Editorials

Return to play in elite sport: a shared This advice is primarily based on the
clinical situation—the context of the
decision-making process real athlete with a very specific
problem. Professional experience,
sport-specific injury and performance
H Paul Dijkstra,1 Noel Pollock,2 Robin Chakraverty,3 Clare L Ardern4 knowledge and a relationship with the
individual athlete, framed by an under-
Illness or injury affected four out of every RTP) of an ill or injured player on the standing of the relevant published sci-
five athletes on the Great Britain Track field of play should be made by a entific evidence, are the important
and Field Team before, during or immedi- healthcare professional. The coach or elements of the decision-making
ately after the 2012 Olympic Games.1 manager should have no say in whether process. In elite sport, this advice is
The return to play (RTP) decision is a the medical team should attend the usually informed by input from the
case of risk management, and athletes athlete, or in immediate player supporting team of healthcare profes-
may continue to train or compete, despite assessment.3 sionals who work with the athlete.
being ill or injured. This begs the ques- Where an athlete has the capacity to 2. Athlete: When fully competent, the
tion: ‘How is the return to play decision make a decision, we propose (and use) a athlete should make an informed deci-
made in elite sport’? shared decision-making (SDM) process; sion about his/her readiness and desire
RTP decisions are complex, specific this approach improves outcomes and sat- to RTP. This decision is based on per-
to the athlete and type of sport, and isfaction with treatment.4 sonal circumstances and experience,
often influenced by ‘decision modifica- The three key steps in SDM are:5 his/her intrinsic view on risk taking,
tion’ factors (eg, pressure to return for 1 Choice: making the athlete and coach the environment and specific informa-
a major event).2 In the case of a sprinter aware that reasonable options exist; tion regarding health and performance.
with a hamstring strain 2 weeks from 2 Option: providing more detailed infor- Contextual factors that may be relevant
the World Championships, the final mation about the different options; to the athlete include sponsorship deals
RTP decision-maker might be the 3 Decision: guiding the athlete and coach or media pressure. Despite the athlete’s
athlete. However, the healthcare profes- to consider their preference and decide preference, at the highest level of elite
sional should be the final RTP decision- what is best. sport, there are often wider perform-
maker when athlete decision-making ance implications with impact on other
capacity is compromised (eg, concus- athletes in the team (and in individual
sion). Decisions regarding the immedi- Role definition in sports medicine SDM events) that need to be considered (ie,
ate medical management (including The three key people in SDM (figure 1): one rower causing a rowing 8 to fail).
1. Healthcare professional: The most Therefore, the final decisions regarding
1 appropriate person to evaluate the selection, participation and RTP are
Sports Medicine Department, ASPETAR, QATAR not usually made in isolation. The ath-
Orthopaedic and Sports Medicine Hospital, Doha,
health status of the athlete and provide
Qatar; 2British Athletics, Hospital of St Johns and St objective advice on management lete’s input is a pre-requisite.
Elizabeth, London, UK; 3British Athletics, National options and possible clinical outcomes 3. Coach: The informed coach evaluates
Performance Institute, Loughborough, UK; 4Research following RTP (usually a sports phys- the current ability of the athlete to
Department, ASPETAR, QATAR Orthopaedic and Sports ician and/or physiotherapist). This perform to a specific required standard,
Medicine Hospital, Doha, Qatar
includes the short-term risk of per- based on knowledge of the athlete, the
Correspondence to Dr H Paul Dijkstra, Sports training missed, the athlete’s functional
Medicine Department, ASPETAR, QATAR Orthopaedic
formance detriment or reinjury, the
and Sports Medicine Hospital, PO Box 29222, Doha, consequences of reinjury and the long- progression in rehabilitation and the
Qatar; paul.dijkstra@aspetar.com term health (and performance) risk. information provided by healthcare

Br J Sports Med March 2017 Vol 51 No 5 419

 Editorials
trust among the key people involved, and
ultimately, the quality RTP decision.
For more information on shared
decision-making, see the suggested reading
list in the online supplementary appendix.

Twitter Follow Hendrik Dijkstra at @DrPaulDijkstra,

Noel Pollock at @drnoelpollock, Clare Ardern at
@clare_ardern
Contributors HPD substantially contributed to
conception and design, coordinated authors, drafted,
revised and approved the final version of the
manuscript. NP, RC and CLA participated in drafting
and revising the manuscript and approved the final
version to be published.
Competing interests None declared.
Provenance and peer review Not commissioned;
externally peer reviewed.
▸ Additional material is published online only. To view
please visit the journal online (http://dx.doi.org/10.
1136/bjsports-2016-096209).

To cite Dijkstra
DijkstraHP,
HP,Pollock
PollockN,N,Chakraverty
ChakravertyR,R,etetal.al. Br
JBrSports
J Sports
MedMed 2017;51:419–420.
2016;0:0–0.
Accepted 10 July 2016
Published
Br J SportsOnline First 29 July 2016
Med 2016;0:0–0.
Br J Sports Med 2017;51:419–420.
doi:10.1136/bjsports-2016-096209
Figure 1 The size of the contributing circles to the shared decision-making (SDM) processes are doi:10.1136/bjsports-2016-096209
influenced by different factors, including health status, participation risk and other decision
modifiers. The position of the SDM circle might therefore vary: for a concussed athlete with ‘no
REFERENCES
1 Dijkstra HP, Pollock N, Chakraverty R, et al. Managing
capacity’ to take part in the SDM process, the decision is firmly within the healthcare professional the health of the elite athlete: a new integrated
circle. In the case of the athlete and coach travelling alone to a training camp/competition, the performance health management and coaching model.
healthcare professional might be absent from the SDM process. Br J Sports Med 2014;48:523–31.
2 Creighton DW, Shrier I, Shultz R, et al. Return-to-play
in sport: a decision-based model. Clin J Sport Med
professionals. The coach’s contribution healthcare.6 Coaches can influence injury 2010;20:379–85.
3 A Doctor’s Duty of Care at a Football Game (cited 20
to the RTP discussion relates to the occurrence through load management,
Jan 2016). http://www.fsem.ac.uk/news/position-
sport-specific context. For example, implementing appropriate prevention statements/a/a-doctors-duty-of-care-when-attending-a-
the coach of an Olympic triple jumper strategies and optimising the athlete’s football-game.aspx
will not use the same RTP criteria as technique.7 8 Coaches can also contribute 4 McCartney M, Treadwell J, Maskrey N, et al. Making
the coach of an Olympic football or to the athlete wisely addressing contextual evidence based medicine work for individual patients.
BMJ 2016;353:i2452.
rugby sevens team. In elite sport, only factors (ie, sponsors/media) with respect 5 Elwyn G, Frosch D, Thomson R, et al. Shared decision
the coach can place this current to RTP (and this may influence the ath- making: a model for clinical practice. J Gen Intern
‘ability-to-perform’ into the perform- lete’s RTP attitudes and decisions). Med 2012;27:1361–7.
ance context of the upcoming oppos- The healthcare professional’s role is 6 Shay LA, Lafata JE. Where is the evidence? A
systematic review of shared decision making and
ition, event/match conditions, stage of objective—to accurately inform the
patient outcomes. Med Decis Making
the season, importance of the competi- athlete and coach about health status and 2015;35:114–31.
tion, impact on later competitions and risk. The athlete and coach ultimately 7 Gabbett TJ. The training-injury prevention paradox:
the ability of potential replacements. evaluate the information and make a deci- should athletes be training smarter and harder?
Whether SDM improves athlete health sion about RTP. Successful SDM depends Br J Sports Med 2016;50:273–80.
8 Orchard JW, Blanch P, Paoloni J, et al. Cricket fast
or performance outcomes has not yet on effective communication within per- bowling workload patterns as risk factors for tendon,
been studied. But SDM improves satisfac- formance teams; clear and consistent, muscle, bone and joint injuries. Br J Sports Med
tion and reduces decisional conflict in ongoing communication is vital to achieve 2015;49:1064–8.

420 Br J Sports Med March 2017 Vol 51 No 5