return to play after sports injury

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Injury Definition, Classification and their Consequences for Return-to-Sport

Return-to-play after sports injury

Fellowship In Arthroscopy(South Korea)International Olympic Committee Diploma Sports Medicine(UK)Sports Physician RIO Olympic 2016

Dr.RAJAT JANGIRConsultant Arthroscopy and Orthopedic SurgeonSaket Hospital, MansarovarAssistant Professor Mahatma Gandhi Medical College, Jaipur

Injury Definition

Varies greatly by study causing inconsistencies in reported data and study comparison difficult.

Consensus statements Football. Fuller, 2006 Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2006;16:97-106.

Rugby. Fuller, 2007 Fuller CW, Molloy MG, Bagate C, et al. Consensus statement on injury definitions and data collection procedures for studies of injuries in rugby union. British journal of sports medicine 2007;41:328-31.

Injury Consensus

Standardization of: Injury definition Injury classification

type, location, event Injury location Specificity: anterior or posterior thigh, Type of Injury new, recurrent, medical attention, non-fatal catastrophic, acute, overuse, non-structural vs. structural, etc

Injury Classification

Most studies have only collected time loss injuries

Recent development and validation of a new method for the registration of overuse injuries

Found 10 times as many overuse injuries than standard injury registration methods.

Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire. British journal of sports medicine 2013

Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. British journal of sports medicine 2009;43:966-72

OBJECTIVES

Multiple factors that may influence return to play decisions

To outline the process by which physicians may approach decision making

To introduce a 3-stage decision-based model of RTP

3 Reasons R-T-P is Difficult

No absolute contraindications to sports participation

Pressure to use treatment approaches that are not scientifically validated

Return-to-play decisions are usually made on a case by case basis

Why is RTP Important?

Greatest risk for injury is past injury return-to-play decisions affect injury rates

For team physicians, RTP is central to our work; it is what we spend most of our time doing

The treatment of individual cases (case-by-case) limits our ability to understand populations and generalize treatments

Return to Play Questions

Would you allow a rugby player with a grade 2 AC sprain to play with pain 1 week after injury?Would you inject the AC joint with lidocaine if asked?Would you inject it for 4 weeks in a row for a game?Would you return a rugby player to same game if asymptomatic after 1st concussion with no LOC?Would you return a rugby player to same game if asymptomatic after 1st concussion with LOC?Would you return a rugby player to same game if asymptomatic after 2nd concussion (3 mos.) no LOC?

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Return to Play Questions

Would you allow a rugby player with a grade 2 MCL sprain to play 2 weeks after injury?Would you make them wear a brace?Would you let a female runner with a BMI of 16 compete despite no weight gain the past 3 weeks?Would you let a soccer player with mono diagnosed one week ago compete if asymptomatic & no findings?Would you allow a gymnast with a new pars stress fracture to compete for the last 6 weeks of season?Would you allow a female runner with 1.5 SD low BMD & amenorrhea, BMI 18 to continue running?Would you allow a soccer player with large single compartment OC knee lesion to continue playing?

IOC Advanced Team Physician CourseMatheson, 2008

Would you allow a rugby player with a grade 2 AC sprain to play with pain 1 week after injury? 100%Would you inject the AC joint with lidocaine if asked? 77%Would you inject it for 4 weeks in a row for a game? 26%Would you return a rugby player to same game if asymptomatic after 1st concussion with no LOC? 74%Would you return a rugby player to same game if asymptomatic after 1st concussion with LOC? 13%Would you return a rugby player to same game if asymptomatic after 2nd concussion (3 mos.) no LOC? 60%

IOC Advanced Team Physician CourseMatheson, 2008

Would you allow a rugby player with a grade 2 MCL sprain to play 2 weeks after injury? 56%Would you make them wear a brace? 46%Would you let a female X-country runner with a BMI of 16 compete despite no weight gain the past 3 weeks? 74%Would you let a soccer player with mono diagnosed one week ago compete if asymptomatic & no findings? 53%Would you allow a gymnast with a new pars stress fracture to compete for the last 6 weeks of season? 23%Would you allow a female runner with 1.5 SD low BMD & amenorrhea, BMI 18 to continue running? 76%Would you allow a soccer player with large single compartment OC knee lesion to continue playing? 40%

Importance of Signs Influencing RTP

Practice Management of Musculoskeletal Injuries in Active ChildrenBoudier, Revret et.al. ,BJSM, 2010

Who CantPlay?

repeated concussion retirementno evidence+based guidelinesRTP after fever/acute infection?use cautious common sense

one kidney or testis?evidence remains limited

first time shoulder dislocation?not an easy question to answer

spondylolysisavoid extension activities

patellar tendinopathyconservative treatment

chronic groin painthere are no short cuts

corticosteroid injection shoulderno definitive effectiveness

plantar fasciitisrest, stretch, inject + all else is controversial & unsupported

RTP Definitions

Allowed to practice

Partial return (no contact)

Medical clearance of an athlete for full participation in sport without restriction (strength and conditioning, practice, and competition)

Clearance v/s Monitoring

Clearance decisions require the assurance of appropriate monitoring of identified problems

If clearance is dynamic, physicians must feel comfortable with follow-up & participation status

If a team physician does not fully inform an athlete of the potential dangers associated with playing with a particular injury, or the risks of a proposed treatment, the athletes decision is uninformed.

DiCello N. Exploiting Professional Athletes. 2001;49:507+538

The Most Important Factor?

.....................is not a factorIt is an approachSynthesizing evidenceBlended into a decision making process

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From Evidence to Decision MakingExtensive literature review

Categorized variables noted in the literature

Many factors mentioned, but poor evidence regarding importance

Decision Making: the Influence Diagram

Representation:States of nature elements are circlesCircumstances under which decisions are madeDecision elements are squaresArrows are used to illustrate when information from one element contributes information to another elementIntegrates and sequences factors, how they interact and when they should be considered in the clinical decision process

Your Role?

Advisor / Advocate?

Paternalistic / Authoritarian?

By What Standard are you Judged?

Daily Environment= SPORTCoachManagerAgentProfessional Environment= MEDICALColleaguesLicensing bodiesMalpractice Insurer

Whos in Charge?

Who has the final say?Medical staffOfficial, coach, manager, administrator?

Who assumes final responsibility?point personliability

Take Home Message

Many factorsConsider them in the right orderMedicalParticipation RiskDecision ModificationCan be recursiveIn sport medicine we look after the athleteWe should practice good medicine in sport, and look after our patient, the athlete

Fellowship In Arthroscopy(South Korea)International Olympic Committee Diploma Sports Medicine(UK)Sports Physician RIO Olympic 2016

Dr.RAJAT JANGIRConsultant Arthroscopy and Orthopedic SurgeonSaket Hospital, MansarovarAssistant Professor Mahatma Gandhi Medical College, JaipurMobile- 8104855900

dr.rajatjangir@gmail.com