Sport-Related Concussion II: Managing the Injured Athlete and Return-to-Play Decision-Making

BackgroundClinical decision-making around intramuscular tendon injuries of the hamstrings is a controversial topic in sports medicine. For this injury, MRI at return to play (RTP) might improve RTP decision-making; however, no studies have investigated this.ObjectiveOur objectives were to describe MRI characteristics at RTP, to evaluate healing and to examine the association of MRI characteristics at RTP with reinjury for clinically recovered hamstring intramuscular tendon injuries.MethodsWe included 41 athletes with hamstring intramuscular tendon injuries and an MRI at baseline and RTP. For both MRIs, we used a standardised scoring form that included intramuscular tendon injury characteristics. We recorded reinjuries during 1-year follow-up.ResultsAt RTP, 56% of the intramuscular tendons showed a partial or complete thickness tendon discontinuity. Regarding healing from injury to RTP, 18 of 34 (44% overall) partial-thickness tendon discontinuities became continuous and 6 out of 7 (15% overall) complete thickness tendon discontinuities became partial-thickness tendon discontinuities. Waviness decreased from 61% to 12%, and 88% of tendons became thickened. We recorded eight (20%) reinjuries within 1 year. Intramuscular tendon characteristics at RTP between participants with or without a reinjury were similar.ConclusionComplete resolution of an intramuscular tendon injury on MRI is not necessary for clinically successful RTP. From injury to RTP, the intramuscular tendon displayed signs of healing. Intramuscular tendon characteristics of those with or without a reinjury were similar.

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Return to play after hamstring injuries in football (soccer): a worldwide Delphi procedure regarding definition, medical criteria and decision-making

British Journal of Sports Medicine ◽

10.1136/bjsports-2016-097206 ◽

2017 ◽

Vol 51 (22) ◽

pp. 1583-1591 ◽

Cited By ~ 37

Author(s):

Nick van der Horst ◽

FJG Backx ◽

Edwin A Goedhart ◽

Bionka MA Huisstede

Keyword(s):

Decision Making ◽

Field Testing ◽

Return To Play ◽

Hamstring Injury ◽

Feedback Report ◽

Hamstring Injuries ◽

Starting Point ◽

Delphi Procedure ◽

Hamstring Flexibility ◽

The Moment

There are three major questions about return to play (RTP) after hamstring injuries: How should RTP be defined? Which medical criteria should support the RTP decision? And who should make the RTP decision? The study aimed to provide a clear RTP definition and medical criteria for RTP and to clarify RTP consultation and responsibilities after hamstring injury. The study used the Delphi procedure. The results of a systematic review were used as a starting point for the Delphi procedure. Fifty-eight experts in the field of hamstring injury management selected by 28 FIFA Medical Centres of Excellence worldwide participated. Each Delphi round consisted of a questionnaire, an analysis and an anonymised feedback report. After four Delphi rounds, with more than 83% response for each round, consensus was achieved that RTP should be defined as ‘the moment a player has received criteria-based medical clearance and is mentally ready for full availability for match selection and/or full training’. The experts reached consensus on the following criteria to support the RTP decision: medical staff clearance, absence of pain on palpation, absence of pain during strength and flexibility testing, absence of pain during/after functional testing, similar hamstring flexibility, performance on field testing, and psychological readiness. It was also agreed that RTP decisions should be based on shared decision-making, primarily via consultation with the athlete, sports physician, physiotherapist, fitness trainer and team coach. The consensus regarding aspects of RTP should provide clarity and facilitate the assessment of when RTP is appropriate after hamstring injury, so as to avoid or reduce the risk of injury recurrence because of a premature RTP.

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Return-to-Play Practices Following Hamstring Injury: A Worldwide Survey of 131 Premier League Football Teams

Sports Medicine ◽

10.1007/s40279-019-01199-2 ◽

2019 ◽

Vol 50 (4) ◽

pp. 829-840 ◽

Cited By ~ 1

Author(s):

Gordon Dunlop ◽

Clare L. Ardern ◽

Thor Einar Andersen ◽

Colin Lewin ◽

Gregory Dupont ◽

...

Keyword(s):

Decision Making ◽

Online Survey ◽

Return To Play ◽

Hamstring Injury ◽

Professional Football ◽

Multiple Stakeholders ◽

Related Factors ◽

Beliefs And Practices ◽

Premier League ◽

Key Stakeholders

Abstract Purpose Return-to-play (RTP) is an on-going challenge in professional football. Return-to-play related research is increasing. However, it is unknown to what extent the recommendations presented within research are being implemented by professional football teams, and where there are gaps between research and practice. The purposes of this study were (1) to determine if premier-league football teams worldwide follow a RTP continuum, (2) to identify RTP criteria used and (3) to understand how RTP decision-making occurs in applied practice. Methods We sent a structured online survey to practitioners responsible for the RTP programme in 310 professional teams from 34 premier-leagues worldwide. The survey comprised four sections, based on hamstring muscle injury: (1) criteria used throughout RTP phases, (2) the frequency with which progression criteria were achieved, (3) RTP decision-making process and (4) challenges to decision-making. Results One-hundred and thirty-one teams responded with a completed survey (42%). One-hundred and twenty-four teams (95%) used a continuum to guide RTP, assessing a combination of clinical, functional and psychological criteria to inform decisions to progress. One-hundred and five (80%) teams reported using a shared decision-making approach considering the input of multiple stakeholders. Team hierarchy, match- and player-related factors were common challenges perceived to influence decision-making. Conclusions General research recommendations for RTP and the beliefs and practices of practitioners appear to match with, the majority of teams assessing functional, clinical and psychological criteria throughout a RTP continuum to inform decision-making which is also shared among key stakeholders. However, specific criteria, metrics and thresholds used, and the specific involvement, dynamics and interactions of staff during decision-making are not clear.

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Return to Play after Cervical Spine Injuries: A Consensus of Opinion

Global Spine Journal ◽

10.1055/s-0036-1582394 ◽

2016 ◽

Vol 6 (8) ◽

pp. 792-797 ◽

Cited By ~ 5

Author(s):

John C. France ◽

Michael Karsy ◽

James S. Harrop ◽

Andrew T. Dailey

Keyword(s):

Decision Making ◽

Cervical Spine ◽

Clinical Decision Making ◽

Clinical Symptoms ◽

Clinical Decision ◽

Return To Play ◽

Spine Injury ◽

Cervical Cord ◽

Clinical Scenarios ◽

Cord Injury

Study Design Survey. Objective Sports-related spinal cord injury (SCI) represents a growing proportion of total SCIs but lacks evidence or guidelines to guide clinical decision-making on return to play (RTP). Our objective is to offer the treating physician a consensus analysis of expert opinion regarding RTP that can be incorporated with the unique factors of a case for clinical decision-making. Methods Ten common clinical scenarios involving neurapraxia and stenosis, atlantoaxial injury, subaxial injury, and general cervical spine injury were presented to 25 spine surgeons from level 1 trauma centers for whom spine trauma is a significant component of their practice. We evaluated responses to questions about patient RTP, level of contact, imaging required for a clinical decision, and time to return for each scenario. The chi-square test was used for statistical analysis, with p < 0.05 considered significant. Results Evaluation of the surgeons’ responses to these cases showed significant consensus regarding return to high-contact sports in cases of cervical cord neurapraxia without symptoms or stenosis, surgically repaired herniated disks, and nonoperatively healed C1 ring or C2 hangman's fractures. Greater variability was found in recommendations for patients showing persistent clinical symptomatology. Conclusion This survey suggests a consensus among surgeons for allowing patients with relatively normal imaging and resolution of symptoms to return to high-contact activities; however, patients with cervical stenosis or clinical symptoms continue to be a challenge for management. This survey may serve as a basis for future clinical trials and consensus guidelines.

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