Return to Play/Injury Protocol: When in Doubt, Keep them Out
Over the last several years there has been a major focus on education regarding athletic injury and the return to sport/play, especially for concussion. While this attention has led to new state laws, safety protocols, policies and knowledge, there is still a lot of work to do. Ignorance of the dangers of returning to play too soon can and does lead to catastrophic results. We can’t say that what we are doing is good enough, just because it is better than 5 years ago. We must constantly improve training and education, and apply new technologies designed to keep our athletes safe.
As a former youth soccer coach, I remember the parental pressure, the athlete’s desire to play and the desire to win sometimes overruling good judgment. The education, training and common sense that good clinicians and trainers have in abundance is ideally supported by the data generated by technology to help them “sell” their sometimes unpopular decisions to the players and parents. It’s easy to get so caught up in winning at all levels that we can rush to put someone back on the playing field, overlooking the marathon of life and sport, and just looking at the sprint.
There are more and more research studies, some by renowned clinicians, in recent years regarding the effect of returning to play too early. That’s something I don’t hear anyone talking about. For orthopedic injuries, return too early exposes the athlete to not only increased orthopedic risk, but also concussion risk because you are a step too slow. On the other side, return to play from concussion too early can not only lead to death from 2nd impact syndrome, but also increases the orthopedic injury risks, because of the slower reaction times.
Finally, we are big in athletics these days on baselines for concussions (cognitive testing), but do not baseline the athlete for orthopedic issues, when there are statistically 6-10 times as many lower extremity injuries as concussions every year. Subjective assessments are primarily relied on to evaluate those injuries, and statistically, the pain goes away when there is still a 25 – 30% movement deficit. And how relevant is a cognitive baseline test for an athlete? I understand a cognitive only test for the math team or chess team, but not for athletes playing action/movement sports that demand elevating the heart-rate and dynamic movement. Ask yourself if an annual cognitive test is good enough for YOUR young athlete? Or is it just better than it was 5 years ago. Remember, When in Doubt, Keep them Out
Anecdote – St. Mary’s Hospital
A high school female soccer player had a TRAZER baseline in the fall of 2017 during a St. Mary’s testing event. We give the athletes our clinic information and a card telling them where their test is on file. In the spring of 2018, she was struck in the back of the head and then fell over and hit her head again. Immediately after the hit/fall she was dazed and unsteady and reported nausea, tiredness and vomited once; no seizures or other symptoms. During her office visit the following day she felt better, was alert and responsive with no symptoms. A TRAZER return-to-play repeat of her baseline was ordered for the same day and during the 360 jump she reported headaches, with a decline in reaction time and balance errors and therefore, was not cleared. She was tested again 3 weeks later and failed, and again 4 weeks later during her pre-season physical. She was cleared to return to play after the final test resulted in no symptoms and return to baseline assessment levels.
Taking a cognitive test only, she could have passed without affecting the vestibular and prompting symptoms. She could have been returned to play too early and been put at high risk. Let’s do our best to mitigate these risks.