals a disproportionate focus on knee injuries, particularly ACL injuries, in RTS testing research.
There is a notable lack of studies concerning hip and ankle injuries, which may hinder evidence-based practices for those conditions.
Need for Broader Research: Expanding research to include a wider variety of injuries, particularly hip and ankle, could enhance understanding and guidelines for RTS protocols in diverse athletic populations
CAUTION: Most return to sport criterion lack validity
Lack of Standardization: Variability in Protocols and No Universal Guidelines
Incomplete Assessment: Focus on Physical Factors and Limited Functional Testing
Lack of Predictive Validity: Insufficient Evidence Linking Failure to Account for Individual Differences
The most consistent finding across injury risk factor literature:
1 risk factor for having an injury is previously having that injury
due to various factors, including residual physical deficits (like strength or range of motion), psychological barriers (such as fear of re-injury), and biomechanical changes that may persist after recovery
Return to sport testing goal:
Determine physical and psychological readiness
While respecting biological healing
Reduce risk of re-injury
Determine Physical and Psychological Readiness:
Assess strength, flexibility, endurance, and functional movement to ensure the athlete can meet the physical demands of their sport.
Utilize objective measures (e.g., strength tests, functional movement screens, sport-specific drills) to evaluate performance.
Evaluate the athlete’s mental state, including confidence, anxiety levels, and coping strategies.
Respect Biological Healing:
Adhere to Healing Timelines
Monitor for Signs of Overtraining or Pain
Reduce Risk of Re-injury:
Implement Comprehensive Assessments
Develop Individualized Rehabilitation Plans
Educate Athletes on Injury Prevention
Passing RTS criteria does not mean the athlete can go right back to game play:
It means they are cleared to begin a RTS progression
athlete has met specific benchmarks regarding physical and psychological readiness but does not guarantee they are ready for full competition or gameplay
signifies that the athlete can safely engage in a graduated RTS progression, which may include modified practices, drills, or scrimmages designed to gradually reintroduce them to the demands of their sport
Return to any sport:
82%
majority of athletes who undergo rehabilitation for an ACL injury manage to return to some form of sport
while many athletes can resume physical activity, it does not necessarily reflect the quality or level of participation
Return to pre-injury sport:
63%
while many can resume activity, there is still a notable percentage that may not return to the exact sport they were engaged in prior to the injury, possibly due to changes in confidence, function, or sport-specific demands
Return to pre-injury competition level:
44%
highlights the significant barriers that athletes may face in regaining their previous performance levels, which could be due to physical limitations, psychological factors, or changes in the athlete’s context (such as team dynamics or age)
Second ACL injury rates
Under 25 yo and RTS:
23%
heightened risk for younger athletes, possibly due to factors such as immaturity of the knee joint, aggressive return-to-play strategies, and incomplete rehabilitation
How do clinicians make their return to sport decisions?
Only 13% of studies used some sort of objective measure
Even worse: of those 13% the majority used a Lachman as their ONLY objective measure
Many rely heavily on subjective assessments, such as patient self-reports, clinician observations, and functional assessments based on experience rather than standardized protocol
subjective assessments can provide valuable insights, they are inherently influenced by individual clinician biases, experience levels, and interpretations of an athlete’s readiness
How many young athletes actually meet recommended RTS cutoff after ACL reconstruction?
few meet various cutoffs
very few meet all combined RTS criterion cutoffs (14%)
those meeting both strength cutoffs (>90% LSI) continued at the same level of sports participation at higher proportions than those that did not
General Principles:
Time (biology)
Symmetry:
ROM full (unless risk factor)
Strength minimum of 90% contralateral
Objective Measures:
ROM
Strength
Functional Testing (including qualitative)
Patient Reported:
Function
Fear/Confidence
Time (biology):
Follow tissue healing timeframes
Ligamentization, Bone Bruise, Mechanoreceptors
We can’t rush biology… yet
Time alone does NOT guarantee physical readiness
Ligamentization:
This refers to the process by which the graft used in ACL reconstruction undergoes maturation, transitioning from a non-functional tissue to a ligament-like structure.
This process can take several months to years, affecting an athlete’s readiness to return to sport.
Bone Bruise Healing:
Bone bruises, often associated with ACL injuries, require time to heal fully.
The healing process can take several weeks to months, and athletes may still experience pain and limitations during this period.
Mechanoreceptor Recovery:
Mechanoreceptors play a crucial role in proprioception and joint stability.
Recovery of these receptors can take time, impacting an athlete’s coordination, balance, and overall joint function.
LE Strength Testing:
MMT is NOT good enough
Use HHD, 1 rep max testing, Dynamometer
LE Negative clinical exam:
Special tests, ROM, effusion, etc
Lachman Test:
Assesses anterior cruciate ligament (ACL) integrity.
A negative test means no excessive anterior translation of the tibia relative to the femur.
Anterior/Posterior Drawer Test:
Evaluates the ACL and posterior cruciate ligament (PCL).
Negative findings indicate no excessive translation.
Valgus/Varus Stress Tests:
Evaluate the integrity of the medial and lateral collateral ligaments (MCL and LCL).
Negative results indicate stability in those ligaments.
Ankle Anterior Drawer Test:
Assesses the anterior talofibular ligament (ATFL).
A negative test shows no excessive anterior translation of the talus.
Ankle Talar Tilt Test:
Evaluates the integrity of the lateral ligaments of the ankle.
A negative test indicates stability with no excessive tilting.
LE Functional Testing:
Compare to uninvolved limb or published norms
If uninvolved limb is not healthy, use norms
Single-Leg Hop Tests
Vertical Jump Tests
Functional Movement Patterns
*squats or lunges
ACL outcomes - symmetrical strength
6 months: 20% deficits
12 months: 10-20% deficits
24 months: 1/3 have >10%
ACL outcomes:
quad strength:
- associated with function
- critical to dynamic knee stability
problem: athletes return 6-12 months likely with deficits
prolonged deficits to a critical dynamic stabilizer
recommended objective cut-off: 90% contralateral side
* even if passing, can still fail for poor quality of movement
Knee Outcome Survey (KOS) score:
Score of 90% or Higher
Athlete has achieved a high level of functional performance and is likely to have minimal knee-related symptoms during activities
Meeting this threshold is associated with a lower risk of re-injury, especially in high-risk populations such as those recovering from ACL injuries
Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) Score:
above 56
measures the psychological aspects of recovery, focusing on confidence, anxiety, and overall readiness to return to sport
score ranges from 0 to 100, with higher scores indicating greater psychological readiness
score above 56 indicates that the athlete has a positive mindset and confidence in their ability to perform at the desired level without fearing re-injury
Athletes who score above this threshold are generally more likely to adhere to rehabilitation protocols and engage in safe return-to-sport practices, reducing the risk of re-injury
simple decision rules - reduce reinjury rate after ACL reconstruction:
in the first 2 years after ACL reconstruction, 30% of people who returned to level I sports sustained a reinjury compared with 8% of those who participated in lower level sports
for every month that return to sport was delayed, until 9 months after ACL reconstruction, the rate of knee injury was reduced by 51%
more symmetrical quadriceps strength prior to RTS - significantly reduced knee reinjury rate
Conclusions:
RTS does reduce second injury risk
Need to objectively measure
Can’t Assume
Time alone is not enough
curve ball: limb symmetry indexes can overestimate knee function after ACL injury
uninvolved limb may undergo deconditioning due to changes in activity levels, compensatory movement patterns, or altered loading mechanics
deconditioning can lead to a decrease in the strength and function of the uninvolved limb, potentially skewing LSI results in favor of the injured limb
nearly one-third of individuals may meet the commonly used cutoff of 90% LSI after ACL rehabilitation
RTS Progression - Graded Exposure:
Return to practice drills
Return to practice contact drills
Return to game (limited time)
Return to game full time
Progress using intensity, opponents, time/volume
There is a large gap in our healthcare system for this population
UE Return to Sport
Current Recommendations:
Very little evidence
75% use only time
No pain/instability
Full ROM
90%+ strength (Higher if dominant arm is the involved arm)
No symptoms with sport specific exercise/drills
6 Months post-op for shoulder instability
Throwers:
Return to throwing progression (elbow or shoulder)
Progress intensity and/or distance, throw type
After cleared for significant injury:
ABC’s -> Bleeding -> Spinal/head injury -> Fracture/dislocation
If the player wants to return:
Determine if continuing to play will increase risk of injury severity
Determine if there are any impairments and if they can play safely with those
Determine if continuing to play will increase risk of injury severity:
Rules sometimes bent depending on the importance of the game
Determine if there are any impairments and if they can play safely with those:
Protective strength
Neuromuscular control
Protective sensation
Functional testing: Running, cutting, jumping, push-up (Sport & Position specific)
