BRINGING SCIENCE TO TREATMENT

Should amateurs model elites in return to sport?

 England’s Courtney Lawes with team physio during training Action Images via Reuters / Paul Childs Livepic 

The first question an athlete asks after they suffer an injury is, “How soon can I return to play?” This is one of the most challenging questions for a clinician because every case is different. An athlete’s healing and rehabilitation depend on several factors. Some, as Andrew Hamilton explains, they can control such as nutrition and sleep. Other factors, like the extent of tissue damage, is beyond anyone’s control. Even an athlete’s psychological readiness plays a significant role in return to sport (RTS), as Tracy Ward explains in her article on how an athlete’s mindset impacts their RTS.

Despite the individual nature of injuries, there remains a desire to develop some sort of guidelines or expectations for the duration of time needed to rehab specific injuries. A recent multi-center study conducted a post-hoc analysis of injury data collected from elite European male soccer teams between 2001 and 2017 to determine the parameters for return to play in the sport of soccer(1). They defined injury as any physical complaint suffered during play or training that required abstaining from participation in a game or practice. The data recorded the number of days before each player was cleared to resume either training or play. The study also analyzed the required time off for re-injury, defined as any complaints arising from the same place as previously injured.

The data arose from 494 team-seasons and consisted of 22,942 injuries. Of these, 19,926 were primary injuries while 3,016 were re-injuries. The most common injuries were mild contusions, joint strains, and overuse pain syndromes. These typically required not more than 7 days before RTS. The more moderate injuries included muscle strains, usually in the thigh and groin, and required less than 20 days off before RTS. Those injuries that were most severe and required greater than 20 days away from play all occurred in the knee joint.

Only nine of the 31 most common injuries contributed to over half of the required time off from sport. These injuries consisted of structural muscle injuries in the thigh and calf, as well as damage to the lateral ankle and medial collateral knee ligaments. While these injuries were defined as moderate due to the RTS after a median of 13 days, the volume of these injuries was high. Though they occurred in different muscles, it appears that the required time for healing a muscle tear was consistent no matter which muscle group was affected.

Anterior cruciate ligament (ACL) and lateral meniscal tears were the only two injuries within the 31 most common that were classified as severe, requiring more than 28 days away from sport. Of the ACL injuries, most players returned to play far sooner than the nine months recommend as the minimum time away from sport. The median RTS was 205 days, and the mean was 210.2 days. Remarkably, the re-injury rate was only 6% while, as Alicia Filley explains, the re-injury rate in the non-elite population is typically reported as up to 25%. Does this point to the fact that perhaps elite players receive more intensive and individualized rehabilitation?

Fixing it right the first time

Injuries in six locations (Achilles tendon, calf, groin adductor, hamstring, and quadriceps muscle) showed a significant difference between the time off after the initial injury and the longer time after re-injury. The authors of the study wondered whether the primary lesion was adequately rehabilitated in the first place (see table 1). The most common re-injuries occurred in the thigh, calf, and ankle. Interestingly, although these injuries were classified as moderate initially, they contributed to the most time off due to the frequency with which they occur. However, the re-injuries that required the most time off from sport occurred in the knee, groin, low back, calf, ankle, and shoulder.

Location of injuries with resulting re-injuries that required more than seven days prior to return to sport(1)

Location of injuryMedian days before return to sport after initial InjuryMedian days before return to sport after re-injury
Knee MCL16.013.0
Hip flexor pain8.013.0
Hamstring muscle 13.015.0
Quadriceps muscle13.016.0
Calf muscle13.016.0
Groin 8.017.0

This raises the question of using this data set as a guideline for the rest of the population. The authors contend that these RTS statistics occur under the best possible circumstances with personalized and professional care as long and as often as needed. For those practicing in typical settings, resources may have to be used sparingly. Furthermore, as the high rates of re-injury and longer times off of play afterward support, achieving the fastest possible RTS may not be the best strategy. In addition, this study highlights the fact that while severe injuries get a lot of attention, they occur relatively infrequently in the elite population. While this large homogeneous study provides valuable information for the niche population, amateurs and athletes who aren’t as well trained shouldn’t strive for these return to play times. Rather, continue to explain to athletes the need to meet certain performance criteria before clearing for return to sport.

Reference

  1. Br J Sports Med. 2019;0:1-6 Epub ahead of print

 

 

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