# Ready or Not; A Narrative Synthesis of Sports Medicine Practitioners' Practices During Return to Play in the Management of Musculoskeletal Injuries

## TL;DR

This review summarizes how sports medicine practitioners make return-to-play decisions after musculoskeletal injuries, highlighting the need for clearer guidelines and collaboration.

## Contribution

The study provides a narrative synthesis of RTP practices across different practitioner groups and identifies gaps in current decision-making frameworks.

## Key findings

- Knee injuries, especially ACL, are the most studied in RTP decision-making.
- Medical doctors focus more on injury timelines, while MDTs consider psychological readiness and sport-specific testing.
- Shared decision-making with an athlete-centered approach is preferred, but collaboration and clear tools are lacking.

## Abstract

The purpose of this narrative synthesis was to identify and synthesise the literature focused on sports medicine practitioners' (SMPs) decision‐making practices during return to play (RTP) after musculoskeletal (MSK) injury. Using the Preferred Items for Reporting Systematic Reviews and Meta‐Analyses guidelines, four electronic databases were searched from the start of the database to July 2024 using terms related to SMPs and RTP in MSK injury. The Appraisal Tool of Cross‐Sectional Studies (AXIS) and the Johanna Briggs Institute (JBI) critical appraisal tools were used to assess the overall quality of the identified studies. A narrative synthesis format was considered the most appropriate methodological approach to review and synthesise the pool of literature. Data synthesis included the participating SMPs profession, study sample size, injury location, activity level, RTP outcome measures and results. Data were further characterised by the RTP practices for specific MSK injuries, including spine, shoulder, wrist, hand, hip, knee, ankle and foot. Eighty‐seven (n = 87) publications were identified based on the inclusion and exclusion criteria. Forty‐seven percent (n = 41) of the studies focused on surgeon practices and 29.9% (n = 26) reported practices of multidisciplinary teams (MDTs). Almost half of all studies (40.2%; n = 35) addressed knee injuries, 85.7% (n = 30/35) specific to the anterior cruciate ligament (ACL). Eighty‐three percent (n = 34/41) of medical doctors consider injury and postoperative timelines compared to other SMP groups (47.8%; n = 22/46). Multidisciplinary team studies report the use of psychological readiness (50%; n = 13/26) and sport‐specific testing (38.5%; n = 10/26) criteria in RTP studies. Functional assessment and strength are reported in at least 50% of physiotherapist (n = 18) and rehabilitation specialist (n = 2) studies. Reference to RTP frameworks, guidelines and protocols in RTP decision‐making was found in less than 20% of the publications. Studies addressing input from other SMPs to assist decision‐making was also found in less than 20% of the studies despite research. From these studies, shared decision‐making with an athlete‐centred approach is preferred. The type of sport and the ambition of the athlete were the biggest influencing factors on decision surrounding RTP both reported in 26.4% (n = 23) of all SMP studies. This suggests an athlete‐centred approach to SMPs RTP decision‐making. Similar RTP criteria was used between practitioner groups, although criteria were weighted differently, due to the different scopes of practice and complexity surrounding RTP decisions. This review provides context for future research to assist and guide RTP decision‐making practices after MSK injuries. The need for clear, uncomplicated and practical definitions, guidelines, protocols and criteria will improve the RTP process and reduce the risk of reinjury after MSK injury. This review included all study designs and there was heterogeneity in the analysed studies, which can be viewed as a limitation.

The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration ID: CRD42021270638) and OSF registries (registration doi: https://doi.org/10.17605/OSF.IO/DKQ7V).

The majority of the studies to date focus on the knee, especially ACL injury.Although SMPs may consider similar criteria during RTP, each criteria is weighted differently. Return to play healing time was the criteria considered the most frequently.The present review highlights that without collaboration and practical tools with clear strategies, SMPs may struggle to be consistent in RTP practice.

The majority of the studies to date focus on the knee, especially ACL injury.

Although SMPs may consider similar criteria during RTP, each criteria is weighted differently. Return to play healing time was the criteria considered the most frequently.

The present review highlights that without collaboration and practical tools with clear strategies, SMPs may struggle to be consistent in RTP practice.