“When Can I Play Again?”
For most physiotherapists that work with athletes, this is one of the first questions asked by any injured competitor. Regardless of the nature of the injury, most athletes are looking for that magical date in time when they will be able to return to their competitive sport and play just as they were prior to their injury.
As a physio however, we know that there are many factors that need to be considered before any player steps back into competition. Return to Sport (RTS) should be viewed as a continuum that begins at the initial assessment, continues through the rehabilitation process, and progresses through the performance phase. In the First World Congress in Sports Physical Therapy, the RTS was outlined as having three distinct stages.1
In the Return to Participation phase, an athlete may be allowed to participate in training sessions with clearly outlined parameters and/or restrictions. This phase serves as a great stepping stone in returning to sport when athletes are not quite ready for the full demands of their sport. These reasons could include medical, physical, or psychological factors.
The Return to Sport phase sees an athlete fully participating in their specific sport but not at their ideal performance level. Sometimes an individual can view this stage as the point in which they have completed their return to sport. This can vary on the individual and the desired end goal. For example, a varsity level hockey player who tears her ACL in her final year of college may be happy to return to rec league hockey following her rehab. Conversely, a competitive grade 10 hockey player looking to obtain a university scholarship will be wanting to ensure that she is even stronger and faster than she was pre injury to achieve this goal as well as be ready for the demands of varsity hockey.
The Return to Performance phase is when the athlete has achieved or exceeded the level of performance that they were at prior to injury. Individuals in this phase are now looking at higher performance goals, improved metrics of performance, and PR’s better than their pre injury level.
So how does a physiotherapist progress an athlete through these phases safely? What markers or guidelines are there to know when an athlete should be progressed or even regressed in this RTS continuum? Fortunately, there are various models or frameworks that can help guide the therapist’s decision in RTS.
(1) The Strategic Assessment of Risk and Risk Tolerance (StARRT)
This was one of the 3 models put out by the 2016 Return to Sport Consensus Statement.1 Its intent is to estimate the risks of outcomes associated with Return to Sport.
Step 1 looks at tissue health and what load the tissue can absorb. What stage of healing is the athlete at? Is this a recurrent injury? Answering these questions help to determine the overall tissue health and whether the athlete is ready to Return to Sport.
Step 2 determines the types of tissue stress, analyzing this increasing load and the ability of the injured structure to withstand this. Important factors to consider here include type of sport, level of competition, position, and psychological readiness. Knowing the types of stress that the tissues need to be able to withstand, better help determine whether the athlete is ready to Return to Sport or not.
Step 3 looks at factors that could alter the tolerance for risk and influence return to sport by providing a final ascertained risk to the athlete. For example, extra pressure could be added to a player if playoffs are coming up or if fans create pressure via social media sources.
(2) Load Management
One of the key components in Return to Sport is load management. Human physiologist Dr. Tim Gabbett’s research on the Acute to Chronic Workload Ratio (ACWR) outlined that the training load of any given week (acute workload) should be 0.8-1.3 times the average of the training load of the previous 4 weeks (chronic workload).2 Loading tissue more than this could create failure of the structure or increase risk of injury. However, failure to increase load sufficiently could also not adequately prepare the athlete for the demands of his or her sport. In general, chronic workload should not increase by more than 10% of the previous week’s load to ensure injury risk remains below 10%. As these studies were based on healthy individuals, these parameters may need to be adjusted in the rehab setting.
The bold black line outlines % risk of subsequent injury, with the green zone representing optimal workload ratio for an athlete. It's important to note that injury risk can increase if the ACWR also goes too far below this zone, because even though the workload is reduced, this deconditioning effect can increase risk of injury when the workload does increase again.
(3) Control Chaos Continuum (CCC)
This model outlines a 5-phase progression that challenges athletes by modifying running speed, direction, and load while varying impact forces and the number of training sessions.3 In this continuum, the athlete goes from a high control/low chaos situation towards one of low control/high chaos. This initial controlled environment minimizes risk to athlete while allowing them to begin sports specific movements. Athletes progress, as tolerated, towards faster more reactive drills that mimic the difficulty and volume of their competitive sport.
The five key phases are:
High Control: return to running, high control over running speeds/loads, low impact, build player confidence
Moderate Control: introduce change of direction with the ball, reduce control, progress high speed running load
Control to Chaos: add sport-specific weekly structure to overload game-specific demands to transition from control to chaos (add reactive movements within limits)
Moderate Chaos: increase HSR, reduce limits on reactive drills, increase specificity of sports drills
High Chaos: return to weekly full training sessions and drills designed to test worst case scenarios (high speed/ high chaos)
Number of Training Sessions
Many athletes assume that as soon as they can do some running or multidirectional drills with the ball in the clinical setting that they are then ready to use limited game minutes to further their rehab and fitness. It has been shown that competitive game situations have a 7-fold increase in injury rates compared with normal training sessions.4 This increased chance of injury is largely due to the much larger loads put on the athlete, the reactive type of drills, and the competitive environment that encompasses game situations. One study showed that the first match back for an athlete returning after injury can have an 87% higher injury rate than the rate for regular season matches and the chance of a muscle injury is 158% higher.5 It makes sense then to see that increasing the number of training sessions an athlete completes before returning to competition correlates inversely with the likelihood of reinjury. It has been shown that athletes who completed less than four training sessions before stepping into games were 3x more likely to become injured than those athletes that completed four or more.5 Each additional training session beyond this lowered the risk of injury by 13% with this data recommending a minimum of six training sessions before returning to competitive play.5
As this blog intends to outline, Return to Sport is an entire process to ensure an athlete can adequately handle the specific demands of their sport. These models show many of the different approaches that a physiotherapist can draw from to ensure the athlete is ready both mentally and physically. It is most important to remember that proper Return to Sport is a highly individualized process designed to meet the unique needs of each athlete.
(1) Br J Sports Med.2016; 50:853-864
(2) Br J Sports Med. 2016; 50: 471-475.
(3) Br J Sports Med. 2019; 53:1132-1136.
(4) Br J Sports Med. 2013; 47:732-737.
(5) Br J Sports Med. 2019; 0:1-6.
Karen Nichol, founder of Royal City Physio, graduated from the University of British Columbia with a Bachelor of Science in Physiotherapy. She is currently the head physiotherapist for Coquitlam Adanac Sr A's and head physiotherapist for the Police Academy at The Justice Institute of B.C. She is also a member of the Canadian Physiotherapy Association, and the Physiotherapy Association of B.C. Book with Karen today.