RETURN TO PLAY AFTER SPORTS INJURY I Dr.RAJAT JANGIR JAIPUR

RETURN-TO-PLAYAFTER
SPORTS INJURY

Fellowship In Arthroscopy(South Korea)
International Olympic Committee Diploma Sports Medicine(UK)
Sports Physician RIO Olympic 2016
Dr.RAJAT JANGIR
Consultant Arthroscopy and Orthopedic Surgeon
Saket Hospital, Mansarovar
Assistant 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
1. Would you allow a rugby player with a grade 2 AC
sprain to play with pain 1 week after injury?
2. Would you inject the AC joint with lidocaine if asked?
3. Would you inject it for 4 weeks in a row for a game?
4. Would you return a rugby player to same game if
asymptomatic after 1st concussion with no LOC?
asymptomatic after 1st concussion with LOC?
asymptomatic after 2nd concussion (3 mos.) no LOC?

RETURN TO PLAY QUESTIONS
7. Would you allow a rugby player with a grade 2 MCL
sprain to play 2 weeks after injury?
8. Would you make them wear a brace?
9. Would you let a female runner with a BMI of 16
compete despite no weight gain the past 3 weeks?
10. Would you let a soccer player with mono diagnosed
one week ago compete if asymptomatic & no
findings?
11. Would you allow a gymnast with a new pars stress
fracture to compete for the last 6 weeks of season?
12. Would you allow a female runner with 1.5 SD low
BMD & amenorrhea, BMI 18 to continue running?
13. Would you allow a soccer player with large single

IOC ADVANCED TEAM PHYSICIAN COURSE
MATHESON, 2008
1. Would you allow a rugby player with a grade 2 AC
sprain to play with pain 1 week after injury? 100%
2. Would you inject the AC joint with lidocaine if asked?
77%
3. Would you inject it for 4 weeks in a row for a game?
26%
asymptomatic after 1st concussion with no LOC?
74%
asymptomatic after 1st concussion with LOC? 13%
asymptomatic after 2nd concussion (3 mos.) no
LOC? 60%

IOC ADVANCED TEAM PHYSICIAN COURSE
MATHESON, 2008
7. Would you allow a rugby player with a grade 2 MCL sprain to
play 2 weeks after injury? 56%
8. Would you make them wear a brace? 46%
9. Would you let a female X-country runner with a BMI of 16
compete despite no weight gain the past 3 weeks? 74%
10. Would you let a soccer player with mono diagnosed one week
ago compete if asymptomatic & no findings? 53%
11. Would you allow a gymnast with a new pars stress fracture to
compete for the last 6 weeks of season? 23%
12. Would you allow a female runner with 1.5 SD low BMD &
amenorrhea, BMI 18 to continue running? 76%
13. 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 Children
Boudier, Revéret et.al. ,BJSM, 2010

Who Can’t Play?
repeated concussion retirement no evidence+based guidelines
RTP 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
spondylolysis avoid extension activities
patellar tendinopathy conservative treatment
chronic groin pain there are no short cuts
corticosteroid injection shoulder no definitive effectiveness
plantar fasciitis rest, 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 athlete’s decision is
uninformed.”
DiCello N. Exploiting Professional Athletes. 2001;49:507+538

THE MOST IMPORTANT FACTOR?
….....................is not a factor
It is an approach
Synthesizing evidence
Blended into a decision making
process

FROM EVIDENCE TO DECISION
MAKING
Extensive 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 circles
 Circumstances under which decisions are made
 Decision elements are squares
 Arrows are used to illustrate when information from
one element contributes information to another
element
Integrates 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= SPORT
 Coach
 Manager
 Agent
 Professional Environment= MEDICAL
 Colleagues
 Licensing bodies
 Malpractice Insurer

WHO’S IN CHARGE?
Who has the final say?
 Medical staff
 Official, coach, manager, administrator?
Who assumes final responsibility?
 “point person”
 liability

TAKE HOME MESSAGE
Many factors
Consider them in the right order
 Medical
 Participation Risk
 Decision Modification
Can be recursive
In sport medicine we look after the athlete
We 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 JANGIR
Consultant Arthroscopy and Orthopedic Surgeon
Saket Hospital, Mansarovar
Assistant Professor
Mahatma Gandhi Medical College, Jaipur
Mobile- 8104855900
dr.rajatjangir@gmail.com

RETURN TO PLAY AFTER SPORTS INJURY I Dr.RAJAT JANGIR JAIPUR

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RETURN TO PLAY AFTER SPORTS INJURY I Dr.RAJAT JANGIR JAIPUR