Returning an athlete back into the game- What questions should you ask & what should determine your decisions?

What criteria do you use to return an athlete back into the game following an "injury"?  I use the word injury very loosely because athletes get banged up pretty good each game.  If the injury isn't serious (torn ACL, concussion, etc) then often they can go back into the game.  However, it begs the question.....What criteria do we use to return an athlete back into the game?  

In the 3 months of practice and game coverage that I have covered for football, volleyball, and soccer I have asked myself that question often.  I've had the unique opportunity to discuss this question with sports medicine doctors from Kerlan Jobe, athletic trainers, and sports physical therapists.  While I am far from an expert with 3 months of coverage, I do believe I can offer some guidelines to get you started.  

Ask yourself these questions when an athlete goes down on the field...

1.  Is the athlete a possible spinal cord and/or neck injury?  This is always the very first question, no matter what.  If the athlete is conscious and the MOI was in the upper extremity we always want to clear this first.  Ask them about neck pain, head pain, extremity paresthesia and distal symptoms.  I won't go into the process if it is a neck injury, but this is always an emergency and proper spine boarding is vital.

2.  What was the MOI and location of injured body part?  This is important for dislocations, ligamentous injuries, and serious head injuries.  It also dictates when and how you get the player off the field to the sidelines.  For example, a football player who goes down and dislocates his shoulder may show signs of keeping his arm very close to his body.  You do not want to lift them up by the injured arm.  

3.  Okay, you've determined that the athlete has a bruised bone or a mild ankle sprain.  Whats your return to play criteria for the game?  This is the trickiest part sometimes.  While it really helps to know that athlete personally, often you don't if you're covering multiple teams.  

     -  Can the athlete perform the necessary movements required for their sport?  More importantly, for their position?  A defensive back returning to the game must be able to cut, jump, and sprint on a dime.  Test them, have them backpedal, turn and cut, sprint.  Have them jump single leg and both legs.  Test the injured body part in any position it must go through.  Now as far as dosage for these tests, keep it low.  Why?  Well first of all you're not in a clinic so you don't have the luxury of time.  Second, these are athletes that are playing in a game, don't fatigue them out.  Third, you just need to determine whether they are capable of performing at a safe level.  Ideally, you'd want to test them out to see if fatigue affects the safety of the athlete.  Unfortunately, more than often we cannot do that.  Lastly, what is the mindset of the athlete?  They may test out perfect but if they do not feel ready to go back in the game then this really changes the handling of the athlete.  

While this is not all inclusive, it should serve as guidelines to think about.  
So what is it you should take away from this?  
  -  Determine if its a serious injury.  This dictates your next move.  Know when to refer out.  
  -  Determine MOI and location of injury.  This also dictates your next move and the time you spend with the athlete/questions and objective measure you look at.
  -  If the athlete does not have a serious injury, determine the movements they need to perform.  Test them out, keep dosage relatively low, gauge the athletes response/safety with the movements, make a decision.  
  -  Don't forget about the psychological component of the athlete.  

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