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Perhaps the most common question for every active but injured patient is ‘When can I return to play?’


Return-to-play (RTP) decisions can be difficult and complex.1 The clinician is expected to provide an opinion based on a large number of factors including the history of the injury, physical examination, type of injury, rehabilitation, type of activity, psychological state, competitive level and ability to protect the injury. Further, these decisions do not occur in a vacuum. The athlete may receive advice from family, friends, coaches, other clinicians and, in the case of elite athletes, agents.


Because determining prognosis is difficult and frequently subjective, some disagreements regarding RTP will always occur.2 Differing sociocultural and clinical perspectives of the medical doctor, coach, athlete and others lead to a high potential for conflict. Apart from being challenging and an unpleasant experience, such conflicts are believed to lead to a number of negative scenarios including:


  1. miscommunication

  2. loss of trust

  3. potential litigation

  4. declines in sport participation rates—some individuals never ‘get back in the game’ due to fear of re-injury (despite acceptable levels of risk)

  5. serious medical complications—some athletes return to activity while still at unacceptable levels of risk for subsequent sport-related injury.3, 4, 5, 6


Two important factors may minimise development of such conflict: a formal structure or process outlining how an actual RTP decision should be made and a formal process to guide the interactions between individuals who contribute in any way to the RTP process. It is important to note that in some cultures the clinician is expected to determine the reasonable course of action for a seemingly independent third party—the athlete—who is otherwise capable of making autonomous decisions. In other cultures shared decision making may be promoted by the medical community in general, but the clinician is usually still considered legally responsible for any consequences of the decision. Regardless of the cultural context in which one is situated, having a transparent framework for arriving at RTP decisions should help minimise any conflict that might arise.


The purpose of this chapter is to provide such a framework. In 2010, we published a 3-Step framework7 developed specifically for RTP decision making. The framework is consistent with clinicians’ beliefs independent of country of practice or clinician specialty,8 and represents a framework to help organise complex information; it should not be interpreted as proscriptive. After feedback from clinicians, this has now evolved into a revised framework called the Strategic Assessment of Risk and Risk Tolerance (StARRT).9


The StARRT framework is based on causal relationships and considers that differences in RTP decisions are partly due to differences in (1) risk assessment and (2) risk tolerance. Differences in risk assessment could be decreased through the application of research and knowledge dissemination leading to improved evidence-based practice. Differences in risk tolerance are based on societal ...

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