Return to Play Decisions

Though a beautiful time of year, fall is not
the most idyllic for a sports medicine clinician

Like many of the readers out there, my colleagues and I are deep in a football season, where we are managing various teams and their mounting injuries.  For a sports medicine physician, fall in America must be a bit like early spring for an accountant (tax day = April 15):  it’s the time to buckle down and crank through patients, the time, from a certain perspective, to see the volume of patients that will sustain the business through leaner times of the year.

When I’m out of the clinic and on the sidelines, I’m also doing one of the parts of my job that is the most fun, and I’m sure my colleagues out in the blog sphere will agree.  But I wouldn’t describe the work as an idyll.  I can be enjoying my team’s performance, and then called in three directions at once, treating players and making decisions on whether they can get back into the game:  decisions that can have significant consequences for the player and the team.

I thought I would write somewhat extemporaneously today, and in sharing some of the more interesting cases I have seen of late think in a more structured way about how we primary care sports medicine physicians make return to play (RTP) decisions.

RTP decisions make the headlines all the time.  In the professional leagues of North American sports, in just the last two weeks, we have seen discussions about Kobe Bryant’s return to the NBA from late spring Achilles tendon surgery; Rob Grownkowski’s ‘delayed’ return from a surgically treated forearm fracture; the much anticipated return of Derrick Rose more than a year after his ACL reconstruction; debate over RGIII and whether he has come back too soon from his own multi-ligamentous knee injury…….the list goes on!

The end of a season?

In my own practice, I have been trying to return players back to American football while they have recovered from a kidney contusion, a posterior elbow dislocation, a complete rupture of the ulnar collateral ligament, and a demyelination injury of the axillary nerve.  Of the four, two are back playing; the elbow dislocation is still rehabbing, and i hope to return in a hinged knee brace before the end of the year; and the axillary nerve injury continues to have pain and profound weakness of his deltoid, and his recovery will extend beyond the end of this season (much to the coach’s dismay).

Despite being one of the more important aspects of our job, there is very little in the way of evidence-based medicine to guide a clinician in these decisions.I have turned to the medical literature to help guide me with some of the above decisions.  Perlmutter et al. have written about “Direct Injury to the Axillary Nerve in Contact Sports” and I found an article on NFL players and kidney injuries to be helpful in my management of the player with a kidney contusion.

Taking a more general perspective on the matter, I have found a 2010 CJSM article written by Creighton et al. to be very helpful in my thinking about RTP decisions:  “Return to Play in Sport:  A Decision Based Model.” This article, by the way, is one of the many free offerings we have at the CJSM website; download the PDF and read it on your pad or print it out, but definitely check it out.

The authors break the RTP decision into three components:  Step 1: Assess the Health Status of the Individual Player by making a thorough assessment of the medical factors of the situation; Step 2:  Assess the Participation Risk (factoring in ‘sports risk modifiers’ which include protective bracing, padding etc.); Step 3:  Assess whatever Decision Modifiers may be present.

So in the case of my high school football athlete recovering from a kidney contusion, in Step 1 I would factor in his symptoms, his physical examination findings, the presence and extent of hematuria, and any findings on imaging (distinguishing say a kidney laceration from a contusion).  When his symptoms have abated, his exam has normalized, and he has no more hematuria on urinalysis, I will progress him.  In Step 2 I would note that he has his highest risk in organized sports of reinjuring that organ in a collision sport such as football (of note, a 2012 study in Pediatrics found that, though rare, the highest incidence of kidney injuries in sports were in football; none of them were catastrophic or required surgery in this series of 4.4 million ‘athlete exposures’).  I would also note I could have him wear a ‘flack jacket’ in sport to protect his kidney (a ‘sport risk modifier’).    And finally in Step 3, I would identify his ‘Decision Modifiers’ as multiple:  his age, his own strong desire to get back on the field, his father’s equally strong desire to have him play, and the facts that he is a valuable member of his team and there are three more games in his season.*  More or less that boils down to this:  he is a high school football player and not an NFL player; and in the balance on the other side, he, his family, and his coach are pressuring me.

I’ve made these decisions hundreds of times in my life, but I have heretofore not thought as systematically about the issue.  The Creighton study I think is very informative and very helpful.  I think it is often helpful as a clinician who has practiced for many years to step back and read, and then take a more structured approach to something one has been doing perhaps intuitively.  This is one of the exciting aspects about being in academic medicine, for instance:  when I teach medical students and other physicians-in-training how to do an exam, or read a film, I frequently am forced to read about the teaching point and add some new dimension to my thinking about the problem.  In fact, an old dog can learn new tricks.  This is, of course, one of the major motivations many of you will have for reading the articles in CJSM regularly.

We’ve written about RTP decisions and the responsibilities of the ‘Team Physician’ on a few occasions here on the blog, and the Creighton study is not the only one you would find in the pages of the journal.  My predecessor, Chris Hughes, wrote about a ‘risk tolerance’ approach to RTP decisions in 2012.   I wrote about the Team Physician Consensus Statement, authored by the AMSSM and other governing bodies, this summer.  This topic is important enough that it will be a recurring theme, a conversation: one I hope you will join in.  Be sure to share your comments here or tweet us @cjsmonline.

Enjoy your sporting Sunday!

*p.s. The player in question will be playing this Friday, three weeks out from his injury.