Arden, CL, Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools, A., Gojanovic, B., Griffin, S

14 Pages·2016·0.86 MB·English

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Arden, C. L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen, B., Cools,
A., Gojanovic, B., Griffin, S., Khan, K. M., Moksnes, H., Mutch, S. A.,
Phillips, N., Reurink, G., Sadler, R., Silbernagel, K. G., Thorborg, K.,
Wangensteen, A., Wilk, K. E., Bizzini, M. (2016). 2016 Consensus
statement on return to sport from the First World Congress in Sports
Physical Therapy, Bern. British Journal of Sports Medicine, 50, s. 853-
864.

© 2016 BMJ Publishing Group Ltd & British Association of Sport and Exercise
Medicine
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Consensus statement
2016 Consensus statement on return to sport
from the First World Congress in Sports Physical
Therapy, Bern
Editor’schoice
Scantoaccessmore
freecontent Clare L Ardern,1,2,3 Philip Glasgow,4,5 Anthony Schneiders,6 Erik Witvrouw,1,7
Benjamin Clarsen,8,9 Ann Cools,7 Boris Gojanovic,10,11 Steffan Griffin,12
Karim M Khan,13 Håvard Moksnes,8,9 Stephen A Mutch,14,15 Nicola Phillips,16
Gustaaf Reurink,17 Robin Sadler,18 Karin Grävare Silbernagel,19 Kristian Thorborg,20,21
Arnlaug Wangensteen,1,8 Kevin E Wilk,22 Mario Bizzini23
Fornumberedaffiliationssee ABSTRACT RTS congress in Bern, Switzerland (20–21
endofarticle. Decidingwhentoreturntosportafterinjuryiscomplex November 2015). The aim of the congress was to
andmultifactorial—anexerciseinriskmanagement. present current evidence and guidelines in areas
Correspondenceto
DrClareArdern,Aspetar Returntosportdecisionsaremadeeverydayby where sports medicine clinicians (particularly phy-
Orthopaedic&SportsMedicine clinicians,athletesandcoaches,ideallyinacollaborative siotherapists and physicians) play a major role in
Hospital,P.O.Box29222, way.Thepurposeofthisconsensusstatementwasto helping athletesto RTS after injuryor surgery. The
Doha,Qatar;
presentandsynthesisecurrentevidencetomake congress also acknowledged the important role of
[email protected]
recommendationsforreturntosportdecision-making, practitioners including orthopaedic surgeons, phy-
Accepted1May2016 clinicalpracticeandfutureresearchdirectionsrelatedto siologists, coaches, and strength and conditioning
PublishedOnlineFirst returningathletestosport.Ahalfdaymeetingwasheld professionalsinhelpingathletesRTS.
25May2016 inBern,Switzerland,aftertheFirstWorldCongressin
SportsPhysicalTherapy.17expertcliniciansparticipated.
4mainsectionswereinitiallyagreedupon,then Consensusprocess
participantselectedtojoin1ofthe4groups—each A half day consensus meeting was held following
groupfocusedon1sectionoftheconsensusstatement. the congress (22 November), and 17 members of
Participantsineachgroupdiscussedandsummarisedthe the consensus group participated. Prior to the con-
keyissuesfortheirsectionbeforethe17-membergroup gress, members of the consensus group were
metagainfordiscussiontoreachconsensusonthe invited to write a narrative review on their topic
contentofthe4sections.Returntosportisnota area. Authors were asked to focus on summarising
decisiontakeninisolationattheendoftherecoveryand what is currently known and what are the future
rehabilitationprocess.Instead,returntosportshouldbe advances needed to advance knowledge in RTS.
viewedasacontinuum,paralleledwithrecoveryand This information was disseminated to the group
rehabilitation.Biopsychosocialmodelsmayhelpthe and used as a basis for the first round-table discus-
clinicianmakesenseofindividualfactorsthatmay sion, facilitated by two researchers (CLA and
influencetheathlete’sreturntosport,andtheStrategic KMK), where the four sections of this statement
AssessmentofRiskandRiskToleranceframeworkmay wereinitiallyagreedon.Participantsthenelectedto
helpdecision-makerssynthesiseinformationtomakean join one of the four groups, and each group
optimalreturntosportdecision.Researchevidenceto focused on a different section of the statement.
supportreturntosportdecisionsinclinicalpracticeis Asection leaderwas nominated bythe members of
scarce.Futureresearchshouldfocusonastandardised each group, and participants in each group dis-
approachtodefining,measuringandreportingreturnto cussed and summarised the key issues for their
sportoutcomes,andidentifyingvaluableprognostic section. Each of the groups then presented their
factorsforreturningtosport. summary, and the 17-member group discussed the
keyissuestorefineeachsection.
BACKGROUND
After a sports injury, the first question asked by Objective
most athletes (and coaches) is: ‘When will I (the Thisconsensusbuildsonimportantformativework
athlete) be able to compete again?’ The answer to published over a decade ago, regarding the team
this question is rarely straightforward and is influ- physician’s role in the athlete’s RTS. In 2002, an
enced by many factors. However, in most casesthe expert panel representing the most prominent
goals of the injured athlete and the treating clin- American orthopaedic, sports and family medicine
ician (plus other stakeholders in the decision- member societies placed the team physician prom-
making team, such as coaches, parents and man- inentlyasthegatekeeperoftheRTSdecision.1The
agers) are the same—to facilitate a timely and safe field of sport and exercise medicine has progressed
returntosport (RTS). considerably since then.2 Now, more than ever,
Tocite:ArdernCL,
GlasgowP,SchneidersA, The Swiss Sport Physiotherapy Association along decision-makingmodelsandwaysofpractisingthat
etal.BrJSportsMed withtheInternationalFederation of Sports Physical are athlete-centred are advocated, placing the
2016;50:853–864. Therapyand the BJSMhostedthe firstinternational athlete in the position of an active decision-maker
ArdernCL,etal.BrJSportsMed2016;50:853–864.doi:10.1136/bjsports-2016-096278 853
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Consensus statement
along with other relevant stakeholders.3–5 Our consensus
reflectsthisathlete-centredapproach.
Terminologyandstructure
Figure1 Thethreeelementsofthereturntosport (RTS)continuum.
In recent years, the issues relating to the resumption of sports
participation following injury have often been discussed using
the term ‘return to play’ (RTP). Although RTP is common in
1. Return to participation. The athlete may be participating in
sportsmedicinevernacular,theword‘play’ismostapplicableto
rehabilitation, training (modified or unrestricted), or in
the team sport athlete. This consensus statement is intended to
sport, but at a level lower than his or her RTS goal. The
be relevant to, and inclusive of, all sports and all athletes.
athlete is physically active, but not yet ‘ready’ (medically,
Therefore,weusetheterm‘returntosport’.
physically and/or psychologically) to RTS. It is possible to
Thisconsensusstatementisdividedintofourmainsections:
traintoperform,butthisdoesnotautomaticallymeanRTS.
1. Definitions related to RTS and the sports participation
2. Return to sport (RTS). The athlete has returned to his or
context
herdefinedsport,butisnotperformingathisorherdesired
2. ModelstohelpunderstandandguidetheRTSprocess
performance level. Some athletes may be satisfied with
3. EvidencetoinformRTSdecision-making
reachingthisstage,andthiscanrepresentsuccessfulRTSfor
4. Prioritiesforfutureresearch
thatindividual.
3. Return to performance. This extends the RTS element. The
SECTION 1: DEFINING RTS
athlete has gradually returned to his or her defined sport
To make an informed RTS decision, the definition of each RTS
and is performing at orabove his or her preinjury level. For
processshould,ataminimum,beaccordingtothesport (eg,ice
some athletes this stage may be characterised by personal
hockey, squash, 100m sprint) and the level of participation (eg,
best performance or expected personal growth as it relates
NCAA Division I, English Premier League, local recreational
toperformance.
footballleague)thattheathleteaimstoreturnto.
RTSversusremovalfromsport:introducinganewwayof
RTSsuccess
thinkingaboutRTS
Success means different things to different people and is
In certain situations, the RTS decision may be reversed to a
context-dependent and outcome-dependent. To the athlete,
success might be defined by return to sustained participation in removal from sport decision. In injuries where symptoms grad-
ually increase over time, the shared decision-making process
sport in the shortest possible time (goal focus). To the coach
(andmanyathletes),successmightbedefinedrelativetotheath- mayrelatetoreducingloading(ie,modifyingtrainingorcompe-
lete’s performance on RTS (performance focus). To the clin- tition), or when the athlete should cease participation
ician, success might be defined by the prevention of new (or altogether. In some acute injuries, the clinician must also recog-
nisewhenimmediateremovalfromsportisnecessarytoprotect
recurring) associated injuries (outcome focus). The decision-
the health of the athlete (eg, removal from sport is vital to
makingteammustcollaborativelydecideonhowsuccesswillbe
defined,assoonaspossibleaftertheinjury. protectthehealthoftheconcussedathlete).6
Removal from sport does not necessarily mean that the
athlete ceases all participation. Rather, the shared decision may
Contextualconsiderations
Contextual factors influence the expectations and risk tolerance be to modify the training and/or match load. For example, the
athlete may not complete every training session, or the athlete’s
forRTS.Theseincludethetypeofinjuryorillness(eg,acutevs
chronic), the athlete’s age (or stage of career), type of sport court time might be reduced and partly substituted with
rehabilitation focused training. Decisions about reducing load,
played(eg,individualorteam, contactornon-contact),physical
removalfromsportand thesubsequent RTSrequiretheathlete,
demands of the sport (eg, cutting, pivoting, landing), level of
participation (eg, amateur professional), significance of upcom- coach(es) and clinician(s) to work closely together. However, in
some jurisdictions, clinicians are legally required to act on their
ing participation opportunities (eg, championship match,
Olympicfinal,preseasonpractice)andsocialandfinancialcosts. own initiative if it is necessary to protect the health of the
athlete.
Progressionanddocumentation
RTS:whosedecisionisitanyway?
RTScanbeviewedasacontinuumparalleledwithrecoveryand
rehabilitation—not simply a decision taken in isolation at the In contemporary clinical practice, the RTS decision should be a
end of the recovery and rehabilitation process. As injury is an decision shared4 between all stakeholders. This requires well-
inevitablepartofsportsparticipation,optimalcontingencyplan- defined roles,7 and a dispute resolution system to protect the
ning for RTS might even happen before an injury occurs (or at athlete from coercion when there are competing risk tolerances
leastassoonastheinjuryoccurs). acrossstakeholders.5
Documentation should incorporate (but not be limited to):
definition of sport, relevant contextual factors, RTS goals and Summary
performanceonrelevantclinicalandfunctionalteststogiveevi- The key points regarding definitions of RTS and the RTS con-
dence that could be used to guide RTS decision-making. It will tinuumarepresentedinbox1.
alsooftenbehelpfultodefineanddocumenttheroles,responsi-
bilities and actionsof each memberofthe RTSdecision-making SECTION 2: MODELS TO HELP UNDERSTAND AND GUIDE
team. THE RTS PROCESS
In a RTS continuum we define three elements (figure 1), Theoreticalmodelscanhelpcliniciansmakesenseofthemyriad
emphasisingagraded,criterion-basedprogression,thatisapplic- factors that influence RTS outcomes, as well as encourage con-
ableforanysportandalignedwithRTSgoals. sistency and transparency in RTS decision-making. In this
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Consensus statement
Step 1 (tissue health) of the StARRT framework synthesises
Box1 Keytakehomemessagesregardingdefinitions information relevant to the load (stress) the tissue can absorb
forreturntosport (RTS) before injury. Step 2 (tissue stresses) synthesises information
relevant to the expected cumulative load (stress) on the tissue.
Step3(risktolerancemodifiers)synthesisesinformationrelevant
▸ TheminimuminformationrequiredtodefineRTSis:the
to the contextual factors that influence the RTS decision-
sportandthelevelofparticipationtheathleteaimstoreturn
maker’stoleranceforrisk.
to.
▸ RTSisacontinuumcomprisingthreeelements:returnto
participation,returntosportandreturntoperformance. Biopsychosocialmodel—addressingthebestinterests
▸ IncertainsituationstheRTSdecisionmaybereversedtoa oftheathlete
removalfromsportdecision. Biopsychosocial approaches are common in health settings.9–12
▸ TheRTSdecisionshouldbesharedamongallstakeholders In the athletic injury context, they provide all RTS stakeholders
(exceptinthecaseofhealthrisktotheathlete). with a framework for considering the biological, psychological
and social factors that might influence treatment and outcome
afterathleticinjury,andmightbeimportanttoconsiderforRTS
(figure3).
section, we describe the three models that may help the athlete
and clinician with RTS planning, decision-making and Optimalloading—‘theGoldilocksapproach’
transition. Load progression is a key part of rehabilitation and RTS
decision-making. Achieving and maintaining optimal loading13
are important clinical considerations. Monitoring the training
TheStrategicAssessmentofRiskandRiskTolerance load during the current training week (acute) against the
(StARRT)framework—guidingtheRTSdecision average of preceding four training weeks (chronic) provides an
The Strategic Assessment of Risk and Risk Tolerance (StARRT) acute:chronic workload ratio.14 This ratio might also be a
model8isathree-stepmodelthathelpsestimatetherisksofdif- useful tool in planning load progressions in RTS,14 especially
ferent short-term and long-term outcomes associated with RTS, when the athlete is transitioning from return to participation
andfactorsthatmayaffectwhatshouldbeconsideredanaccept- to RTS, and from RTS to return to performance in the RTS
ableriskwithinaparticularcontext (figure2). continuum. Still further research is needed to evaluate whether
Figure2 StrategicAssessmentofRiskandRiskTolerance(StARRT)frameworkforreturntoplaydecisions.AthletesshouldbeclearedtoRTS
whentheriskassessment (steps1and2)isbelowtheacceptablerisktolerancethreshold(step3),andnotclearedtoRTSiftheriskassessmentis
abovetherisktolerancethreshold(reproducedwithpermission).
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Consensus statement
Figure3 BiopsychosocialmodelofRTSafterinjury.151Examplesofphysical,psychologicalandsocialfactorsthatmayinfluenceRTSarelisted
(reproducedwithpermission).
the acute:chronic workload ratio applies in a rehabilitation important in RTS decision-making are based on prospective
setting. studiesdefiningtheriskfactorsforinjury.
Summary AssessingreadinesstoRTS
The key points regarding how RTS models can help guide the Most functional test procedures are based on closed skill tasks
RTSdecisionandtransitionarepresentedinbox2. (eg,singleortriplehop,Tdrill,figure8runs),butsportrequires
openskillsinadditiontoclosedskills.Openskillshaveareactive
element to execute the motor task, usually in addition to
SECTION 3: WHAT EVIDENCE DOWE HAVE TO INFORM
THE CLINICIAN’S CONTRIBUTION TOTHE SHARED RTS decision-making, often in afatigued state. Therefore, relying on
closed skill tasks alone in determining readiness to RTS is not
DECISION?
optimal. Gradual and sequential introduction of sport-specific
In this section, we summarise the evidence regarding RTS in
training can be used as functional tests that include an element
commonly injured body regions. Using an appropriate combin-
of protected reactive decision-making (ideally context spe-
ation of research evidence, athlete preference and clinical
expertise,3 high-quality, intensive rehabilitation15 and a highly cific).19–21Anybatteryoftestsassessingtheathlete’sreadinessto
motivated athlete16 are important for optimal RTS. Functional RTS should consider both open and closed skills, although in
and sport-specific conditioning tests play an important role in some clinical contexts this may be difficult because of factors
RTS decision-making,17 18 and many of the factors deemed includingtime,spaceandresources.Ifthisisthecase,assessment
ofclosed skills in conjunction with otherimpairment-based and
functional parameters gives the clinician and the athlete a
minimumlevelofinformationforRTSdecision-making.
Box2 Keytakehomemessagesregardingmodelsthat PhysicaltestinghashistoricallyreceivedmostattentioninRTS
canguidereturntosport (RTS) decisions, but psychological readiness is also an important
element for optimal RTS. Emotions including fear of reinjury
andcognitivefactorsincludingself-efficacyandmotivationinflu-
▸ Consideringthebiological,psychologicalandsocialfactors enceRTS.22–25TheACL-ReturntoSportafterInjuryscale26and
influencingtheRTSdecisionandtransitioncanassistthe theInjuryPsychologicalReadinesstoReturntoSportscale27are
cliniciantooptimallycontributetothesharedRTSdecision
evidence-based scalesthat mayassist the clinician assessthe ath-
(figure4). lete’spsychologicalreadinesstoRTSafterinjury.
▸ Thecompositionof,androleswithinthedecision-making
teamshouldbedeterminedasearlyaspossible.
▸ MembersoftheRTSdecision-makingteamshouldbe SpecificsportsinjuriesandRTSconsiderations
Acutekneeinjuries
preparedtoregularlyshareinformationamongallrelevant
Prevalence
stakeholders.
▸ Regularassessmentsandreviewofgoalsshouldbe ACL injuries are reported to occur with an annual incidence of
85/100000 people.28 The majority occur as non-contact injur-
scheduled.
ies,29 and adolescent girls are at the highest risk.30 Medial
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Consensus statement
Figure4 IntegratingRTSinformationtomakeanoptimaldecision.Thetoppart (1)describesthemanagementaspectsthatneedtobeaddressed
toleadtherehabilitationproject.Thebottompart (2)showstheprogressionofrehabilitationonatimeline,whereloadisprogressivelyincreasedto
promotetissuehealing,butcanbeexcessiveandrequireadaptationtoavoiddamage.TheseadaptationsgothoroughiterationswheretheStARRT
modelisappliedatdifferenttimepointsuntileventualfullRTS.Finaldecisionsarereachedbyapplyingashareddecision-makingprocess.
collateralligament (MCL)injuriesarethesecondmostcommon Additionally,closefollow-upandhigh-qualitysportsphysiother-
seriousinjuryinfootball(behindtheACL),with70%occurring apyinterventionsincreasethelikelihoodofRTS.16
asaresultofcontact.31Medialandlateralmeniscusinjuriesand Factors associated with increased risk of ACL graft rupture
articular cartilage injuries frequently occur in combination with are young age (<20years), continued participation in pivoting
kneeligamentinjuries.32 sports and the use of allografts.15 32 48–50 Athletes who have
had an ACL injury retire at ayoungerage than athletes without
RTSrateandtimetoRTS previous ACL injury,51 although the reasons for this are yet to
About half of athletes return to competitive sport after primary befullyelucidated.
ACL reconstruction, while 65% return to their preinjury
sport.33 Around 60% of non-professional athletes RTS after
non-operative treatment,34 although this has not been exten- RTScriteria(basedonpublishedliterature)
Supporting optimal physical and psychological function with
sively investigated and the available studies are variable.
respecttoRTSisanimportantclinicalconsiderationtopromote
Regardless of treatment, the RTS rate is affected by factors
including specific sport demands and regional differences.15 35 sustained sports participation. Therefore, we recommend the
incorporation of assessments of direction changes and reactive
RTSratesarelowerafterrevisionACLreconstructionthanafter
primary surgery.36 37 The length of time taken to RTS after agility tests into standard RTS criteria, and the assessment of
psychological readiness to RTS using an instrument such as the
ACLinjuryisvariable,althoughonlyaminorityofathleteshave
ACL-ReturntoSportafterInjuryscale.26
returned to their preinjury level 1yearafter surgical reconstruc-
tion.38 In men’s professional football, almost all players RTS
afterACLreconstruction.39
Acutehamstringinjuries
The mean lay-off time in professional football for all MCL
Prevalence
injuries is 23±23days.40 Most MCL injuries can be managed
Acute hamstring injury isthe most frequent non-contact muscle
conservatively, although grade III MCL injuries, or involvement injury in sports involving high-speed running;31 52–54 with a
of the deep MCL and/or the posterior oblique ligament are consistentlyhighincidence,3155andhighreinjuryrisk.55–58
associatedwithlongerrecoverytime.4142
Athletes who require lateral meniscus treatment have longer
recovery times and lower RTS rates than athletes who require RTSrateandtimetoRTS
medialmeniscustreatment.4344 Time to RTS after acute hamstring injuries varies substantially
between studies, from an average of 11.3days59 to 50weeks.60
Factorsassociatedwithreturningornotreturningtosport Among professional football players, the mean lay-off time was
Younger age, absence of concomitant full thickness cartilage 18±1961 and 19±1762 days. Following surgical repair after
injury, being a professional athlete, psychological readiness and total proximal hamstring ruptures, RTP is generally allowed
symmetrical knee function are important for RTS.15 33 45–47 after6–9months.6364
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Consensus statement
Factorsassociatedwithreturningtosportornotreturningtosport Achillestendon rupture, 29–87% of athletes return to their pre-
Although multiple studies have assessed the possible predictors injurylevel.101–105
for time to RTS,65–69 there is currently no strong evidence that
MRIcanpredicttimetoRTS.65Theindividualvariationintime Factorsassociatedwithreturningornotreturningtosport
to RTSand different RTSdefinitions70 as well as low methodo- Athletes with Achilles tendinopathy who follow a standardised
logicalqualityandtheconsiderableriskofbiasinthecurrentlit- load progression have fewer incidences of recurrence com-
erature65 might be an explanation for this. Clinical findings are pared with those who do not follow a progressive loading pro-
more valuable for prediction of time to RTS than MRI mea- gramme.99 100 This highlights the role of the clinician in
sures,butpredictingtimetoRTSisinaccuratefortheindividual promoting gradual and progressive loading when treating
athlete.67 71 Except for (the relatively uncommon) total ham- patients with Achilles tendinopathy. The pain monitoring
string rupture, not returning to sport is not a major issue in model and rating of perceived exertion may give the clinician
acute hamstring injuries—close to 100% of athletes RTS aftera important clinical cues when working with an injured
hamstringinjury. athlete.106
After Achilles tendon rupture, permanent deficits in calf
musclestrengthandtendonelongationarecommon.107–109Fear
RTScriteria(basedonpublishedliterature) of reinjury often affects the decision to RTS after Achilles
In the absence of validated objective RTS criteria, a number of tendon rupture, especially to the same sport in which the injury
different criteria have been suggested: pain-free clinical evalu- occurred.101
ation,72–74 minimal range of motion and/or strength defi-
cits,59 72 75 76 symmetrical hopping performance,72 successful
completion of a progressive rehabilitation programme and RTScriteria(basedonpublishedliterature)
sport-specific functional field testing,77–80 attained preinjury Athletes with Achilles tendinopathy should complete a full pro-
sprinting speed,60 no apprehensions during full effort gressive loading programme prior to clearance to RTS. Pain
sport-specificmovements73orfull-speedsprints,74ballisticham- shouldnotbegreaterthan5/10duringactivity,andpainshould
stringtest (eg,AsklingH-test).81 subside by the next morning. Pain and stiffness are not permit-
tedtoincreasefromweektoweek.110
Groininjury There are no milestone-based criteria for RTS following
RTSratesandtimetoRTS Achilles tendon rupture. The time-based criteria are for non-
contact sport resumption from 16weeks following injury, and
In general, RTS rates are high (>85% returned to some form
contactsportsfrom20weeksafterinjury.
of sport) after hip and groin injury and surgery, but these are
based on poor quality evidence.82 83 After groin injury, most
athletes RTS within 4weeks, but this must be considered
RTSaftershoulderinjury
against a high recurrence rate (15–25%).84 85 When reinjury
Prevalence
occurs, or if adductor and abdominal injury coexist, a longer
absence from sport can be expected.84–86 RTS times after The average prevalence of shoulder problems in overhead ath-
letes is ∼30%, with a point prevalence of 20%. The prevalence
surgery for long-standing groin pain are similar to RTS times
of substantial shoulder problems, defined as those leading to
after non-surgical procedures,87 butfor full adductor rupturesa
moderate or severe reductions in sports participation or per-
faster RTS is seen with a non-surgical approach compared with
formance,ortotimeloss,is∼10–15%.111112
surgery.88
RTStosportrateandtimetoRTS
Factorsassociatedwithreturningornotreturningtosport
Little evidence exists regarding RTS rates or time to RTS after
Reduced hip adduction strength is associated with adductor
shoulderinjury.
injury, and is a strong risk factor for groin injuries in football
andicehockey.89–92
Factorsassociatedwithreturningornotreturningtosport
Predictors of RTS after shoulder injury are unknown. Loss of
RTScriteria(basedonpublishedliterature)
glenohumeral rotation range of motion, scapular dyskinesis and
Given the association between reduced strength and adductor
external rotator weakness may be risk factors for shoulder
injury,wesuggesthipadductionstrengthshouldbemeasuredto injuryinathletes.113–115
informRTSdecision-making.
RTScriteria(basedonpublishedliterature)
Achillestendoninjuries(AchillestendinopathyandAchilles The specific goals for rehabilitation may depend on the
tendonrupture) sport,113 116 underscoring the importance of the clinician’s
Prevalence knowledge of the sport, and working closely with coaches.
The Achilles tendon is one of the most injured tendons in ath- Broadly, aim for a 10% increased rotator cuff strength on the
letes involved in running and jumping activities.93 The cumula- dominant throwing side compared with the non-dominant
tive incidence (before 45years) in male athletes is 18.2% for side,117 with external/internal rotation ratios from 65% (isokin-
Achillestendinopathyand5.4%forAchillestendonrupture.94 etic)to100%(isometric).118
Scapular asymmetry is normal in overhead athletes.119
RTSrateandtimetoRTS However, scapular upward rotation and scapular stabiliser
Between 10 and 86% of athletes (athletes of various activity muscle strength are hypothesised to be key factors in optimal
levels likely explain much of the variation in RTS rates) RTS sports performance.120 121 Functional performance tests for the
after12weeksoftreatment forAchillestendinopathy.9596After shoulder are gaining interest. However, these tests are not yet
1year, 55–90% RTS.97 98 However, up to 44% of people have fully explored in clinical practice,122–125 and lack normative
a recurrence of Achilles tendinopathy after RTS.99 100 After dataandcut-offvaluesforinjurypreventionandRTS.
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Consensus statement
Important clinical considerations are when the athlete with Priority:quantifyingRTS
shoulder pain may be permitted to throw, and how to manage Participationandperformance
optimal loading in the overhead athlete. Graded progression of Many elite level sports regularly use metrics to quantify per-
load is critical, and must be specific to the demands of the formance (eg, metres gained, goals/points scored, assists) that
sport.126 127 Emerging technologies (eg, load cells) permit may be helpful in describing performance outcomes for team
accurate quantification of load during overhead activities and sports (eg, American football, baseball, soccer) and some indi-
may help the clinician more precisely quantify upper limb vidualsports(eg,cyclingandtriathlontimes).Variousaspectsof
loadingduringactivity.128 loadcanbereadilyquantifiedbytheGlobalPositioningSystems
(GPS), gyroscopes and accelerometers, and offer an interesting
Summary opportunity to benchmark performance levels, quantify load
RTS criteriafor many common sports injuries are not based on and performance, and set sport-specific targets for RTS.133 134
solid scientific evidence, and lack consensus. It is unknown Challenges lie in determining the relevance of specific measures
whetherthiscontributestotherelativehigh incidenceofreinju- to RTS as well as the reliability and availability of these data.
ries or relatively low percentage of athletes who return to their Nevertheless, it is a rapidly developing and exciting field. To
preinjurylevel.ItisalsounclearwhetherfulfillingcommonRTS complement these objective measures, it is also important to
clinicalcriteriapredictsprogressionthroughtheRTScontinuum consider subjective measures of acute and chronic training
(return to participation, RTS and return to performance). loads.135
However, absence of research evidence should not mean imme-
diatecausefordespairthatcurrentpracticeisinadequate—there Follow-upduration
are cases where high-quality clinical practice is associated with Long-term follow-up is needed to examine the impact of injury
excellent clinical outcomes.129 The key points regarding evi- on long-term participation in sport. The length of follow-up
denceforRTSarepresentedinbox3. needs to be relevant to the injury studied (eg, after Bankart
repair, 1year might be considered short-term follow-up, while
SECTION 4: RTS RESEARCH: PRIORITIES AND FUTURE after muscle injury, 1year might be considered long-term
DIRECTIONS follow-up),anddefinedinadvancebytheresearcher.Giventhat
Priority:providingcleardefinitions asizeableproportionofathletesceaseparticipationintheirpre-
injury sport by the medium-term following injury,82 136 it is an
Future studies reporting RTS outcomes should include clear
definitions of injuries sustained, adopting any relevant inter- important avenue for future research to establish whether these
athletesretirefromsportorwhethertheychangesports.
national consensus on the reporting, categorisation and diagno-
sis (eg, the ‘Scapular Summit’ consensus on scapular
SatisfactionandconfidenceinRTS
dyskinesis130ortheDohaagreementonterminologyanddefini-
Reasons for participating or not participating in sport vary
tionsingroinpain).131Itisalsoimportanttoprovidecleardefi-
greatly between different populations and sporting
nitions of what constitutes reinjury, ideally using published
activities.27137Futurestudiesshouldseektoestablishwhysome
guidelines.132
athletes do not RTS and if non-return is related to reasons for
AcleardefinitionofRTSisimportant,andresearchersshould
playing sport initially, and explore whether athletes are satisfied
consider using theRTScontinuum (figure 1)as a basis for their
withtheirpostinjuryparticipation.
definition. In some research contexts it may be necessary to
elaborate on some elements of the RTS continuum. For
(Re)InjuryriskafterRTS
example, for return to participation, to report the number of
Consistent reporting of impairment-based and activity-based
athletes who return to a different sport than their preinjury or
measures, and patient (athlete)-reported outcome measures
the number who return to the preinjury sport but at a lower
during recovery and rehabilitation may help identify subgroups
level (eg, was playing national competition basketball, now at high, moderate and low risk of reinjury. Early identification
playing in a regional competition). Researchers should also
of these subgroups may allow targeted interventions to address
reportthenumberofathleteswhostopplayingsport. risk factors (eg, specific strengthening programmes to address
subcomponents of strength or psychological input for at-risk
groups), which may result in better long-term outcomes.
Quantification of risk may help categorise athletes who are not
Box3 Keytakehomemessagesregardingtheevidence
readytoRTS,thosewhorequiresupervision,andthosewhoare
forreturntosport (RTS)
readytoRTS.
▸ TimetoRTSvariesindependentofthetypeandseverityof
Priority:IdentifyprognosticfactorsforRTSoutcome
injury,reflectingthechallengeinaccuratelypredictinginjury Table 1 summarises some of the key factors that may influence
prognosisandRTStimelines.
RTS outcome and highlights the multifactorial nature of RTS.
▸ RTSdecisionsshouldalwaysuseinformationgatheredfrom
Interrelationships between factors and the impact of these rela-
abatteryoftestsmimickingthereactiveelementsandthe
tionships on RTS remain unclear, and warrant further
decision-makingstepsathletesuseinrealsportsituations.
investigation.
▸ Workloadmaybelinkedtoreinjury,soshouldbetakeninto
considerationwhenmakingRTSdecisions.
▸ Psychologicalfactorsshouldbetakenintoaccountduring Priority:IdentifyandvalidateteststoguideRTS
decision-making
rehabilitationandatthetimetheathleteismakingthe
Tests may be performed prior to injuryas a benchmark, then at
transitionbacktosport.
▸ ConsensusisneededregardingtheRTScriteriaforcommon four key time points: (1) immediatelyafter injury (ie, diagnostic
tests), (2) through the course of rehabilitation (to monitor pro-
athleticinjuries.
gression), (3) at the time of clearance to RTS, (4) after RTS to
ArdernCL,etal.BrJSportsMed2016;50:853–864.doi:10.1136/bjsports-2016-096278 859
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Consensus statement
Performanceandskillexecution
Table1 ReportingoffactorsthatinfluenceRTSoutcomes
Future studies should assess performance measures associated
Riskassessment Contributingfactorsthatshouldbereported with the athlete’s sport. Ideally, this research should include
objective (eg, GPS, game statistics) and subjective measures of
Healthrisk Demographiccharacteristics(including:age,sex)
loadingandperformance(eg,sessionrateofperceivedexertion,
(injury-specificfactors) Informationcollectedfrompatienthistory
(including:injuryhistory,natureandseverityof satisfaction).
initialinjury,pain,medicalhistory)
Clinicalexaminationandphysicaltests(including: Methodologicalconsiderations
signsandsymptoms,strength(andrelevant Using consistent tests and descriptions will improve the ability
sub-qualitiese.g.power,rateofforce
to make comparisons between studies. It might then be possible
development,eccentricstrength,strength
toperformmeta-analysesandcompareacrossavarietyofsports
endurance),rangeofmotion)
Diagnosticimaging(e.g.MRI,ultrasound) andsubgroups.
Activityrisk(performance/ Preinjurylevelofparticipation Future studies should identify, a priori, the appropriate size
activityfactors) Natureofsport(e.g.contact/non-contact; of the cohort and the duration of follow-up. Blinded designs
individual/team;open/closedskills,pivotingvs are encouraged, especially when using subjective outcome mea-
non-pivoting)
sures. Studies should also seek to articulate the statistical and
Specificactivitiesassociatedwiththatsport
Sport-specificfunctionaltesting clinical significance of results. Researchers are encouraged
Psychologicalfactors to follow reporting guidelines for different study types such as
Risktolerance(contextual Socialfactors PRISMA148 for systematic reviews and meta-analyses,
factors) Professionalvsrecreationalparticipation CONSORT149 for randomised trials and STROBE150 forobser-
RTS,returntosport. vational studies. For more details on research reporting guide-
linesvisithttp://www.equator-network.org
measure performance and reinjury risk. Future studies to con- Futuredirections:keyresearchpriorities
sider the prognostic validity of clinical tests for RTS and rein- There are many avenues to be pursued in future research. In
juryareunderway. box 4 we provide some recommendations on priorities for
Areas that warrant further investigation to establish the rela- futureRTSresearch.
tionship to RTS outcomes and interrelationships between
factors include strength, range of motion, neuromuscular
control,psychosocialfactorsandskillexecution.
Box4 Prioritiesforfuturereturntosport (RTS)research
Strength
Theroleofstrengthanditssubqualities(eg,power,rateofforce
▸ Standardisedapproachtoinjurydefinitionincludingthe
development, endurance) in RTS outcomes remains unclear for
manyinjuries.80138Futurestudiesshouldconsidertheinfluence natureoftheinjury,severityandwhetheritisaprimaryor
recurrentinjury.
of rate of force development, eccentric strength and strength
enduranceonRTSoutcomes.139–141 ▸ Standardisedapproachtoreportingpreinjurysporting
activitytoincludethelevelofsportplayed,volumeand
Rangeofmotion(includingflexibilityandpain-provocation intensity.
stretchtests) ▸ StandardisedreportingofRTSoutcomes(eg,performance,
Research investigating the influence of range of motion on RTS (re)injuryrisk,satisfaction)andfollow-up.
outcomes has been largelyequivocal, although there is evidence ▸ Identificationofpositiveandnegativepredictive(or
inbaseballplayersofarelationshipbetweenshoulderinjuryand prognostic)factorsforRTSoutcomes
glenohumeral internal and external rotation deficits.113 142 143 ▸ DesignandvalidationoftoolstoaccuratelymeasureRTS.
Futurestudiesshouldevaluatetheroleofsport-specificrangeof ▸ Identificationofspecificsub-groupswithininjurytypesthat
motionthroughmultiplanarfunctionalmovements. havedifferentRTSoutcomes.
Neuromuscularcontrol
Some evidence exists on the role of neuromuscular control in
CONCLUSIONS
reinjury.140 144 145 However, tests that are commonly used to
Combining information from a biological, psychological and
determine whether the athlete is ready to RTS (eg, single-leg
social standpoint, while considering the risks can help all RTS
hop test and the Y balance test) lack sensitivity,146 are predict- decision-makers—whether they be clinicians, athletes, coaches
able, and controlled by the athlete. Future studies should orotherstakeholders—make optimaldecisions.Integratingclin-
examine the role of more challenging tests associated with
ical expertise, research evidence and athlete preferences is
sport-specific skills, and consider the sensitivity of dynamic
important for RTS decision-making and for longer-term RTS
functionaltestsandreactiveagility(ie,unexpected/unpredictable
success. RTS criteria for many common injuries are not based
challenges)inpredictingRTSoutcomes.147 on solid scientific evidence. Future research should focus on
a standardised approach to defining, measuring and reporting
Psychologicalfactors
of RTS outcomes, and on identifying the prognostic factors
Most of the research examining the impact of psychological
forRTS.
factorsonRTShasbeenofcross-sectionaldesign.Futurestudies
shoulduseprognosticdesignstoconsiderthetemporalrelation-
Authoraffiliations
ship between key psychological factors and RTS. Another
1AspetarOrthopaedic&SportsMedicineHospital,Doha,Qatar
important question to consider is whether interventions that 2DivisionofPhysiotherapy,LinköpingUniversity,Linköping,Sweden
targetpsychologicalfactorscanchangeRTSoutcomes. 3SchoolofAlliedHealth,LaTrobeUniversity,Melbourne,Australia
860 ArdernCL,etal.BrJSportsMed2016;50:853–864.doi:10.1136/bjsports-2016-096278
Downloaded from http://bjsm.bmj.com/ on January 27, 2017 - Published by group.bmj.com
Consensus statement
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