Protocol for Readiness To Return to Play

by Joshua Smith
(Cape Town, South Africa)

According to Brukner and Khan (2001), there are certain criteria that need to be met when deciding if an athlete is ready to return to full sporting activity. These criteria are as follows:

- Time constraints for soft tissue healing have been observed
- Pain free full range of motion
- No persistent swelling
- Adequate strength and endurance
- Good flexibility
- Good proprioception
- Adequate cardiovascular fitness
- Skills regained
- No persistent biomechanical abnormality
- Athlete psychology ready
- Coach satisfied with training form

Along with these criteria, Brukner and Khan (2001) also suggest the following contra-indications:

- Persistent recurrent swelling – indicates a joint is not ready for activity, minor swelling may be tolerated.

- Joint instability – may be controlled by brace or tape and good muscle control.

- Loss of joint range of motion-some loss may be acceptable in certain sports.

- Lack of full muscle strength-strength of atleast 90% of the contralateral limb is recommended (80% strength of the contralateral limb may be acceptable in cases of ligamentous injury as long as there are no functional deficits).

Orchard et al (2005) have noted 4 methods of helping one determine if an athlete is ‘fit’ to return to play. They are:

1. Strength and flexibility testing
2. Imaging
3. Functional field testing
4. Risk management strategies

Each of these methods can aid in determining if the criteria set out by Brukner and Khan (2001) has been met.

Strength testing involves the use of isokinetic strength testing to determine if the athlete has regained 90-95% of the contralateral or uninjured limb. Along with this measurement/evaluation of injured vs. uninjured limb strength, flexibility and the correction of "any flexibility deficit is equally important to a strength deficit in terms of determining return to play." (2). According to Orchard et al (2001), professional UK soccer teams who did not stretch regularly or hold their stretches suffered from an increased incidence of muscle strains.

Imaging involves the use of MRI imaging to assess the severity of the muscle strain (2). Such imaging may allow one to note if the time constraints for soft tissue healing have been observed (1).

Functional Field testing is the traditional method for assessing if one is 'fit' enough to return to play. Functional field testing involves the allowance of training once strength and flexibility has been manually assessed and found to be within the acceptable limits.

From there, functional ability will be assessed at training, and will allow for a decision to be made regarding return to play – if all set tasks can be completed without pain or obvious limitation (2).

Because it has been accepted that these steps can occur without a full return to strength, the involvement of an isokinetic device to measure peak torque should be used, as well as any device/strength test that was used in previous fitness testing protocols. Also, biomechanics should be noted, so as to ensure that the athlete is not altering patterns so as to avoid pain (1, 2).

Risk Management Strategies revolves around the various strategies to administer rehabilitation, the speed of the rehabilitation (conservative or rapid), and if player injury history has any bearing on return to sport.

Because the aim of this thematic seminar is to design a protocol which assesses if an athlete is ready for return, this subject will not be further discussed. Also, it is assumed by this thematic seminar that the athlete is fully fit, yet needs the final functional ability assessment so as to allow for return to play.

The 'Loughborough Intermittent Shuttle Test' has been recognized by Nicholas et al (2000) as a test that stimulates the activity patterns of soccer. It achieves this in two ways, firstly it replicates the accepted distance covered in a soccer match -11.1km, and secondly, it replicates the number of turns and sprints completed in a soccer match – 55-60 (3).

One possible flaw of the test is that is does not include more functional activities related to soccer, such as "jumping, backwards running and time in possession of the ball" (3), this can however be countered by administering field tests related to each of the functional components (jumping – depth jump, backwards running – t-test, and time in possession - training performance and skill rating perceived by the coach).

Throughout the rehabilitation process, it must be noted that field tests will constantly be administered to evaluate fitness levels – of which these will be compared with pre-injury evaluations and pre-rehab evaluations.

The 'Loughborough Intermittent Shuttle Test' will allow us to evaluate if the athlete is able to cope with the energy demands of a soccer game and thus return to play.

Once the 'Loughborough Intermittent Shuttle Test' has been administered, and the athletes response (physiological and metabolic) are acceptable, the athlete should participate in any 'Reserve team' fixtures – this will allow both the coach and Biokineticist to assess if the athlete has indeed returned to full fitness levels and is now ready to return to first team action. The protocol should then be as follows:

- Field tests administered to note individuals fitness profile.

- If athlete’s fitness levels are within the accepted criteria set out by Brukner and Khan (2001), then the athlete should be permitted to return to training.

- Athlete skill and form, as well as physiological response to training demands should be noted by both coach and Biokineticist.

- Functional ability will then be assess once the athletes form (technical and physiological) is deemed acceptable.

- 'Loughborough Intermittent Shuttle Test' will be administered on two occasions. Seven days should be allowed between each test and no high intensity training should be undergone 2 days after the initial test (3).

- Once functional ability has been found to be acceptable, and return to play is allowed, the midfielder will play in a ‘reserve’ team game.

- Return to first team football (soccer) once form in ‘reserve’ game has been noted as worthy of 1st team football.

- References -

1. Brukner, P. & Khan, K. Clinical Sports Medicine, Revised Second Edition. McGraw Hill, Australia, 2001: 182-183

2. Orchard, J., Best, T.M., Verrall, G.M. Return to Play Following Muscle Strains. Clinical Journal of Sports Medicine, 15, 436-441, 2005

3. Nicholas, C.W., Nuttall, W.E., Williams, C. The Loughborough Intermittent Shuttle Test: A field test that stimulates the activity pattern of soccer. Journal of Sports Sciences, 18, 97-104, 2000