Return to Play
Roddy McGee, D.O.
Lawrence Lemak, M.D.
The most common and sometimes only question asked when an athlete has had an injury is, “How long am I out?” Athletes, their parents, and coaches are increasingly interested in descriptions of the anatomy, injury mechanism, and the latest surgical techniques for how the injury is managed. However, they are most concerned with when the player will be able to get back on the field or court.
There are many factors that come into play when making decisions about when to release an athlete to full participation after an injury. By working together, the physician, physical therapist, athletic trainer, coaches, player, and family can follow a plan to ensure a safe return to their sport or activity. They can also work to reduce the risk of another injury and give the athlete their best chance to return to their previous level of performance.
The severity of the injury is the first and most obvious factor that is considered. Muscle strains usually heal faster than ligament injuries or fractures. Injuries that require surgery will typically have a longer time to return than those that do not. In addition to our exam, we use X-ray, MRI, and other diagnostic tests to help us know how serious an injury is and in some cases to help predict time to return. The physician evaluates the athlete during the recovery period to be sure that several criteria are met on a schedule that they expect. Has a surgical wound healed? Curt Schilling's "bloody sock" game in 2004 goes against this idea, but we typically like the wound to be completely healed before a return to activity. Has the swelling improved or resolved? Is the athlete pain free? This may not be an absolute, but continued pain following an injury can be a sign that more needs to be done. Have they regained their full range of motion and stability of the injured area? If any of these factors are not meeting the physician’s satisfaction, the usual course of treatment is altered and this can sometimes prolong the eventual return.
Next, there are sport specific factors that play into our decision. A thumb injury in a baseball shortstop would not have the same return time as for a lineman in football, who can wear a soft cast to protect the injury and still participate in a collision sport with reasonable risk for additional injury. Position specific demands of the same sport can change the plan as well – that same injury on the quarterback’s throwing hand would likely leave him on the sideline.
An injury’s effect on a young person’s self-esteem is often an overlooked element, particularly at the high school level. First, recognize that when an athlete sustains an injury, they have a significant disruption to their daily routine. They are used to a very regimented schedule of school, workouts, and practice. After an injury, they are removed from this structure and also the social environment that those activities provide. They also go through familiar emotional responses – denial, anger, depression, and others, and some kids are better equipped to handle these feelings than others. There is a wide variety in the amount of support available to kids at the youth and high school levels. Coaches and administrators have an opportunity to have a positive impact on their athletes’ lives at a time of significant stress. Losing the identity of being an athlete during a time of injury can be devastating to a young athlete. Every effort should be made to give the athlete the support they need. It is important to include them as part of the team, even though they may be physically unable to perform. There’s another benefit to offering this type of support – athletes that have less stress have a better chance of returning to their sport and they recover faster.
Another important set of issues involves the time of the season and the importance of upcoming contests. Most of our kids are playing sports year-around now. They may have an upcoming tournament or game that could lead to a college scholarship opportunity. There are times when a treatment plan can be tailored to allow an athlete to get through a short period of activity while dealing with the injury. This plan might be quite a bit different if they were in an off-season period. Kerri Strug would not have completed a second vault after injuring her ankle if she was hurt three months before the Olympics. Because it was during the competition, she continued, won the Gold medal, and gave fans a moment that will be remembered forever. If the physician and other members of the sports medicine team aren’t asking these specific questions, it is up to the athlete and the coaches to share this information. The ultimate decision on returning an athlete to full, unrestricted activities takes careful consideration of all these factors and it’s not always clear-cut - even for physicians with experience in handling these issues.
Some injuries and their rehab process have received so much media attention that the athletes know their course before they even get to the office. “Tommy John” surgery for a baseball pitcher is probably the best example. They know that Stephen Strasburg pitched in a game 12 months after his Tommy John surgery and so their only question is often, “What day can I schedule my surgery and when do I start physical therapy?” Other injuries are not as familiar to athletes and those around them. In all cases, it is critical for the physician and the rest of the sports medicine team to have open, clear communication about the injury and all the steps of the process to returning to full participation. It is essential to make the athlete aware of the expectations prior to any treatment, particularly surgery. This is our best chance to have an excellent outcome, to minimize the risk of a repeat or additional injury, and to allow the athlete to participate and perform at a level that they are hoping to achieve.