The Team Physician and Return-To-Play Issues Consensus Statement

Summary

The objective of this Consensus Statement is to provide physicians who are responsible for the healthcare of teams with a decision process for determining when to return an injured or ill athlete to practice or competition. This statement is not intended as a standard of care, and should not be interpreted as such. This statement is only a guide, and as such is of a general nature consistent with the reasonable and objective practice of the healthcare professional. Individual decisions regarding returning an injured or ill athlete to play will depend on the specific facts and circumstances presented to the physician. Adequate insurance should be in place to help protect the athlete, the sponsoring organization, and the physician.

This statement was developed by the collaborative effort of six major professional associations concerned with clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to “bring together sports medicine organizations to best serve active people and athletes.” The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine.

Expert Panel

Stanley A. Herring, M.D., Chair, Seattle, Washington
John A. Bergfeld, M.D., Cleveland, Ohio
Joel Boyd, M.D., Edina, Minnesota
Timothy Duffey, D.O., Columbus, Ohio
Karl B. Fields, M.D., Greensboro, North Carolina
William A. Grana, M.D., Tucson, Arizona
Peter Indelicato, M.D., Gainesville, Florida
W. Ben Kibler, M.D., Lexington, Kentucky
Robert Pallay, M.D., Hillsborough, New Jersey
Margot Putukian, M.D., University Park, Pennsylvania
Robert E. Sallis, M.D., Alta Loma, California

Definition

"Return-To-Play" is the process of deciding when an injured or ill athlete may safely return to practice or competition.

Goal

The goal is to return an injured or ill athlete to practice or competition without putting the individual or others at undue risk for injury or illness.

To accomplish this goal, the team physician should have knowledge of and be involved with:

Establishing a Return-To-Play Process
Evaluating Injured or Ill Athletes
Treating Injured or Ill Athletes
Rehabilitating Injured or Ill Athletes
Returning an Injured or Ill Athlete to Play

Establishing a Return-To-Play Process

Establishing a process for returning an athlete to play is an essential first step in deciding when an injured or ill athlete may safely return to practice or competition.

It is essential for the team physician to coordinate:

Establishing a chain of command regarding decisions to return an injured or ill athlete to practice or competition
Communicating the Return-To-Play process to player, family, certified athletic trainers, coaches, administrators and other healthcare providers
Establishing a system for documentation
Establishing protocols to release information regarding an athlete's ability to return to practice or competition following an injury or illness

It is essential that the Return-To-Play process address the:

Safety of the athlete
Potential risk to the safety of other participants
Functional capabilities of the athlete
Functional requirements of the athlete's sport
Federal, state, local, school and governing body regulations related to returning an injured or ill athlete to practice or competition

Evaluating Injured or Ill Athletes

Evaluation of an injured or ill athlete establishes a diagnosis, directs treatment and is the basis for deciding when an athlete may safely return to practice or competition. Repeated evaluations throughout the continuum of injury or illness management optimize medical care.

It is essential that evaluation of an injured or ill athlete include:

A condition-specific medical history
A condition-specific physical examination
Appropriate medical tests and consultations
Psychosocial assessment
Documentation
Communication with the player, family, certified athletic trainer, coaches and other healthcare providers

In addition, it is desirable that:

The team physician coordinate evaluation of the injured or ill athlete

Treating Injured or Ill Athletes

Treatment of an injured or ill athlete promotes the safe and timely return to practice or competition.

It is essential that treatment of the injured or ill athlete:

Begin in a timely manner (see Sideline Preparedness for the Team Physician: A Consensus Statement)
Follow an individualized plan, which may include consultations and referrals
Include a rehabilitation plan
Include equipment modification, bracing, and orthoses as necessary
Address psychosocial issues
Provide a realistic prognosis as to the safe and timely return to practice or competition
Include continued communication with the player, family, certified athletic trainer, coaches and other healthcare providers
Include documentation

In addition, it is desirable that:

The team physician coordinate the initial and ongoing treatment for the injured or ill athlete

Rehabilitating Injured or Ill Athletes

Comprehensive treatment includes proper rehabilitation of an injured or ill athlete, which optimizes the safe and timely return to practice or competition. The team physician should be involved in a network that integrates expertise regarding rehabilitation. This network should include certified athletic trainers, physical therapists, medical specialists and other healthcare providers.

It is essential that the rehabilitation network:

Coordinate the development of a rehabilitation plan that is designed to:
- Restore function of the injured part
- Restore and promote musculoskeletal and cardiovascular function, as well as overall well-being of the injured or ill athlete
Provide sport-specific assessment and training, which can serve as a basis for sport-specific conditioning (see The Team Physician and Conditioning of Athletes for Sports: A Consensus Statement)
Provide for continued equipment modification, bracing and orthoses
Continue communication with the player, family, rehabilitation network and coaches concerning the athlete's progress
Include documentation

In addition, it is desirable that:

The team physician coordinate the rehabilitation program for the injured or ill athlete

Returning an Injured or Ill Athlete to Play

The decision for safe and timely return of an injured or ill athlete to practice or competition is the desired result of the process of evaluation, treatment and rehabilitation.

It is essential for Return-To-Play that the team physician confirm the following criteria:

The status of anatomical and functional healing
The status of recovery from acute illness and associated sequelae
The status of chronic injury or illness
That the athlete pose no undue risk to the safety of other participants
Restoration of sport-specific skills
Psychosocial readiness
Ability to perform safely with equipment modification, bracing and orthoses
Compliance with applicable federal, state, local, school and governing body regulations

Prior to Return-To-Play, these criteria should be confirmed at a satisfactory level.

Conclusion

Using the information in this document allows the team physician to make an informed decision as to whether an injured or ill athlete may safely return to practice or competition.

The Return-To-Play process should be under the direction of the team physician whenever possible. While it is desirable that the team physician coordinate evaluating, treating and rehabilitating the injured or ill athlete, it is essential that the team physician ultimately be responsible for the Return-To-Play decision. Individual decisions regarding returning an injured or ill athlete to play will depend on the specific facts and circumstances presented to the team physician.

Available Resources

On-going education pertinent to the team physician is essential. Information regarding team physician-specific educational opportunities can be obtained from the six participating organizations:

American Academy of Family Physicians (AAFP)
11400 Tomahawk Creek Pkwy.
Leawood, KS 66211-2672
1-800-274-2237; http://www.aafp.org

American Academy of Orthopaedic Surgeons (AAOS)
6300 N. River Rd.
Rosemont, IL 60018
1-800-346-AAOS; http://www.aaos.org

American College of Sports Medicine (ACSM)
401 W. Michigan St.
Indianapolis, IN 46202-3233
(317) 637-9200; http://www.acsm.org

American Medical Society for Sports Medicine (AMSSM)
11639 Earnshaw
Overland Park, KS 66210
(913) 327-1415; http://www.amssm.org

American Orthopaedic Society for Sports Medicine (AOSSM)
6300 N. River Rd., Suite 200
Rosemont, IL 60018
(847) 292-4900; http://www.sportsmed.org

American Osteopathic Academy of Sports Medicine (AOASM)
7611 Elmwood Ave., Suite 201
Middleton, WI 53562
(608) 831-4400; http://www.aoasm.org

Suggested References

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American College of Sports Medicine, American College of Cardiology, 26th Bethesda Conference. "Recommendations for competition in athletes with cardiovascular abnormalities." Medicine & Science in Sports & Exercise (MSSE), 1994; 26 (10): 5223-5283.

American Medical Society for Sports Medicine, American Academy of Sports Medicine. "Human Immunodeficiency Virus and Other Blood-Borne Pathogens in Sports," (Joint Position Statement) Clinical Journal of Sports Medicine (CJSM), 1995; 5:199-204.

Cantu, R.C. "Return-to-play guidelines after a head injury." CJSM, 1998; 17(1): 45-60.

Cantu, R.C. "Stingers, transient quadriplegia and cervical spinal stenosis; return-to-play criteria." MSSE 1997; 29(7 Suppl): S233-5.

Committee on Sports Medicine and Fitness "Cardiac dysrhythmias and sports." Pediatrics May 1995, 95(5): 786-9.

Goodman, R., Thacker S., Soloman S., et al "Infectious disease in competitive sports." JAMA, 1994, 271 (11): 862-6.

Herring, S.A. "Rehabilitation of muscle injuries." MSSE, 1990, 22: 453-6.

Kibler, W.B., Herring, S.A., Press, J.M. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Aspen Publishers, Maryland, 1998.

Kibler, W.B., Livingston B.P, "Closed-chain rehabilitation for upper and lower extremities." Journal of the American Academy of Orthopedic Surgery, 2001, 9: 412-21.

Maron, B.J. "Cardiovascular risks to young persons on the athletic field." Annals of Internal Medicine, September 1998, 129(5) 379-86.

Mellion, M.B., Walsh, W.M., Madden, C., Putukian, M., Shelton, G.L. (eds). Team Physician's Handbook, 3rd Edition. Hanley & Belfus, Philadelphia, 2002.

Mitten, M.J., Mitten, R.J. "Legal considerations in treating the injured athlete." Journal of Orthopedic Sports Physical Therapy, 1995, 21(1): 38-43.

Preparticipation Physical Evaluation, 2nd Edition. AAFP, AAP, AMSSM, AOSSM, AOASM. The Physician and Sportsmedicine; McGraw-Hill Healthcare, Minneapolis, 1997