Return to play is the last dot point for How is injury rehabilitation managed?

and our last dot

point for Sports Medicine.

This is a very large dot point, covering lots of content and requiring critical thinking as you
examine and evaluate various aspects.

It requires you to understand the indicators used by rehabilitation professions to determine if

the athlete is ready to return to competition. You are required to understand how injury
affects the athlete psychologically, which can be detrimental to performance and
wellbeing if not addressed.

You need to understand specific sports policies and procedures for returning to
competition, as well as consider the ethical use of painkillers and other drugs related to
rehabilitation.

With this information you are required to evaluate tests that could be used to determine an
athletes readiness to return to competition. And you must critically examine the policies and
procedures around an athletes return to competition and be able to present answers to
the questions above.
There are many indicators of readiness for return to play. Athletes need to
have completed rehabilitation, and be completing normal training loads.

They should be moving with fluidity and not shielding the injured area.

However, the two indicators in HSC PDHPE are: pain free, and degree of
mobility.
When an athlete is pain free it indicates that they are nearly ready to return to play.

Pain free means that the athletes injury is pain free when performing in the sport that they
compete in.

This means that a football player returning from a sprained ankle, should not just be pain free
during fitness activities, or pain free doing agility runs. They need to be pain free completing
drills, mini games, and during actual competition simulations.

This level of pain free indicates readiness for return to play.

An athlete who is not yet pain free has a higher chance of re-injury if they return to play.
The degree of mobility refers to the amount of movement around the injured
area.

If the athlete has torn a hamstring then they need to have restored their
mobility or range of movement at both the hip and knee of the injured
hamstring.

The movement should be smooth and show confidence in the hamstring

through both speed and power. If an athlete has restored their mobility this is
an indicator that the athlete can return to play.

Pain free and degree of mobility are the indicators of readiness for return to
play. Together they promote athlete wellbeing and help prevent re-injury.
Monitoring progress during rehabilitation of the athlete is important. This is
usually done by comparing test results.

Athletes, particularly elite athletes, complete regular tests of their physical

fitness. If an athlete is injured, these tests become pre-tests and are
compared with tests done during and after rehabilitation known as post-tests
(after the injury).

These tests are used in monitoring progress. When the tests conducted
produce results similar with the pre-tests, then rehabilitation can stop,
provided other indicators of readiness to return to play are present. i.e.
the athlete is pain free, has good mobility and is psychologically ready to
return to play.
Pre- and post-tests are used for monitoring progress in each component of
fitness. Tests should not just focus on one component, but all components,
especially the components most needed for the sport, and most affected
by the injury.

If an athlete has a sprained ankle, agility testing is vital when monitoring

progress. The ankle may be able to withstand linear forces through the joint,
but once the athlete needs to change direction at speed, different forces
are applied through the ankle and on the ligaments.

However, if the athlete was a swimmer, agility testing is not as applicable as

for a netball player.

When monitoring progress pre- and post- tests (before and after injury is
sustained) should be used to help determine if the athlete can return to
play.
Before an athlete can return to play their psychological readiness to return must be examined.

Physical recovery is vital and must occur before an athlete returns to play, but if they are not
psychologically ready then they should not return as this can lead to re-injury or further injury.

Athletes returning from injury, especially long term injury, such as a knee reconstruction may feel
anxious about returning to play. If an athlete is not confident in their bodies ability to manage
competition they will shield the injured side to protect it. This causes poor technique, and can lead to
injury somewhere else.

Furthermore, a lack of confidence from the athlete will diminish their performance, and in contact
sports can make them hold back from a tackle, which can lead to injury.

However, some athletes are overconfident and eager to return to play. This can occur before they are
ready to return and places the athlete at greater risk of re-injury. Care must be taken and proper
professionals used to determine the psychological readiness of the athlete.

An athlete should not return to play until they have fully recovered physically, showing indicators of
readiness to return to play, but also showing that their psychological readiness to return. Sometimes a
Psychological Readiness to Return to Sport Scale is used. Athletes responses should increase from their
initial injury state.
Trainers can help their athletes psychologically prepare by using various
psychological strategies and providing frequent positive feedback during
training.

Psychological readiness to return to play must be addressed before the

athlete is allowed to return to full competition.
Many athletes are given specific warm up procedures as they return to play.

These warm up procedures are given in addition to the normal warm up, and
can be done before or after the normal warm up.

The specific warm up procedures help to protect the athlete against re-injury
by ensuring the area has an adequate blood supply and is ready for all that
will come during competition.
Extra warm up procedures target the injury to ensure it is properly warmed up.

A hamstring strain will result in more dynamic stretching, and strength based activities around
the hip and knee. Furthermore, agility runs may be added to prepare the hamstring for the
application and absorption of forces, particularly for sports such as tennis and football.

In addition to warm up exercises, specific procedures such as a sports massage may be

added. Sports massage is a passive way for the athlete to increase blood flow to the injured
area. For our hamstring strain, a massage to the legs before active warm up may be advised
to help prevent re-injury during the warm-up itself.

The most important aspect of the specific warm up procedures is that they target the injured
area and replicate competition demands. Warm ups should always be specific to the sport.
This becomes even more important as an athlete returns to play after injury. Specific warm
up procedures should do the same, prepare the athlete, and the injured area, for the
demands of the sport.
Sports each have specific return to play policies and procedures.

Many of these policies and procedures are very similar. Especially for some of the more
common injuries such as a sprained ankle.

These return to play policies and procedures need to be followed by coaches and athletes in
order to promote player safety and wellbeing.

Many return to play policies and procedures are developed in conjunction with academic
organisations such as Sports Medicine Australia (SMA).

For example, Rugby League, AFL, and FIFA use the SMA Position Statement-Concussion to
guide their policies and procedures for concussion injuries. These return to play policies and
procedures are also specific to the sport, as some sports are more dangerous than others an
require a stricter policy for return to play than other sports.
Many protocols for return to play involve:
A medical clearance
Scans being completed and reviewed (x-ray, MRI, ultrasound etc)
Fitness and skills tests
Other professional clearance (physiotherapist, exercise physiologist etc)

For HSC PDHPE you are required to:

Critically examine policies and procedures that regulate the timing of return to play,
considering questions such as:

There are a range of return to play policies and procedures that can be easily found
through research. In addition to those above the Brisbane Netball Association has return to
play policies for soft tissue injuries and concussion. The Brisbane Netball Association
Concussion Management Policy details the procedures required for an athlete with a
concussion to complete before they can return to play at any level. The Netball Return to
play soft tissue policy provides some details for returning to play after a soft tissue injury. Both
of which require the athlete to be cleared by a medical professional before competing
again.
The NRL Policy Return to Play sets things out differently, listing injuries that
require medical clearance, which includes concussion, heart attacks and
broken bones and many more.

Though these policies are very similar there are also differences. If we add
the Australian National Boxing Federation Rules and Regulations which are
different again, especially in relation to an athlete being knocked out or
suffering concussion.
Why arent such policies applied to all sports?

These return to play policies and procedures are not blankly applied to all
sports because each sport is different and therefore, require different
policies. Many sports that are similar adopt very similar return to play policies
and procedures, but then adapt them to be specific to the sport. Two (2)
examples will help explain.

Football has a very different policy to boxing when it comes to a player

being knocked out. In boxing the athlete is banned from competition and
sparing for a minimum of 28 days the first time and 3 months the second,
while in football, the player cannot return to the match that day, but once
he is cleared by the medical team can return to normal activities. This is
because there is a greater chance of re-injury in boxing for a player being
knocked out or suffering concussion.
A further example is to look at a sprained wrist in both football and
swimming.

Swimming relies on the athlete using her wrist and hand to create force and
returning to play before complete rehabilitation and medical checks could
lead to re-injury.

However, in football the hands are not allowed to be used and so there is
less chance of re-injury and of the injury affecting the athletes performance.
The athlete can also wear compression bandages while playing, where as
this would hinder performance in swimming.
Who should have ultimate responsibility for deciding if an athlete returns to
competition?

This question is more complex then it first seems. Although the fast answer is
the athlete whose career, money etc is on the line, and who is most directly
affected by the injury.

However, return to play policy and procedures mean the athlete cannot
make this decision alone,
Athletes are not trained to understand injury and injury rehabilitation. They do
not know the risks associated with a return to play that is early and may
cause themselves an injury they did not expect.

For this reason, it is important that the athletes decision is made in

conjunction with medical and professional staff, such as physiotherapist. This
helps ensure that the athlete makes properly informed decisions.
However, is addition to this, it is important that clearance be given if the risk
of re-injury is high and/or the injury is large.

In this situation the medical staff MUST give clearance and are responsible
for deciding that the athlete CAN return to play.

After this, the coaching staff may wish to ensure the athlete is ready to
return to full competition through further training, game exposure and
psychological testing.

But even once the coach has given the clear for the athlete to return, the
athlete can still refuse if they do not feel ready. The final responsibility lays
with the athlete, although they may not get to return as fast as they wished
due to the NEED for medical and coaching clearances.
Should athletes be allowed to use painkillers in order to compete when injured?

This question I have left to be addressed with the ethical considerations of return to play.

There are plenty of ethical considerations around an athletes return to play, but HSC PDHPE
only require you to learn two (2):

Ethical consideration 1 the pressure to participate

Pressure to participate and return to play is an ethical consideration within Sports medicine.
All athletes, regardless of their level of competition feel pressure to participate in
competition.

However, there is no doubt that more pressure is placed upon the elite athlete than a
novice. Pressure to participate can be both internal (from the athlete) and external (placed
upon the athlete).
External pressure
External pressure to participate in competition before the athlete is ready can come from coaches,
teammates, and fans.

But external pressure can also come from financial or sports ranking loss while not competing.
Coaches can see their players as a commodity and see to get from their athlete what they are
costing the club.

Teammates, may need the athlete to return because they care such a vital member of the team and
they want to win. Fans pressure athletes to return early as they also want to see their side winning.

Internal pressure
The most dangerous pressure comes from the athlete themselves. Athletes are often very driven and
motivated people. They want to succeed, they dont want to let their teammates, fans or coaches
down, but mostly they want to be involved.

Many athletes compete in a sport they love, and sitting on the sideline is hard. This pressure can cause
them to return to play early, or to lie to the medical staff about symptoms they are experiencing in
order to return faster.

It is unethical for coaches and other staff to place external pressures upon the athlete to return to play
before they are ready. It will lead to greater injury, more time off the field and can destroy an athletes
career.
Ethical consideration 2 use of painkillers
The use of painkillers in order to return an athlete to play is another ethical
consideration.

Pain exists to tell the athlete when a particular movement causes further
damage to the body. Pain is an indicator that injury is occurring or has
occurred.

To stop an athlete from being able to feel pain will lead to the athlete
causing greater injury to their body because they will not be able to identify
when a movement is causing further injury and will not be able to modify
their movements accordingly.
There are also the considerations around the type of drug and its concentration.

It may be ethical for an athlete to use Panadol or Neurofen, but is it ok for them to use an
opioid (narcotic) drugs such as: codeine, methadone or morphine?

Ethical considerations also come with who is administering the painkiller. Is it ok for the
athlete to inject themselves, or should it be measured and administered by a qualified
medical practitioner?

All of these affect the safety and ethical consideration around painkillers.

However, there will be times when the athlete and their medical team will decide to use
pain killers anyway. This is often in high-pressure matches or when there is a long break
coming after the competition. An example, might be an athlete who suffers a level 1
hamstring strain during the grand final or in the last game of their career.

They are likely to risk further injury and continue to compete because they know they have
3-6 months to recover afterwards, and they may win the trophy, and possibly a large pay
packet to go with it.
There is greater pressure during an individual sport than in a team sport,
because often a substitution can be made in a team sport, but to pull out as
an individual guarantees the loss.

Athletes and their medical team need to weight up the risks and rewards of
the use of painkillers during competition. This ethical consideration should not
be taken lightly, especially for a young athlete beginning their career.
Should athletes be allowed to use painkillers in order to compete when injured?
To answer this question, the ethical considerations around painkiller use should be
addressed.

Is the risk of further injury high, and if so, how long do they have after the competition to
recover?

What pressures are being placed on the athlete in order to continue to play or return to play
early? Has the athlete been checked and given a medical clearance?

All of these ethical considerations need to be addressed when considering if painkillers

should be allowed. There are times when painkillers are used simply to relieve pain from a
muscle spasm, with no injury, in such cases the use of painkillers may be ethical.

While an injury such as a torn hamstring in a young player early in the season, may make the
use of painkillers unethical, because it places the athletes wellbeing at great risk, with little or
only short term gains.

These are just some of the ethical considerations for return to play.