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Doctors' Decision To Clear Athletes To Return To Play After Injury: Wide Variability In Factors Considered

Study finds doctors give greater weight to medical and sport risk modifiers, not external factors important to teams, coaches, parents

 

The lack of a systematic approach to making return-to-play (RTP) decision-making has resulted in a high degree of variability among sports medicine doctors in weighing different factors, with some factors considered important by athletes, teams, coaches, and parents viewed as unimportant by doctors in the RTP decision, finds a new study. [1]  Doctor examining injured teen basketball player

Researchers surveyed 67 experienced sports team doctors from around the world as to whether they would "clear" an athlete to RTP under different injury scenarios and asked them to rank the importance of each of the 19 factors in a previously published 3-step RTP decision-making model.[2]

Not surprisingly, the vast majority (95%) of team doctors said they would "clear" an athlete for RTP if they had no symptoms and no elevated risk of reinjury and no risk of long-term problems, and more than half (53%) would clear the athlete for play with continued symptoms or signs as long as they felt they were not of sufficient concern to place the athlete at undue risk for either reinjury or adverse long-term health problems as a result of returning.

One in four (23%), however, would still clear an athlete for RTP despite an increased risk of reinjury if there was no increased risk that RTP would have an adverse effect on the athlete's long-term health, and a slightly higher pecentage (29%) would clear the athlete where there was no increased risk of reinjury but there was an increased risk of long-term problems.

Reassuringly, only 6% of the team doctors would clear an athlete where they was an increased risk of both acute reinjury and long-term health problems.  

Clearly unclear 

But when team doctors were given a choice of six options (no restrictions, can compete but with modified role, practice only, practice with modified activity, supervised strength and conditioning, or no activity) instead of having to choose between only two ("cleared" and "not cleared"), they tended to place more restrictions on the athlete as the severity of the injury and the risk of re-injury or long-term health effects increased.

If "cleared" was arbitrarily defined as the responses "no restrictions" or "compete with modified role" and "not cleared" was defined to include the other 4 response options, researchers found increased variability across some injury risk scenarios, and that team doctors were more likely to not clear, given 2 choices, but clear given 6 choices.

The findings, said researchers from Stanford, McGill, and the University of Calgary said, not only showed how misleading the term "cleared" can be, but that more precise definitions decreased but did not eliminate the variability among doctors in their approach to RTP decision-making.

Weighting of RTP factors: highly variable 

The study also found limited agreeement among the survey respondents in the weighting of the 19 factors in the previously published 3-step decision-making model.

Within each step of the decision-based RTP model, the factors potential seriousness of injury (step 1, 36%), type of sport (step 2, 57%) and timing and season (step 3, 48%) received the highest ranking, while some factors in step 3 were selected as "not applicable" (ranging from 10% for timing and season and pressure from athlete to 45% for fear of litigation).

The finding that most clinicians used some non-medical factors at times, but that some clinicians consider 1 or mor of the non-medical factors as either unimportant or not relevant to the decision at other times had "important implications," said Rebecca Shultz, PhD, of Stanford Medical School and the study's lead author. "At the heart of the RTP decision is the ability to assess the risk of injury to the athlete and the factors in steps 1 and 2 of the RTP decision-making model affecting this risk were generally considered important."

That factors that reflect other athletes' needs/desires (Step 3) were more often considered nonimportant to the RTP decision process, she said, "suggests that sports medicine clinicians may have a more restricted view of the 'athlete's best interest' compared to the athlete him/herself."

"If so, either the generally recommended shared decision-making process may not be applicable in some or all sport medicine contexts or would require a change in culture/legal liability framework before it could be effectively implemented," Shultz writes. 

Ranking of Factors Within the Decision-Based RTP Model (0=Not Important;1=Least Important, 8=Most Important (%)

Factors for Each Step                                                                      
    0    
   1       2    
   3     
   4    
   5  
    6   
   7         8   
Step 1: Medical Factors                  
Potential seriousness of injury
 0 14
7
2
5
10
14
12
36
Symptoms  0  0  5  7  14  5  21  24  24
Signs  0  2  2  5  14  19  19  26  12
Functional testing (e.g.  range of motion)  0  2  10  10  17  26  12  19  5
Personal medical history
 0  5  17  21  12  21  14  5  5
Laboratory tests
 0  5  17  21  26  17  7  2  5
Psychological state 
 0  14  31  29  7  2  5  5  7
Patient demographics  2  55  12  7  7  0  2  7  7
Step 2: Sports Risk Modifiers
                 
Type of Sport
0
12
5
2
2 24
57
   
Competition Level
0 10 7 7
19
43
21
   
Ability to protect injured body part
2
2
36
36 40 10
10
   
Position Played
5
17 36
36
21
21
0
   
Limb dominance 5
55
12
12 14 2
12
   
Step 3: Decision Modifiers                  
Timing and Season (i.e. pre-season or before playoff game) 10 7
2
7
10
17
48
   
Pressure from athlete
10
5
5
10
17
38
17
   
External pressure (coaches, athlete's family, sponsors or  media)  21
7
14
17
29 7
5
   
Masking of injury
19
10 17 17 12
10
17
   
Fear of litigation
33
26
10
12
7
5
7
   
Conflict of Interest (team's interest versus athlete's interest) 45
7
19
17  5 7
0
   

Better definition of "clearance" needed

The study demonstrated, said its authors, that "return-to-play decision making remains a complicated issue in sports medicine, as it is multifactorial in nature and affects many players, from the athlete, team, coaches, and parents," and "most sports medicine clinicians currently believe that factors affecting risk of injury are important, but some believe that other factors of potential importance to athletes should not be considered in RTP decision making." 

"Although further data is needed to understand RTP clinical decision making," says Shultz, "it is likely, at this point, that a more granular definition of 'clearance' would be helpful for quantitative analysis.


1. Shultz R, Bido J, Shrier I, Meeuwisse WH, Garza D, Matheson GO. Team Clinician Variability in Return-to-Play Decisions.  Clin J Sport Med. 2013;23(6):456-461.

2. Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model.  Clin J Sport Med. 2010;20:379-385.

 

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