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Get Young Athletes Back in the Game Safely
Monday November 15, 2010


For injured juvenile athletes, the first question to a healthcare professional is often, “When can I play again?”

But returning to play, or RTP, is usually a complex decision involving myriad factors, including the type of injury, the psychological readiness of the player, the impact of the sport and, of course, the chance of re-injury, says Brad Walters, MSPT, of Next Level Physical Therapy and Sports Performance in Golden, Colo.

“The pressure is often huge on the physical therapy team to return athletes to their sport,” says Walters. “But our No. 1 question is, ‘Why do you need to go back so soon?’ If there is a gray area, we are always going to go conservative. There are always considerations such as senior year or a championship game, but we have to ask them — the patients, parents, coaches — in the long-term are they willing to risk a re-injury that could last a lifetime?”

To address the issues of RTP, a panel of U.S. and Canadian sports medicine clinicians and researchers developed a three-step guide, based on previous literature, for healthcare professionals to use when assessing patients. Despite the importance of RTP decision-making in sport medicine, there is little scientific evidence to guide the process, physical therapists say.

“Our model helps clarify the processes that clinicians use consciously and subconsciously when making RTP decisions,” say the researchers, led by Gordon Matheson, MD, PhD, director of the sports medicine program at Stanford (Calif.) University School of Medicine. “Providing such a structure should decrease controversy, assist physicians and identify important gaps in practice areas where research evidence is lacking.”

The guide, which was published in the September issue of Clinical Journal of Sport Medicine, breaks the decision down into an evaluation of health status, evaluation of participation risks and, finally, decision modification, which takes into account external pressures.

Exams Help With Decision
Matheson’s model can help guide the initial conversations with the athlete, parents and coaches, says Mark Paterno, PT, MS, MBA, SCS, ATC, coordinator/physical therapist at Cincinnati Children’s Hospital Medical Center. The study also shows how much further research is needed before RTP decisions can be made using science-based evidence.

“Return to play is often based more of the art of medicine, not the science,” he says. “At the end of the day, there’s still some guesswork involved. It’s important to determine what variables to study and to evaluate prior to allowing an athlete to return to sports. There may be a variable no one is currently measuring that is a reliable indicator of how well an athlete will do on the field after they return.”

At Elite Sports Medicine, part of the Connecticut Children’s Medical Center in Hartford, a one-hour RTP examination that includes range-of-motion testing, isokinetic strength testing, hamstring-to-quad ratios and numerous jumping tests is conducted on each patient before the patient is released, says Jason Booker, PT, CSCS, with the sports medicine facility.

“We do the isokinetic strength testing at 300 degrees per second, close to the speed the athletes are using in their sport,” Booker says. “And we measure their jumping on one leg, both legs and multiple jumps.”

Often a juvenile athlete in rehab elsewhere is not exposed to jumping until the test, Booker says, even though such moves are routine in sports.

The exam can be found online at, under Therapy.

More Studies Coming
Paterno and colleagues recently studied 56 athletes who underwent a biomechanical screening on a vertical drop after an anterior cruciate ligament injury and were then followed for one year. Thirteen of the athletes re-injured their ACL.

“Much has been written about the core and hip strength to avoid knee injuries, and we found in studying hip movement during a landing activity that athletes who re-injured themselves had altered neuromuscular control of the hip and knee,” Paterno says. “Also, athletes who were unable to balance forces between their legs were re-injured.”

The study was published in the September issue of the American Journal of Sports Medicine.

Walters and his colleague Joe Bryant, PT, also at Next Level, developed a detailed function test to assess RTP involving a series of 13 tests that take one hour to conduct in all. The Next Level staff have conducted this functional test on 70 young athletes. Of the group, five returned to the clinic with new injuries, Walters says.

The function test, which has been submitted for publication, uses specific tests of agility, endurance, power, flexibility, eccentric control and objective strength testing.
“PTs can observe this through comparing with the other, healthy side,” Walters said. “We often compare range-of-motion, strength, gait, atrophy, tenderness and flexibility. The functional test allows us to delve deeper into a true return to sport for our athletes.”

Other Strategies
Psychological readiness, which is discussed in Matheson’s three-step RTP guide, is critical to determining RTP, Walters says. “You have to create confidence through an internal spark,” he says. “One way to build confidence in a patient reluctant to return is to have him shadow another player during practice without actually having to play at full speed.”

Communication with the team coach, athletic trainer and others involved with the athlete is vital to transitioning the athlete back to the field or court, Paterno says. Becoming familiar with practice exercises can help guide the coach in what the returning athlete can do, and when.

“There’s often a lot of pressure from the coach for the athlete to participate,” he says. “But take this guide as a way to get the coach to see how they can help. Make them an advocate and a partner in the transition of the athlete back to play, as opposed to you telling them over and over again what the athlete can’t do.”

Paterno says it’s important for the athlete to stay connected with the team in some form, even if they are not able to stay in the same position or play in games during recovery. “Team unity eases the transition back,” he says. •

Teresa McUsic is a freelance writer.

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Monday November 15, 2010
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