Return to Play Criteria (For Coaches, ATC’s and YOU!)

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There is an issue that we have been seeing with Return to Play after Injury in high school aged athletes. It’s a small issue, more bureaucracy – not actual treatment issue.

It’s the problem of athletes/patients seeking treatment outside of the school.

As in, the high school softball player coming to my sports based chiropractic clinic for treatment for her sprained ankle.

I have presented this idea at high school in-services and have had great feedback and great implementation of plan improvement with a minimal effort and next to no expense.

My proposed idea gets the athletes, coaches, athletic trainer and ancillary staff on the same page and makes discussion of injury much more thorough with a huge addition of information. This, in my opinion, allows for better treatment of injured athletes, better compliance from the athlete and an improved ability to evaluate progress while returning from an injury.  

The above idea is what we all kind of have in our heads as the right way to work athletes.  It’s EXACTLY what the parents think happens. That the coaches and AT’s and the docs and the personal trainers all get together and discuss each case and nail out a full proof recovery action plan for every sprained ankle and tweaked muscle.   

The problem lies in reality.  

I don’t have your number and possibly even the time to go through every case.  My own kid’s practice is right after work and many of us in every field – aren’t getting home until 9 pm some nights!

If a patient is seeing another doctor, outside of the athletic trainer’s room, the buck passes to the MD, Pediatrician, chiropractor, PT etc rather the the athletic trainer and coach to make treatment, rehab and return to play recommendations.

While this may seem like a great idea for administration and liability issues, it creates room for problems.

Although I think the diagnosis and occasionally rehab/treatment for some athletic injuries and definitely for illnesses can best be managed by an adjunct doctor… 

The athletic trainer in conjunction with coaches is best suited to assess the athlete’s day to day recovery and return to play and practice.

The doctor is hampered in this regard as we just don’t get to monitor day to day function and have to rely on standard and structured testing to secure our diagnosis. Our job, as ancillary staff, is in the diagnosis. Further x-rays, testing, recommendations for surgery, ruling in/out major illness etc is our job and where our expertise is best utilized.

How long a basic sport injury keeps an athlete out of activity is not our strong suit.  

In this article I will explain this idea in more depth with a proposed idea on how to implement a BASIC but possibly improved “return to play criteria” for your athletes.

Let’s use an ankle sprain, in a high school track athlete, as an example.

A junior in high school 400 m track athlete sprains her ankle while playing pick up basketball one day after practice.   

Because the injury happened “after hours” – the parents take her to a minor ER clinic just down the road from their house.

The doctor makes the easy diagnosis of a grade 1 to 2 ankle sprain and recommends rest, ice, compression and elevation. Common Injury, Standard treatment.

The athlete then gets a note for time away from activity as it’s needed for the sports participation/ athletics period etc. as well as a courtesy for the coaches and training staff.

In some instances, this athlete may not even be able to receive additional treatment from the Athletic trainer due to the issue happening outside of the school. That’s a shame. Most of the athletic trainers I know would still treat the athlete… however their hands may be tied due to policy.

Before this athlete can return to play and practice, the MD that saw her must sign a note for release.   

Typically, the parents call the clinic and say, “Can I get a note for my kid to get back to competition?”    

That’s a fair enough request and this is how the system works on paper. It seems uncomplicated and proper policy. The MD wrote the note and decided, based on their expertise, the treatment plan.

And here is where the bureaucracy train starts the locomotive of inadequacy.

The doctor, in all good conscious, cannot sign a letter for return to play or practice without first running the athlete through a set of tests again to see if the ligaments are in fact strong enough, as in enough healing has occurred, to allow for resistance and activity.  To protect the athlete from further injury.

Is there a set standard – what should be done? This is in a clinic remember, not on the field of play – this is at the doctor’s office and even this is assuming the same doctor is in the same stand alone minor ER setting. It could be weeks before the athlete’s and doctor’s schedules even match up. Anyway, what should the doctor do in this situation?

Just call it in?  Have the receptionist just write a note after the suggested time frame?  That’s poor doctoring, I don’t think you’ll get much of that anymore…so what else?   Feel it? Have the athlete stand on it? Run up and down the hallway a time or two? Or more commonly – just go by the standard 6 weeks! rest and no activity.   I mean, that’s safe right?   (NOTE: recovery for this injury should not take 6 weeks.)

Is this doctor even qualified to make these decisions? A license as a chiropractor, MD, DO, dentist, PA, NP etc don’t necessarily make you expert level at sports injuries.  Diagnoses? Yes. Treatments and Return to Play, not necessarily. That kind of stuff takes experience even if you did have a sports specialization – which most don’t have – not to the degree an Athletic Trainer does.

Even if the athlete looks strong through the clinical exam and testing – Does that correlate well with the sports field, the track and the court?  The demands are completely different and maximal ‘game play’ exertion is unobtainable in the clinical setting.

So let’s assume this athlete waited 6 weeks for the ankle sprain and then has been cleared medically…ahhh finally. Well half the season has passed and now the athlete has not only been deconditioned and is behind the curve competitively but I would make a strong argument that 6 weeks of rest has in fact, not helped the sprain heal well but mostly just decreased pain. The initial sprain has need of a progressive resistance return and strengthening program and usually sooner rather than later.

Stated differently- Rest may have in fact, weakened the entire joint complex at the expense of rest and pain control.    

Again, the most qualified person to perform these treatments and exercises are an athletic trainer although I’ll allow the argument of a sports based physical therapist/ rehab specialist such as some chiropractors and even personal trainers work as.   There are qualified people, I’m just suggesting, most athletes at the middle school/high school level aren’t getting this.

Communication is the key to any and all patient recovery. It speeds up everything. But let’s not forget reality. This isn’t the NFL and there is not an infinite resource of trained staff and doctors and athletic trainer in a one on one setting out in the field. 

The athletic trainer ratio to athlete is not 1 to 1. More like 1 to 150, especially in the high school setting.

The athlete needs help – the Athletic Trainers need help too!

Using coaches in decision making.

Coaches are the ones out there. Despite not having as extensive of background to make complex medical decisions, they intimately understand body mechanics, gait, pain levels, wimpiness as well as just “knowing their athlete.”

Coaches can tell how hard to push an athlete and any ethical coach will not want to push an athlete too far. They need that competitor on their team!

Coaches and Athletic trainers have much more immediate communication with both the athlete and the injury. The athletic trainer with coaches input ARE THE BEST at the evaluation of the injury itself with regard to recovery.

Is the athlete going to make themselves worse? Do they need further consultation? Are they OK to move?

Ancillary staff – chiropractors, PT’s, pediatricians, team doc, surgeons etc can work one on one to help mitigate serious risk and allow for more direct work in a one on one setting and help get through the injury itself.

Again, my argument is that the ancillary staff is not qualified for return to play criteria. We aren’t on the field and don’t get to see the athlete in movement and sports specific situation.

Athletic trainers and coaches are together, the best qualified and should work together with input from the athlete on any and all return to play.

If “passing the buck” to ancillary medical staff, plan on a generic 6 weeks rest.

Basic return to play criteria

Use “pennies”

In the upper level sports and professional – the use of different colored jerseys or “pennies” are extremely common.

These pennies allow for immediate recognition to the coaches and staff both in live practice and video that the athlete is not 100%.

They allow for the athlete to still be present, play in correct positions, see in-play decision making for game day corrections, have movement and be participating with the team.

Teammates can easily recognize the injured athlete is not 100% – so contact, speed etc should be appropriately controlled so as to allow for recovery.

Coaches can evaluate practices with the understanding that the athlete is understanding week by week adjustments and is engaged mentally with the ability to digest that the athlete may not be fully functional in practice but with the understanding that by game day they may. Reps, even at a reduced speed,contact and ability is infinitely better than no reps and I think in 2019 everyone can agree rest alone is almost never the best recovery option.

My suggestion: use pennies in nearly every practice. Get the athlete on the field.

I utilize a 6 day recovery to 100% model for low grade injuries.

Day 1 : 50%

Day 2 : 65%

Day 3 : 75%

Day 4 : 85%

Day 5 : 95%

Day 6 :100%

The athlete can not go past his assigned percentage for each day.   

If the athlete passes the day with no setbacks or recurrences he is moved up the chart to the next percentage.

If there is a re exacerbation, the athlete stays at the same percentage for the following day or a reduction in percentage based on the Athletic Trainer’s and coach’s discretion.   

Further therapies, rehab techniques, clinical work etc is done IN ADDITION to practice, not in substitution of.    

Certain max ability drills such as sprints, gassers, max out weight room workouts etc are not done until the athlete can tolerate them. The additional therapies required for maximal recovery may work into these time slots.

By game day, the AT and the coach will have a good “working idea” of the athlete’s ability and chance of exacerbation and re-injury.

The reality is in all sports, the athlete may not be 100% in each case. I’m not suggesting 100% before competition as I think that’s another “on paper” reality that isn’t a realistic in the sports world.  By 6 games in to a typical high school football season, I would argue, no one is 100%. I bring this up because I had conversation with an athletic trainer that didn’t want his athlete’s seeking out my care as a sports based chiropractor because he had a policy of “100% healthy or No Play.”   This meant that if they were seeing me for a pre-game “tune-up” , it equated to being injured and he threatened to sit athletes out of competition that week.

The reality of this is that athletes rarely would seek out treatment form the athletic trainer for fear of being benched for little tweaks or tight muscles. They knew that if they had any reported “complaints” it was viewed as injury.

This is a double kill situation where the athletic trainer saw very few athletes. He could go about his day blissfully unaware of basic, simple care his teams would benefit from – completely confident that his teams were perfect with no complaints.  The actuality was no one dared seek their team’s “professional.” The coaches wouldn’t use him as they knew he would sideline their players, the parents used outside staff exclusively for the same idea and the athlete’s themselves had no confidence or even worse were scared to talk to the athletic trainer about injury or sports performance. The best qualified member of the staff was “out of the loop.”

Back to return to play…

The alternative to doing what I feel is correct, is rest. Wait for a release from a doctor that doesn’t have any way to make a decision other than allotted time, and I feel, a significant chance of re-injury, as the athlete has had no ability to re adapt and prepare for the demands of competition.

I understand there needs to be policy. I understand that policy at certain districts are at odds to my proposed ideas. Understand this is a very generic, very vanilla return to play criteria offering an improvement in the current status quo with minimal effort level.   It benefits the athlete, the team, the coach and the training staff. It isn’t created to circumvent policy but to focus on the fact that the sports arena as a whole has a lot of gray areas and a one policy for all is a dangerous concept and often not in the athlete’s best interest.  

Obviously, any criteria for an injury and return to play is a case by case scenario and should be adapted for each individual case to best match the needs.

My points…

We are having the return to play being either negated or done sub par in cases.

Often it is by the wrong provider based on circumstance and perhaps policy.

Policy should reflect what is best for the athlete, not be based on the degree of the practitioner.   

I argue that the Athletic Trainer with help from the coaches is THE BEST qualified people to create and implement return to play criteria, not a note from an ancillary provider.

Communication helps. Use the information from the ancillary staff to help make better informed decision in certain cases. A text or quick call makes a huge difference.

Return to Play can be fairly simplistic and done in a way that benefits…EVERYONE.

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