Return-to-Play in Sport: A Decision-based Model
David W. Creighton, MS,* Ian Shrier, MD, PhD,† Rebecca Shultz, PhD,*
Willem H. Meeuwisse, MD, PhD,‡ and Gordon O. Matheson, MD, PhD*
Objective: Return-to-play (RTP) decisions are fundamental to the
practice of sports medicine but vary greatly for the same medical
condition and circumstance. Although there are published articles
that identify individual components that go into these decisions, there
exists neither quantitative criteria nor a model for the sequence or
weighting of these components within the medical decision-making
process. Our objective was to develop a decision-based model for
clinical use by sports medicine practitioners.
Data Sources: English literature related to RTP decision making.
Main Results: We developed a 3-step decision-based RTP model for
RTP decision: health status, participation risk, and decision modification.
In Step 1, the Health Status of the athlete is assessed through the eval-
uation of Medical Factors related to how much healing has occurred. In
Step 2, the clinician evaluates the Participation Risk associated with
participation, which is informed by not only the current health status but
also by the Sport Risk Modifiers (eg, ability to protect the injury with
padding, athlete position). Different individuals are expected to have
different thresholds for ‘‘acceptable level of risk,’’ and these thresholds
will change based on context. In Step 3, Decision Modifiers are con-
sidered and the decision to RTP or not is made.
Conclusions: Our model helps clarify the processes that clinicians
use consciously and subconsciously when making RTP decisions.
Providing such a structure should decrease controversy, assist
physicians, and identify important gaps in practice areas where re-
search evidence is lacking.
Key Words: return to play, medical decision making, sport
participation, injury, preparticipation physical examination
(Clin J Sport Med 2010;20:379–385)
Previous injuryis associatedwithup toa 4-fold increase in
the risk of reinjury,1and the treatment of all injuries includes
advice on when it is safe to resume sport participation. For this
reason, return-to-play (RTP) decisions are critical to the practice
of clinical sportmedicine. In general,previous research related to
RTP decision making has focused on conditions with serious
long-term morbidity or potential mortality such as concussion,2–
12spinal cord injuries,13–17and cardiovascular abnormalities.18–27
Even though musculoskeletal trauma represents the majority of
them. In the absence of clear scientific evidence, RTP decisions
lack standardization28–30and can be a source of confusion and
disagreement for physicians, athletes, coaches, and administra-
tors.31,32More importantly, the RTP process may be open to
influence by those not trained or experienced in medical decision
making.33,34Practices such as game-day injections to mask pain
and deviations from the typical medical approaches to allow full
healing have become commonplace in sports medicine practice,
leading to questions among bioethicists,35,36media,37,38legal
professionals,39and medical professionals.40–44
In 2002, the American College of Sports Medicine
issued a ‘‘consensus statement’’ on RTP to help team
physicians ‘‘make an informed decision as to whether an
injured or ill athlete may safely return to practice or
competition.’’45Although it includes a list of the various
elements involved in RTP, the consensus statement fails to
describe how or why those elements influence the medical
decision-making process. Indeed, the statement reflects the
difficulties and complexities in RTP medical decisions:
n This statement is not intended as a standard of care, and
should not be interpreted as such. This statement is only
a guide, and as such is of a general nature consistent with
the reasonable and objective practice of the healthcare
professional. Individual decisions regarding the return of an
injured or ill athlete to play will depend on the specific facts
and circumstances presented to the physician. Adequate
insurance should be in place to help protect the athlete, the
sponsoring organization, and the physician.
The purpose of this article is to synthesize the available
literature concerning RTP and to propose a model for RTP
decision making in sports medicine. We believe that this model
Submitted for publication May 10, 2010; accepted July 22, 2010.
From the *Division of Sports Medicine, Department of Orthopaedic Surgery,
Stanford University School of Medicine, Palo Alto, California; †Centre for
Clinical Epidemiology and Community Studies, Lady Davis Institute for
Medical Research, Jewish General Hospital, McGill University, Montreal,
Quebec, Canada; and ‡Sport Injury Prevention Research Centre, Faculty of
Kinesiology, University of Calgary, Calgary, Alberta, Canada.
The authors report no conflicts of interest.
This publication represents work done by members of RAISEM (Research
Alliance in Sport and Exercise Medicine). RAISEM undertakes group
research projects on sport injury prevention, clinical treatment, and return
to play. The members of the group include clinicians, content experts,
epidemiologists, biomechanists, and
members collaborating on specific projects.
Reprints: Ian Shrier, MD, PhD, Centre for Clinical Epidemiology and Community
Studies, SMBD-Jewish General Hospital, 3755 Cote Ste-Catherine Rd,
Montreal, QC H3T 1E2, Canada (e-mail: email@example.com).
Copyright ? 2010 by Lippincott Williams & Wilkins
physiologists, with associated
Clin J Sport Med?Volume 20, Number 5, September 2010www.cjsportmed.com|379
helps clarify the processes that clinicians use consciously and
subconsciously when making RTP decisions. Providing such
a structure provides a logical rationale for the RTP process with
the hope that it will decrease controversy, assist physicians, and
identify important gaps in practice areas where research
evidence is lacking. The model is applicable for emergent,
urgent and nonurgent decisions, although the weighting of
individual components will differ with the context partly
because of importance and partly because it may not be
possible to obtainall theinformation whendecisions need tobe
made rapidly—but a decision still has to be made nonetheless.
RETURN-TO-PLAY DECISION MAKING: THE
DECISION-BASED RTP MODEL
In clinical practice, RTP may refer to ‘‘full return without
restrictions,’’ ‘‘partial return,’’ ‘‘allowed to practice,’’ and so
forth. The model proposed in this article is applicable to any of
these definitions, but for clarity, we will use the following RTP
definition for our examples:‘‘medical clearance ofan athlete for
full participation in sport without restriction (strength and
conditioning, practice, and competition).’’
The most common type of decision-making model is the
rational decision model,46–48in which individuals weigh the
advantages and disadvantages of decision ‘‘A’’ (eg, allowing an
athlete to compete) against the advantages and disadvantages
of decision ‘‘B’’ (eg, restricting an athlete from participation).
In the medical context of RTP, the issue is more complex
because the physician is actually making a decision that affects
someone else. There are additional factors and influences
(medical and otherwise) that must be considered.
Figure 1 shows the decision-making model for RTP
using an influence diagram.49In an influence diagram, the
states of nature elements (the circumstances under which
a decision is made) are illustrated with circles. Decision
elements are usually illustrated with squares (we have used
a rectangle in our diagram), and arrows are used to illustrate
when information from one element contributes information to
another element. The model integrates and sequences the
many factors mentioned in the published literature and shows
how they interact and at what point they should be considered
in the RTP decision-making process. We first describe
the model globally and then explain each component in
subsequent sections of the article.
The first step in the decision-making process is the
Evaluation of Health Status of the athlete. Evaluating health
status requires an assessment of the athlete’s recovery from
a biological, psychological, and functional standpoint and
is done by considering several Medical Factors. In essence, it
is an evaluation of how much healing has occurred and how
close to ‘‘normal’’ the previously injured tissue is. This is
essential because tissue that has not healed is generally weaker
or less functional than it was before the injury and therefore
more likely to be reinjured.
Evaluation of Health Status (Step 1) is the most important
piece of information that clinicians have for the Evaluation of
Participation Risk. However, there are several other factors
associated with the sport or activity (Sport Risk Modifiers) that,
although not directly related to the evaluation of health status,
have the capacity to substantially increase or decrease the
participation risk for a given health status. For example,
a swimmer with a medial collateral ligament injury to the knee
may have a different risk than a football player (different sports),
a first basemanwithrotatorcuff disease mayhave a different risk
than a pitcher (different positions), and a recreational field
than an Olympian (different competitive levels).
Evaluation of Participation Risk (Step 2) is essential in
the rational decision-making model because a high reinjury
risk represents the main disadvantage of allowing RTP
(Decision A). However, there are additional factors that also
represent disadvantages or advantages for Decision A (or
similarly for Decision B of not allowing participation).
We have called these factors Decision Modifiers (Step 3)
because they may change the decision that would have been
made if Participation Risk had been considered alone.
Although it might be argued that the health of the athlete
should be the only concern, all activity is associated with risk.
Therefore, the clinician’s role is to help determine what is
an acceptable level of risk, and this evaluation must occur
within the context of the Decision Modifiers present in a given
situation. There are 3 important points related to decision
modifiers. First, unlike Participation Risk, these factors are not
restricted to the athlete. For example, family, coaches, and
even the doctor may benefit or be harmed if the athlete is
allowed to RTP or is prevented from RTP. Second, some
clinicians may not consider all the factors listed as appropriate
(eg, a physician in a conflict of interest may risk losing
employment), but the factors are included because we believe
that they are currently being considered in clinical practice
today. Third, Decision Modification is set aside from the other
steps because Participation Risk does not contribute in-
formation about Decision Modification, and Decision Mod-
ification cannot be used to determine RTPexceptin the context
of knowing participation risk.
The next section discusses each of the components in
greater detail. The main purpose of this article is to make note
of what the literature defines as the individual components that
make up the RTP medical decision. The actual value of each of
these components with respect to contribution and weight
in the decision-making process may or may not be quantifi-
able, but the value of RTP guidelines lies in the consideration
of all such components before making an important decision.
SPECIFIC CONSIDERATIONS FOR RTP
Evaluation of Health Status: Step 1
Although estimates of biological healing time can be
considered in the Evaluation of Health Status,14,30,50–53
a complete evaluation of the health status for any particular
injury or illness based on history, symptoms, signs, laboratory
tests, and functional testing is preferable. We recognize that
this is a developing clinical science. For example, plain
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Clin J Sport Med?Volume 20, Number 5, September 2010
FIGURE 1. Decision-based RTP model. The decision-based RTP model for an injury or illness is specific to the individual practitioner
making the RTP decision. The large black circles represent the states of nature elements (the circumstances under which a decision
is made). The RTP square represents the final decision that actually results in an action being taken. The texts on the far right are
individual factors or components identified from the literature that contribute information to the states of nature. These factors are
grouped into Medical Factors, Sport Risk Modifiers, and Decision Modifiers and are on the left because they represent the general
concepts the clinician should focus on when making a decision (the details are provided on the right). In Step 1, the health status of
the athlete is assessed through the evaluation of Medical Factors. For example, symptoms, signs, and testing provide information on
how much healing of the injury or illness has occurred. In Step 2, the clinician evaluates the risk associated with participation. For
example, the health status is usually heavily weighted when the known reinjury and long-term sequelae risks are high (eg, if an
athlete participates with only partial healing). However, there are Sport Risk Modifiers that also affect the risk associated with
participation. For example, it may be possible to protect the injury with padding or to minimize risk by changing the position of the
player. Although the RTP decision is fundamentally based on the risk associated with participation, decision making in all fields is
based on a risk–benefit balance. There may be benefits to an athlete that affect what is considered an acceptable risk. For example,
play-off competitions may result in significant financial and nonfinancial gains. Accounting for these Decision Modifiers (Step 3) is
the final step in the process that leads to the actual RTP decision. Decision Modification is set aside from the other steps because
Participation risk does not contribute information about Decision Modification, and Decision Modification cannot be used to
determine RTP except in the context of participation risk. Finally, the process is recursive; decisions to not clear an athlete for
participation are revisited as the healing process continues, and decisions that allowed an athlete to play are revisited if symptoms
or signs recur or if the status of any of the Sport Risk Modifiers or Decision Modifiers are changed.
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Clin J Sport Med?Volume 20, Number 5, September 2010 Model for Return-to-Play Decision Making
radiographic or magnetic resonance findings lag behind the
physiological healing of bone after a stress injury.54,55
? Patient demographics: Sex and age50,56–59influence the
health status because of hormonal and age-related factors
that can affect tissue regenerative abilities.
? Symptoms: History of the present illness provides very
important information in the evaluation of an athlete’s health
status. Pain is considered an essential factor in the evaluation
by most authors,14,16,30,51,52,56–69presumably because it is
indicative of incomplete healing. Other symptoms that are
often used by clinicians, such as stiffness or sensation of joint
stability, are not explicitly discussed in the literature.
? Personal medical history: The literature emphasizes some
aspects of the history that are related to the current
injury.58,62,70For example, authors have distinguished be-
tween first-time injuries versus recurrent injuries.13,15,50,71,72
Family history and medical history can predispose an athlete
to other medical conditions or injuries, and the medical
history provides the physician with a context in which to
evaluate the health status.
? Signs: Like symptoms, the presence or absence of signs on
physical examination have been used by some authors to
propose RTP recommendations based solely on these criteria.
These recommendations are summarized in Table 1. Of these
signs, muscular strength and joint range of motion (ROM)
are most frequently mentioned. Most authors suggest that
muscular strength should be at or near preinjury levels
(often measured compared with the uninvolved limb) before
returning an athlete to sports.14,30,51–53,56–61,65,67,68,71,73–79
However, the acceptable range for near normal is 70%53
to 100%,58and these recommendations seem to be based on
opinion and clinical experience, most likely because of the
paucity of good scientific evidence. Similar criteria have
been proposed for ROM,13,14,17,30,51–53,56–61,64,65,67,68,72,73,75–80
and others have added criteria that ROM should be pain
free.30,52,57,72In addition, some authors suggest that the
injury site should be functionally stable13,15,28,52,53,61,62,71,72,81
and nontender,51,66,69,82and joints should be without
swelling30,61,62,80or effusion.30,60Although girth has been
mentioned,30no specific criteria have been provided.
? Laboratory tests: Imaging techniques such as plain radio-
scan,63and ultrasound58can provide objective evidence of
tissue healing and detect some of the structural and
physiologic abnormalities that suggest incomplete heal-
ing.13,17,65,72,79Laboratory tests are also of value in recovery
from illness and some injuries.
? Functional tests: At times, an injured tissue may be healed
biologically, but deficits remain that are secondary to the
injury. Functional testing allows the clinician to assess
the status of the athlete with respect to function by testing
exercise maneuvers that simulate sport-specific actions. An
appropriately designed battery of functional tests helps
assess the integration of muscular strength, ROM, pro-
prioception, endurance, and confidence,28,60,77,83and each
individual test within the battery should mimic the forces
and stresses that will be experienced by that athlete in a
competitive situation.14,28,30,45,52,56,57,62,68,84,85In general,
authors recommend that RTP should occur when there is
no pain,30no instability,30normal kinematics,14,30and near
symmetrical performance compared with the contralateral
? Psychological state: Authors have recently emphasized the
importance of psychological ‘‘readiness’’ or ‘‘confidence’’
before RTP.45,50,57,86,87Apprehension, fear, and anxiety are
associated with a higher risk of reinjury86in addition to
negative effects on performance.
? Potential seriousness: Finally, the health status is related
to the particular tissue injured, its extent, and the propensity
for healing.15,29,34,50,58,59,62For example, the evaluation of
health status is very different for a concussion versus an
ankle sprain. This is an important field for further research
because short-term and long-term effects of participation
after injury can substantially affect health after retirement
Like symptoms, the presence or absence of signs
on physical examination has been used by some authors
to propose RTP recommendations based solely on these
criteria, without accounting for other factors affecting risk or
the decision-modifying factors.69,79Although some authors
have suggested that RTP should only be allowed after
complete resolution of symptoms,17,30,69,78,79the proposed
model clearly demonstrates why these individual components
cannot be considered in isolation. Although they are
considered before the Evaluation of Participation Risk and
Decision Modification, they remain only the first step in the
RTP process. Further, the model helps us to understand why
providing general recommendations without describing any of
the specific symptoms is of limited value.
TABLE 1. General Recommendations for Each of the Physical Signs Used by Clinicians to Evaluate Whether an Athlete Should Be
Allowed to Return to Play
Range of motion
Inflammation or swelling
At or near pre-injury levels or symmetrical with unaffected side
At or near pre-injury levels or symmetrical with unaffected side
Injury site should be nontender
No swelling or inflammation
No specific recommendation provided
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Evaluation of Participation Risk: Step 2
? Type of sport: Participation in collision sports (eg, football
and rugby) generally poses a higher risk of acute injury
comparedwithparticipationincontact sports (eg,basketball),
which poses a higher risk compared with participation in
noncontact sports (eg, swimming).15,30,50–52,56–60,62,64,78,82,88,89
However, high velocity sports (eg, alpine skiing) without
collision or contact are also associated with high risks.15,89
Noncontact sports may not present a high risk for acute
injury, but RTP decisions may need to be conservative
because disabling overuse injuries do occur in some activ-
ities60(eg, femoral stress fracture in a long-distance runner
and patellar tendinopathy in a football lineman).
? Position played: Different positions within a sport are
exposed to different forces and stresses and therefore
different risks.30,50,56–58,90For example, an acromioclavicular
sprain in a quarterback is repeatedly stressed during the
throwing motion but receives much less stress in a field goal
? Limb dominance: An athlete’s hand (or foot) dominance
affects whether an injury is likely to be repeatedly stressed
during activity (eg, a baseball pitcher with an injury to the
dominant vs nondominant shoulder).30,59
? Competitive level: In general, greater size, speed, and
strength in the more competitive athlete mean that these
athletes will experience greater forces and greater stresses
on the body. Furthermore, competitive athletes may be more
likely to push themselves beyond the levels of non-
competitive athletes in an attempt to win. Therefore, for
the same health status, higher levels of competition are
associated with higher health risk.50,57,58,64,66,91
? Ability to protect: For some injuries, taping, bracing,
splinting, or padding may reduce the risk for the same level
of tissue healing.30,45,52,61,62,81,82A related consideration
should be whether the piece of equipment poses a higher
risk of reinjury to other athletes,45,88but this is usually
governed by the rules of the sport.
Decision Modification: Step 3
? Timing and season: During the off-season, there may be less
benefit to the athlete to return sooner. Allowing an athlete
to participate in the play-offs may carry significant benefits
in the form of bonus payments, scholarships, and so forth.
Furthermore, the risk of reinjury in this situation may include
only short-term disability but no long-term consequences.
Therefore, for the same level of risk, the balance of
advantages and disadvantages changes with respect to the
timing and season involved.14,17,32,50,57,58,63,66,81
? Pressure from athlete: In most jurisdictions, the clinician
must make the legal decision for RTP, although disagree-
ment does exist about the extent to which the athlete should
be involved in the decision.17,29,32,41,59,73,74,92,93In brief, the
primary decision is left to the clinician because it is often
difficult to determine if the athlete is in a position to provide
informed consent because of the nature of the injury
(eg, concussion) or if she/he is being coerced by ‘‘handlers’’
or ‘‘superiors’’ (eg, coach) or family members. Within this
context, the clinician’s assessment of what constitutes an
acceptable risk may contradict the athlete’s assessment.41,74
Although the clinician has more experience evaluating the
absolute level of injury risk, the athlete may (or may not) be
in a better position to evaluate other risks, such as job
security, potential scholarships, contract offers, and endorse-
ments, and any of the athlete’s other goals within
? External pressure: In the context of both competitive
amateur and professional sport, many different groups of
people stand to benefit (in a variety of ways) from a timely
return of the athlete to competition, including coaches,
teammates, relatives, team administrators, agents, sponsors,
league officials, fans, and media.14–16,32,34,41,50,88Some of
these groups may provide valuable additional information
for the evaluation of risks and benefits, and some may
provide misinformation and undue pressure related to their
focused concern. Within an overall complex matrix of
decision making, all the groups have the potential to
influence the RTP decision. Although the immediate
reaction of some clinicians may be to suggest these all
be discounted, an athlete mayconsider thehopes and dreams
of family members (or team members) as valid and
important factors that need to be considered when balancing
risks and benefits.
? Masking the injury: The use of cortisone injections, local
anesthetics, and analgesics is very common in sport
medicine34because it can increase function and allow
injured players to participate. This factor could be
considered under either Evaluation of Participation Risk
or Decision Modification or both. For example, if some-
one has an acromioclavicular sprain and is able to return
to play because it was injected with lidocaine, they may be
at increased risk of worsening the pathology and pro-
longing the disability. To keep the decision-based RTP
model as simple as possible, we have chosen to include it
as only a Decision Modifier because there are other
contexts where masking the injury has little effect on
? Conflict of interest: Although it is the ethical obligation of
the clinician to be an advocate for the athlete,34,41clinicians
also have obligations to the team if they are paid employees.
Potential conflicts of interest arise when the team’s best
interestsand the athlete’s
aligned.33,41,88,93In this context, advocating too strongly
for the athlete means that the clinician may enter into
a conflict with coaches or risk losing his or her job,
including all of the perks, status, and money associated with
it.41In essence, the clinician should be transparent with the
athlete about dual roles and responsibilities so that the
athlete is properly informed (analogous to informed
consent). How often this occurs is difficult to determine
because clinicians are subject to the same frailties as the
general public, and it must be considered as a potential
modifying factor for RTP decisions.
? Fear of litigation: This is actually a special form of conflict
of interest. Physicians are typically sued for damages that
may result when an athlete is injured after an RTP decision
that is deemed as too early or if an athlete is deemed
inappropriately restricted from returning to play with
consequent financial or nonfinancial loss.93Although this
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Clin J Sport Med?Volume 20, Number 5, September 2010Model for Return-to-Play Decision Making
fear concerns only the clinician’s welfare, the fear is based
on the potential benefits and harm that the athlete may be
exposed to. Furthermore, in other areas of medicine, this
fear is tempered by providing informed consent. However,
the concept of informed consent is weak in sport medicine.
For example, although adult athletes are considered capable
of making every other decision in their life including
medical ones, RTP decisions have been considered the
responsibility of the team physician and ‘‘informed
consent’’ is not considered a general defense. That said,
regardless of the RTP decision, clinicians need to fully
inform athletes about therisk of RTPand properlydocument
all instructions and restrictions given to the athlete should it
need to be drawn on as evidence in the future.29,34,41,61,88,92,93
CONCLUSION AND RECOMMENDATIONS
We have outlined a 3-step decision-based model for RTP
that provides the clinician with structure and transparency
within a complex process. The model includes the major
factors within the Evaluation of Health Status and Evaluation
of Participation Risk, as well as factors involved in the
Our hope is that each of these individual components
will become topics for future research. Progress needs to be
made quantifying the importance of each of the individual
components of each step, and ethical constructs need to focus
on the unique sports medicine environment.
The decision-based RTP model provides a foundation
for research into the individual factors and components that,
when integrated, provide clinicians with an evidence-based
rationale for RTP decision making.
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