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Return to play: Too soon or too safe?

An athlete suffers an injury. As the Athletic Trainer you have two options; remove the athlete from participation, or clear them to return to their respective sport. As a qualified healthcare provider the individual Athletic Trainers discretion comes highly into play with this decision as each person may make a different decision on the sideline compared to the other. What about the athlete that was removed from participation and has been going through rehabilitation, how do you make the decision to return to play? How do you make the decision in such a way that it is in the best interest of the athlete?

As I thought about answering this question myself there really isn't a black and white answer. The gray areas to answering this question are a broad spectrum to what may influence how the Athletic Trainer could approach this.

Pre-participation screenings
Whether it be the FMS, 3D MAPS, the Assess and Correct approach, or whatever you may do to approach Screening your athletes prior to competition this assessment contributes to how and when they return to play. I also combine this data with their respective sports conditioning tests from a sports performance stand point, this way an athlete can see that if their scores aren't near what they were before they were injured how can they return to their sport both safely but also efficiently.

Doctors release
How often does one of our athletes come in with a release from their doctor ready to go from 0 to 100 miles an hour? Too often for my taste in my experiences with an athletes getting released to return to play. This is can be an issue for a coupe of reasons:
1.) The athlete may have gone to physical therapy and there hasn't been communication between the physical therapist and athletic trainer about what the athlete has been doing on both sides. Now the athlete is being treated multiple times in multiple ways and its unclear of what may be helping or aggravating their condition. So how do you foster excellent communication between the two professions without stepping on toes or it becomes a contest?
2.) The athlete has been doing some functional movements relating to their sport but has not participated in said sport or done them enough to become as fatigued as they would be during a practice let alone a game. This becomes a source of much debate as how do you prepare an Athlete to practice for 2-4 hours, how do you give the athlete a certain level of physical contact that they would expect during play, and how do you challenge all of the energy systems and muscle fiber types needed in their respective sport during their return to play protocol or continuum ?
3.)The athlete has been not done any treatment by anyone and has been cleared to play by a doctor so now the parents, the athlete, AND the coach now expect the athlete to be in practice immediately. How do you educate all of the above that the athlete is not ready AND prove it to them?


Objectivity
This is probably one of the toughest of all of the reasons that we may return and athlete to participation or hold them back. Objectivity can come in several forms:
1.) We as the Athletic Trainer like the athlete. This athlete is on time, tells you the truth about what they have or haven't been doing, they listen to what you are telling them to do, and are genuinely the typical athlete you want to work with. Not saying that we don't want everyone to do well but this athlete holds a special place in your heart so of course you push to get them back in the game. How do you stay objective enough to look at the data you have and make the call to hold them out if they need it? OR How do you stay objective when they don't need to be held back but you have concerns because you don't want them suffer re-injury?
2.) We strongly dislike the athlete. Everyone has encountered this athlete, they miss appointments, lie to the coaches and parents about getting treatment, they don't even attempt to do exercises with any enthusiasm or care, and they may even have a bad attitude to boot. How do you stay objective enough to (a.)not hold them out, out of sheer spite or (b) use the data we have to make an informed decision?
3.)It's a high stakes game. We have all encountered this one as well. It is senior night, homecoming, state, nationals, or the championship to end all championships. Now you have pressure from everyone to get this athlete back. Pressure is coming from the parents, the athlete, the coaches, Athletic Directors, anyone who has some kind of stake in the upcoming game. When everyone is thinking about a win and you are the only one looking out for the athletes best interests, how do you stay objective when it may not be safe to have the athlete return or pull them if they get injured during the game?


Returning an athlete to participation is never cut and dry as everyone would like it to be, due to the layers that are involved. However, approaching this proactively, preventatively, and with a certain level of communication can eliminate headaches that exist in the immediate future and down the road. So what is your approach?
Audric Warren MS, ATC, CAFS, NASM-PES, NASM-CES
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