Introduction
This is my final post on the Return to Play Conundrum (hallelujah!). If you have not read my previous three posts, I highly suggest you circle back in order to create context for this one. Just to quickly recap, in my first post I indicated the importance of fostering sustainable relationships with the multidisciplinary team, establishing lines of communication, and outlining roles and responsibilities of everyone involved. In my second post, I focused on adopting validated models that will guide decision-making through the return to performance process. In my last post, I stated a clear objective, goals, and defined the process, while outlining factors to consider when creating a plan. This may seem like a lot of information, but its critical to build a strong foundation and structure that will allow our system to flourish. Within my final post, I will use my previous posts to plan each phase of the Return to Performance Continuum.
Return to Performance Continuum
Now to the fun part, outlining each phase of the Return to Performance Continuum! The structure and process outlined below is heavily influenced by the 2016 Consensus Statement (which I refer to in all my posts), which outlines three important phases (1):
Return to Participation: allows athlete to be physically active in rehabilitation or training
Return to Sport: athlete return to their defined sport, but at least initially will not be performing at their desired level
Return to Performance: athlete at least reaches or exceeds their pre-injury level with potential for growth related to performance.
I have expanded on this continuum, combining elements of Sizer and Falsone’s The Slide framework and Bill Knowles’ Performance Model (2, 3). The Slide framework (shown in the figure below) uses an integrated, evidence-based approach that moves the athlete back from pain to high performance. I will use many of the elements Falsone describes in great detail in her book, Bridging the Gap from Rehab to Performance, which I will refer to throughout the continuum. I wrote about Knowles’ Performance Model in my previous post, which focuses on training around injury and maintaining an emphasis on graded reconditioning. I have combined elements of these models within the Return to Performance Continuum you see below. The colours represent the athlete’s status and involvement in sport. Red represents none to minimal, orange and yellow represents moderate, while green represents up to full participation in sport. As we know, there are a number of factors that can influence how an athlete progresses along this continuum, so the performance testing outlined in my previous post will serve as clearance criteria to help create objectivity, as well as ensure the athlete has met the prerequisites for increasing demands. You will notice that each stage has an objective, reason, and criteria, while stating roles and responsibilities of the multidisciplinary team. This makes it clear what all contributing members are responsible for within each stage of the process, as well as establishing objective criteria for clearance to the next phase. As outlined in the 2016 Consensus Statement, testing will be employed immediately after the injury, throughout the course of reconditioning, at the time of clearance for a full return to sport, and after return to sport to measure performance and reinjury risk. Lastly, I have included assessment of acute:chronic (A/C) ratio and performance of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. This ensures a consistent evaluation of the athlete’s physical and psychological state as it relates to their performance. Since there are so many layers involved and the circumstances can greatly differ depending on the injury, individual, and sport, I will discuss mostly in generalities and provide examples when appropriate.
Return to Performance Continuum
Initial Consultation
This phase was not directly defined in any of the aforementioned models or frameworks. However, Ardern et al. suggests that optimal contingency planning for RTP might even happen before an injury occurs or at least as soon as the injury occurs (1). In my opinion, this is the most important phase since it’s the first opportunity for everyone to get on the same page. Essentially, this is the jumping off point of the Athlete-Centered Model I wrote about in my second post. Therefore, it is vital for the multidisciplinary team and the athlete to meet with the onset of injury. This ensures a clear understanding of the injury and collaborating on interventions from each discipline in order to create a plan moving forward. Numerous factors must be considered when deciding what to emphasise within training, such as the type and mechanism of injury, sport and position, time of year, and physical status of athlete. According to Falsone, it is critical to identify the dysfunction, determine short and long-term goals for improvement, and create a plan to fix it (2). As stated in Knowles’ Performance Model, the multidisciplinary team strategically works backwards from where the athlete needs to be physically as it pertains to the demands of their sport (3). Although aspects of the plan may change based on how the athlete progresses, the multidisciplinary team can use the Criterion/Performance-Based Method outlined in my second post to provide a clear direction for success. Ultimately, this phase serves to enhance communication between all members to ensure that the RTP process is optimised (4).
Return to Participation
According to the 2016 Consensus Statement, within Return to Participation phases, “the athlete may be participating in rehabilitation, training (modified or unrestricted), or in sport, but at a level lower than his or her return to sport (RTS) goal. The athlete is physically active, but not yet ‘ready’ (medically, physically and/or psychologically) to RTS. It is possible to train to perform, but this does not automatically mean RTS” (1). Using this as a guideline, we will dive into each stage within this phase.
Stage 1
The goal of this phase is to promote tissue healing and avoid deconditioning (2, 3). This involves a combination of direct rehab and reconditioning, as outlined by Knowles’ Performance Model. Falsone indicates that most of this phase will be spent with the ATC (and/or Physical Therapist), but depending on the injury, the Sports Performance Coach (SPC) can and should work around the injury to maintain/develop physical performance qualities. This also includes maintaining the athlete’s fitness level to avoid being de-conditioned in the later phases of RTP. The worst possible scenario is to immobilise the injury and take the athlete completely out of training. Once the injury has been examined and diagnosed (or surgically corrected), the next step is to initiate treatment immediately. This involves managing biological healing, such as pain management, swelling, and protection of injured tissues (2). Falsone refers to this section as Pain Generator and Motion Segment (as noted in the figure above). Pain Generator serves to accurately identify the problem in order to appropriately direct treatment. Pain is individual specific, as we don’t all experience it the same way; involves many systems, being both peripheral and central; and the cause and location of pain doesn’t always match (2). Therefore, the ATC must use evidence- based practice to accurately assess and diagnose the injury. This will determine appropriate interventions to accelerate healing, such as soft tissue modalities, dry needling, cupping, etc.
Using these in conjunction with controlled, protective progressive range of motion puts a priority on tissue quality and improving range of motion. The ATC can also use forms of muscle activation techniques to improve muscle contraction capabilities. If these are compromised, the athlete will have limited ROM and strength capabilities that could lead to imbalances and asymmetries (2). If Pain Generator looks to address the source of pain, Motion Segment looks to address the cause of pain. This puts an emphasis on how the injured tissue relates to the whole body. To re-establish the Motion Segment is to prepare the body for more advanced movements to come in later phases. It’s important to look at localised contractile ability of injured tissues, but it’s just as important to integrate the injured tissue back into the whole system (which may be dependent on the injury). This will serve to prioritise optimal firing of localised tissue and integrate this into improving movements patterns to limit compensations and asymmetries. This is where we start to bleed into the next section (which is why it’s a continuum!). Ultimately, this will help to reduce potential for reinjury and optimize loading. This is where the ATC and SPC can work together on evaluating and integrating movements to enhance reactivation. As stated above, the SPC should also be implementing a reconditioning plan to work around the injury and reduce de-conditioning. This will allow a seamless transition into the next phase as the athlete begins to load the injured tissue. In regards to clearance criteria, this is heavily influenced by the type of injury and/or if surgery took place. Localised reactivation can be assessed with manual muscle testing to evaluate voluntary muscle action. For range of motion, comparison to baseline measures can be used. Improving ROM will ensure the athlete can access the necessary ROM prior to loading the tissue. These can be used as part of the objective “checklist” criteria to progress the athlete to the next stage. Meanwhile, the Sport Coach needs to keep the athlete involved in team activities to maintain a sense of belonging, as well as limit negative psychological effects of the injury. The Sport Coach should also integrate the athlete into practice through low-level sport related activities that don’t involve the injured area. For example, if it’s a basketball player with a lower extremity injury, the athlete can perform form shooting sitting in a chair. This serves to keep the athlete involved with the team, while maintaining a thread of technical components of the sport.
Stage 2 At this point, we have allowed biological healing to run its course. The athlete has also demonstrated the ability to achieve active open-chain full ROM compared to baseline and/or non-injured limb as we improved reactivation of the injured tissue. Now it’s time to integrate the tissue within the whole system. This is an extension of Falsone’s Motion Segment and Psychomotor Control sections, as well as shifting from a rehab focus to a reconditioning focus as demonstrated by Knowles’ Performance Model. According to Falsone, Psychomotor Control involves the fine tuning that ensures proper posture and movement to avoid developing compensations that may have evolved from injury (2); or this could be the cause of injury, which appropriate diagnosis would’ve revealed. We need to ensure the correct muscles are firing at the right times. As stated in the previous stage, this is where we continue to integrate the injured tissue back into the whole system and correct faulty patterns. This will have a heavy influence on motor control, biomechanics, and proper neuromuscular facilitation. In layman’s terms, get the athlete to move well and sustain this. Once again, this is where the ATC and SPC will collaborate and work together using modalities such as proprioceptive neuromuscular facilitation, muscle activation, functional range conditioning, postural restoration, and dynamic neuromuscular stabilisation techniques. It is beyond the scope of this article to go into depth on all of these concepts, but globally, these address that physical structures do not act on their own but involve numerous systems to optimize efficient movement. Incorporating these techniques will also serve to transfer to Falsone’s next section, Somatosensory Control, which involves proprioception, balance, awareness, and the integration of these during movement. Simply, we need to account for the nervous system and how it processes information. This helps to increase the available degrees of freedom to perform a task in any given environment (2). Depending on the injury, we can systematically challenge the athlete to improve their functional variability through changing the task, such as altering the base of support or center of gravity; or changing the environment, such as altering the sights, sounds, or surface. Improving the athlete’s mobility, efficiency, and proprioception doesn’t have to be mutually exclusive to initiating a training program. Although we do not want to load on top of dysfunction, we can integrate the techniques listed above within the reconditioning model the athlete is already undergoing (including maintaining fitness level). As the athlete improves their movement efficiency, we can systematically progress strength qualities. This is where we integrate Falsone’s Fundamental Performance section, in which building strength will create the foundation to perform sport related activities. This is where the continuum shifts primarily to the SPC. Although the type of training is highly dependent on the injury, athlete, and sport, it is paramount to employ periodisation strategies and have a basic understanding of the specific adaptation to imposed demands (SAID) principle and super compensation. Once again, this is beyond the scope of this article, but involves implementing a structured plan that applies a training stress with intermittent periods of recovery. Understanding the classification of strength qualities (relative, functional, hypertrophy, and endurance), how they relate to the individual athlete and sport, and applying appropriate modalities is essential to achieving specific adaptations (5). A SPC has a number of tools at their disposal, in which they can use to apply training methods that acquire the strength qualities listed above. Furthermore, this involves understanding training variables that can influence the desired adaptation, such as tempo, volume, intensity, rest, exercise selection, frequency, and density. We must also progress the athlete to acquire movement literacy in all planes of movement a sport is not uniplanar. A lot of traditional strength training movements are great for improving relative strength, but most of these modalities are used within the sagittal plane. As we know, most team sports are multi-directional and require competency in all patterns (linearly, laterally, rotationally, up, and down). Manipulation of these variables must be in a progressive manner that ultimately prepares the athlete for the demands of their sport and position. Also, the SPC can begin to integrate low impact plyometrics and movement mechanics. This will serve to build tolerance for impact related activities, such as jumping and running, as well as improve neuromuscular coordination. This is highly dependent on the injury, sport, and stage of development. However, we need to strategically progress impact related activities as long as they have the eccentric strength required to tolerate these. This is particularly important if it’s an athlete with a lower extremity injury who participates in a field or court sport. In regards to clearance criteria, we can use baseline tests of the Functional Movements Screen, Y-Balance Test, and/or other assessments to objectively evaluate mobility. For strength, we can use manual muscle testing for localised tissue and previous performance tests, such as a squat, deadlift, rear foot elevated split squat, bench press, or chin-up, for integration of overall strength. Obviously, this is dependent on the injury, but it’s still important to assess the athlete’s overall strength to ensure they are prepared for the demands of the next phase. Simultaneously, the Sport Coach should continue to keep the athlete involved in team activities. Low-level sport related skills should be progressed as long as they align within the athlete’s current stage of development. For example, to continue with the basketball player example used earlier, at this point they will be weight bearing and progressing impact related activities. So, they may be performing spot shooting, passing, and some ball handling drills for technical development.
Return to Sport
According to the 2016 Consensus statement, within RTS phases, “the athlete has returned to his or her defined sport, but is not performing at his or her desired performance level. Some athletes may be satisfied with reaching this stage, and this can represent successful RTS for that individual” (2). Using this as a guideline, we will dive into each stage within this phase.
Stage 3
Up to this point, the athlete should have improved their movement efficiency and acquired the strength necessary to increase specificity. Ultimately, the athlete will need to be able to move varying loads, at varying speeds, in different patterns (2). That is what we will address within this stage. Once again, this will primarily be directed by the SPC. Using elements of Falsone’s Fundamental Advancement section and integrating controlled sport skills as eluded to in Knowles’ Performance Model, the athlete will improve application of universal movements and athletic competencies that may have diminished after an injury. This will prepare the athlete to express sport related activities as we approach the coming sport-specific phase. However, in order to express sport related activities, the athlete must be able to translate the strength acquired in the previous stage, into power and speed. Power is the product of force multiplied by velocity. To improve power, the athlete must move higher loads at higher velocities. This takes an understanding and integration of the force-velocity curve (shown below). The curve signifies an increase in force causes a decrease in velocity, and vice versa. Shifting the curve to the right improves rate of force development, which ultimately reflects an increase in how quickly force can be generated (6). The quicker an athlete develops force, the more explosive they become. Application is highly dependent on the injury, but may include integrating patterns such as Olympic lifting, medicine balls, acceleration, deceleration, plyometrics, and change of direction. The reason we prioritised strength first, is it’s not only a prerequisite for power and speed, but it creates the eccentric strength necessary to tolerate the above activities since most injury occurs during deceleration actions (3). When integrating and progressing these movements, we must take the same periodised approach to building strength as noted in the previous section. Using Jacob Jennings’ progression as outlined on Strength of Science (7), below are some practical considerations:
Quality before quantity
Bilateral before unilateral
Linear and lateral before multidirectional
Slow before fast
Low impact before high impact
Short before long
Using these considerations, the SPC can progressively increase the complexity and impact of training to match the development of the athlete. All of these qualities above are executed in a controlled environment with minimal additional stimuli. The difficulty of a task greatly increases if other stimuli are introduced, such as a ball and/or an opponent(s). The athlete needs to demonstrate they have the ability to perform optimally in a controlled environment before the complexity is increased. This also includes a return to running, which falls under the acceleration, deceleration, and change of direction applications mentioned above. As the athlete improves strength, coordination, impact tolerance, and motor patterns of running, they can progress linear based running. In regards to clearance criteria, we can use our baseline performance tests to assess competency. This is dependent on the injury, but may include both a unilateral and bilateral test to assess general power, speed, and agility qualities (ie. jump variations, sprint tests, and controlled change of direction tests). It’s also important to monitor the fitness level of the athlete. Are they fit enough to withstand the demands of practice, and ultimately competition? At this stage of reconditioning, this may be a more general test as we have not progressed to sport specific qualities yet. The mile can provide an objective measure of fitness level compared to pre-injury status. This stage is also where the Sport Coach becomes much more involved, as they are the experts in technical skill development. They should provide feedback on how the athlete is performing and progressing their skill development to provide insight to both the ATC and SPC. The Sport Coach should begin to increase sport related skills in a controlled environment as it mirrors the athlete’s current stage of development. For example, to continue with the basketball player, they may have progressed from individual skill development without the ball, to skill development with the ball. This will prepare them for the increased demand of open skills and stimuli introduced in the next stage.
Return to Performance
According to the 2016 Consensus statement, within Return to Performance phase, “extends the RTS element. The athlete has gradually returned to his or her defined sport and is performing at or above his or her preinjury level. For some athletes this stage may be characterised by personal best performance or expected personal growth as it relates to performance” (1). Using this as a guideline, we will dive into each stage within this phase.
Stage 4
At this point the athlete has returned to practice and demonstrated the ability to perform controlled general power, speed, and agility movements, as well as improved their fitness level to minimise the negative effects that fatigue may have on re-injury. The athlete may also have increased some involvement with the ball (if applicable for their sport and injury) and participated in certain drills in a controlled manner. Now it’s time to get more specific. This stage is an extension of Falsone’s final section, Advanced Performance, and Knowles’ Return to Team Training, which is all about the individuality of the athlete, the sport, and the position they play. There are sport-specific and position-specific skills and patterns the athlete will need to acquire before a return to competition. Progressing from general athletic movement in the previous phase, to sport and position specific movement, ensures the athlete is prepared for the unpredictability of competition (2). This involves heavy participation from both the SPC and Sport Coach as they will use objective and subjective measures to evaluate the athlete’s performance. The Sport Coach’s involvement is vital to the end stage of reconditioning as they are experts in the sport and the position-specific demands needed. Up to this point, the athlete has performed mostly controlled, closed skills, but sports are not played in a controlled environment. Exposing the athlete to random, unpredictable, and chaotic movements is imperative to developing competence. This can involve progressing interactions between them and the ball, teammates, opponents, surface, and even weather conditions. Using visual, audible, and tactile cues can integrate external cues that trigger appropriate movement patterns. Tactile cues may be one of the most important components in team sports that involve contact. At the end stage of reconditioning, its vital to incorporate ways to challenge the integrity of the athlete’s movement patterns to adapt to contact. This should be done in a progressive manner prior to them playing in simulated games, since a game environment will provide uncontrolled and unpredictable contact. Although we cannot completely mirror a real game environment, we can progress open skills involving those stimuli to increase the physical and mental demands placed on the athlete. Using modified scrimmages, small-sided games, situational game scenarios, and ultimately full scrimmages, can bridge the gap from practice to competition. As with everything, this should be a graded progression in which the athlete can demonstrate mastery. The athlete should also be undergoing sport-specific conditioning modalities that prepare them for the demands of practice and competition. Especially in team sports, this should incorporate an intermittent, high intensity change of direction component. This is where the YoYo Intermittent Level 1 or 2 (YoYo) can provide an objective measure to the athlete’s preinjury fitness level. The YoYo tests have been proven as a valid evaluation of physical performance in intermittent sports (8). This ensures the athlete can sustain the high intensity repetitive change of direction inherent in team sports. Lastly, the ultimate decision for a return to competition should be made. Along with sport-specific clearance criteria, the multidisciplinary team can use the A/C ratio and I- PRRS scale to ensure the athlete is both physically and mentally prepared for a return to competition.The multidisciplinary team should also use the Shared-Decision Making Model and Strategic Assessment of Risk and Risk Tolerance (StAART) framework outlined in my second post. These allow the multidisciplinary team and athlete to come to a collective decision based on all risk factors associated witha return to competition.
Evaluation
We made it! The athlete has been thoroughly reconditioned and has made a full return to competition. To quickly recap, this involved the multidisciplinary team collaboratively planning and executing a periodised program of escalating demand, using clearance criteria, and implementing performance testing throughout the continuum to progress the athlete. Throughout the continuum, the A/C ratio was employed to monitor that the athlete was progressed at an optimal pace and the I-PRRS scale was used to evaluate psychological readiness. The multidisciplinary team used the Athlete-Centered Model to keep the athlete as the focal point, while implementing the StAART Framework and Shared-Decision Making Models to evaluate the risk associated with progressing through each phase. The multidisciplinary team also met weekly in order to maintain consistent communication on the weekly plan, discuss how the athlete is adapting, address any changes or modifications needed, and hold everyone accountable for their roles and responsibilities. Weekly meetings also served to incorporate the four key habits of an athlete-centered return to sport plan as outlined in my second post, which includes empowerment, engagement, feedback, and transparency (9). Now it’s time to evaluate how the process went. This phase is not directly defined in any of the aforementioned models or frameworks, however, it’s vital to audit the process to find ways to refine and improve protocols. Each member, including the athlete, should be an active participant in how the process can be improved.
Closing
“The difference between success and failure is a great team.”- Unknown. I have provided a ton of information in the past four posts. This was to not only to serve as support for the Return to Performance Continuum outlined above, but also to demonstrate the complexity of the process. There are a ton of layers and moving parts. And every situation is different. We all have varying degrees of experience, with different resources, and in different environments. But ultimately, it comes down to having a committed team that executes a plan. Professionals must put egos aside and collaborate on a plan that puts the athlete as the focal point. We must avoid prioritising our own agendas and thinking our area of expertise is superior. You cannot go at it alone. Use every resource you have, be humble in your approach, and create a framework that works for your setting.
References
2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern
Bridging the Gap from Rehab to Performance
Sports Injury Prevention and Rehabilitation
Energy System Development and Load Management Through the Return to Play Process
Poliquin Performance Theory 1 Manual
The yoyo intermittent recovery test: a useful tool
Want to Improve Return to Sport Outcomes Following Injury? Empower, Engage, Provide Feedback and be Transparent: 4 Habits!
About the Author:
Griffin Waller is a Certified Strength and Conditioning Specialist by the NSCA. Griffin has a Bachelor of Science in Exercise and Sport Science, and a Master of Arts in Kinesiology, Concentration in Exercise Physiology. Griffin has close to a decade of experience working in a university based environment including; Starting at the University of Portland as an athletic performance intern, followed by various roles at the University of Florida, the University of Stanford and Missouri State, before Griffin return to the University of Portland as the Director of Athletic Performance in 2017. Griffin is also an IUSCA Advisory Board member.
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