"When Can I Play Again, Doc?" Sport Medicine Physicians Face Dilemmas

Newswise — When should injured athletes be allowed to return to competition? Making these decisions is a core responsibility of team physicians and sport medicine doctors, yet they often find little guidance from medical research. The November/December issue of the Clinical Journal of Sport Medicine is a special thematic issue providing updates on key topics related to return to play after athletic injuries.

In addition to medical uncertainties, return-to-play decisions often pose ethical challenges, write Drs. Thomas M. Best and P. Gunnar Brolinson, guest editors of the thematic issue. Athletes need full information on the risks of returning to play, yet doctors often have little high-quality evidence on which to base these estimates. They may also face pressures to hasten return to play—not only from the athletes, but also from parents, teammates, coaches, and even the media. "Office-based and sideline clinicians are typically faced with several options and little highest quality evidence on which to make final return to play recommendations," the editors write.

The ten reviews in the thematic issue highlight the lack of research data. For example, athletes recovering from infectious mononucleosis face a risk of potentially serious injury to the enlarged spleen. One common belief is that athletes in football and other contact sports can safely return to play when the enlarged spleen is no longer palpable. However, a review in the thematic issue finds no strong evidence supporting this or any other single rule. Ultrasound or other imaging studies might provide useful information in equivocal cases—but again, this recommendation is unsupported by research.

There is at least one common sports injury for which research has led to consensus guidelines: concussion. In 2004, an international panel of sport medicine experts met in Prague to develop evidence-based guidelines for evaluation and management of concussions in athletes. The guidelines were published earlier this year in CJSM and other major sport medicine journals.

The Prague Group guidelines highlight the importance of classifying concussions according to the quality and timing of recovery—the true severity of injury can only be determined in hindsight, after all symptoms have cleared and neurological and cognitive status have returned to normal. Clinicians now have a standard set of recommendations to guide return to play after concussion: a period of physical and mental rest, followed by gradual return to activity once the athlete is completely free of symptoms.

Other topics reviewed in the thematic issue include:

· Cardiac symptoms.—The risk of serious problems is very low in healthy athletes, but evaluation should occur in particular situations.· Exercise-induced asthma.—An increasingly common problem at all levels of competition, but there are no research data to guide return-to-play decisions.· Muscle strains.—Allowing an early return to play might be acceptable if the risks of recurrent injury are low to moderate.· Stress fractures.—The risk of recurrent injuries is high for stress fractures in certain areas, low in other areas.· Upper limb injuries.—Experts generally agree about return to play after a separated shoulder, but disagree for many other injuries.· Spinal injuries.—Questions remain about this complex and controversial area. Evaluation and return-to-play decisions are guided by clinical evaluation and diagnostic imaging, used in combination with evidence-based decision making.· Sideline documentation.—Handheld computer-based systems allow full access to medical records on the sidelines when injuries occur.· Psychological issues.—Some "causative psychological factors" may affect risk and recovery times.

In a personal perspective essay, Dr. Peter Brukner cites the "sleepless nights" that are part of return-to-play decisions for sport medicine physicians. In the case of concussion, the research-based Prague Group guidelines have alleviated much of this uncertainty. Meanwhile, newer issues such as surgery to repair injuries of the anterior cruciate ligament knee—which yields excellent immediate results but may carry a long-term risk of disabling osteoarthritis—raise new questions that must be answered by future research. "Rigorous, evidence-based criteria for return-to-play decisions were not a feature of the past," Dr. Brukner concludes. "They will, hopefully, become part of our future."