Reading material on improving movement analysis and therapy

The process of making decisions about returning to sport 

The decision to return to sport after an injury should take into account the patient’s clinical condition, mental state, and short- and long-term sports goals. When making such a decision, you always try to find a balance between the athlete’s health and his effectiveness in the field. Unfortunately, this is always fraught with risk. Returning too early may have negative consequences for the athlete’s health (e.g. re-injury), being too cautious and delaying the decision to return can eliminate the athlete from important competitions and cause them to lose their position in the team. The decision to return to sport is usually supported by the opinions of several people. An important voice belongs to a medical doctor and a physiotherapist, but the opinion of a psychologist, trainer, and the closest environment of the athlete is also important. However, it is the athlete himself who makes the final decision. At this point, education about the nature of the injury and its consequences is very important, because research shows that athletes often neglect long-term health prognosis and decide to return to the game as soon as possible for short-term sporting success. It is usually easy for athletes to make the decision to return to play too early when a risk-reducing factor is available to them. This may be a cue to wear a stabilizer for the duration of the activity, or to be active at less than 100%, possibly playing until it hurts, “you can get off the field at any time, someone will replace you”. Considering the athlete’s well-being, it is desirable that the decision to return to sport is made more consciously, based on a thorough health and risk analysis. Normative tools such as StaRRT can help in this. 

The Strategic Assessment of Risk and Risk Tolerance (StARRT) strategy was created to facilitate the decision to return to sport after a musculoskeletal injury. The starting point for the creation of StaRRT was the return-to-sport decision-making model published in 2010 by Creighton et al. In this model, the decision process was based on the analysis of three groups of factors: medical factors, sports factors that may modify the risk associated with returning to sports, and factors modifying the decision to return to sports. In the StaRRT, the way of looking at the problem has changed a bit. The StaRRT assessment assumes that the decision to return to sport should be based on an assessment of the risk associated with this return and comparing it with risk tolerance. If the risk assessment is higher than the risk tolerance, a decision should be made to postpone the return to sport. In the first stage of the assessment according to the StaRRT model, it is estimated from the available information what load can be applied to the athlete’s body before it is damaged. The tissue damaged in a sports injury should have optimal conditions for healing. Any stress on the tissue can interfere with the healing process. Therefore, the next step in the StaRRT model is to assess how the stresses of the planned sports activity may affect the risk of re-injury. The psychological readiness of the athlete is also considered at this stage of the return to sport decision process. In the last, third step of deciding to return to sport, the threshold of acceptable risk should be determined. This is not an easy task, because the risk acceptance threshold is highly subjective and largely depends on the athlete’s personality traits and the values that guide the community that surrounds the athlete. For example, from a medical point of view, it can be determined that returning to sport is beneficial if the risk of re-injury is no more than 10%. But if an athlete has a vision of not competing in the Olympics and is at risk of depression because of it, the acceptable risk of re-injury can be raised to 15 or even 20%. The structure of the risk assessment and risk tolerance strategy is shown in Figure 1 below. 

Fig. 1. Strategic Assessment of Risk and Risk Tolerance framework, reproduced from Shrier, I. (2015). Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making. British journal of sports medicine, 49(20), 1311-1315.  

Additionally available in the e-manual: 4 pillars of on-field rehabilitation