How do I know when it’s safe to return to sport after an injury?

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You’ve sprained your ankle, pulled your hamstring or subluxed your shoulder – you’ve stopped playing sport for a week or so and now you’re wondering when is it okay to start again? When is it safe to return?

While most athletes will want to return to sport as soon as possible, care must be taken to get through an appropriate rehabilitation process, in order to reduce risk of re- injury. There are a few indicators which guide us in this decision making:

  • Swelling management
  • Controlled pain
  • Range of motion/degree of mobility
  • Normal movement patterns
  • Adequate cardiovascular fitness level
  • Confidence and readiness
Swelling management

While swelling is the body’s protective mechanism initially after an injury, it is an important indicator for our readiness to return to sport. Swelling can decrease muscle activation, impairing some of the protective forces around a joint. As a result, it is important that all swelling is eliminated before returning to sport.

Controlled pain levels

Firstly, it is important to note that pain does not always correlate with tissue damage. An example of this is while having a hot shower after getting sunburnt may cause pain, it does not mean you’re creating further damage. Depending on the injury, creating pain during exercise may even be required. For injuries like tendinopathies, a condition that requires progressive loading, research demonstrates that painful rehabilitation has no detrimental effects on recovery. Those who perform rehab with some pain report greater symptomatic improvements compared to those who keep their rehab completely pain free.

The human body is resilient and adaptable – loading joints and muscles when injured is critical to return to full function and performance. If you train and pain is present, think of the pain as a stimulus for adaptation – you’re making your body stronger and giving it the best opportunity to recover. While pain should not be the only criteria in judging how well your recovery is going, it can be a useful guide in progressing your rehabilitation program.

Using a pain scale allows us to recognise the level of pain and make changes as required for the individual. It requires rating your pain a score out of 10: with 10 being the worst pain ever for YOU, and 0 being NO pain. If you are experiencing 0-3/10 pain, then you may be OK to increase the loads. Pain between 3-5 is OK, but maybe keep the load the same. Experiencing pain between 5-10 is a sign you need to modify what you are doing and that you are not ready to return to sport.

It’s also important that your pain/symptoms quickly settle back to baseline levels within 24 hours. Other factors such as training frequency and duration may need to be modified if baseline pain levels are not being achieved fast enough.

Improved range of motion

Range of motion is defined as the normal degrees of motion for a particular joint, which will differ for each individual. Restoring range of motion is critical not only in the therapy process and to return to play, but to minimizing the risk for future injury. If a joint is unable to move properly, secondary to tightness, swelling, or weakness in the muscles, it is exposed to increased risk of re-injury. An example of this could be that your injured knee has as much bend (or flexion) as the opposite knee before returning.

Normal movement patterns

Before returning to sport, it is imperative that we do not demonstrate compensatory patterns, such as limping. Limping is our body’s way of offloading the injured area and allowing us to continue with reduced pain. Unfortunately, when we try continuing to run in pain or without our normal running pattern, we are reinforcing the compensatory movement patterns. The problem with this is that we are placing more stress and strain on tissues that are unconditioned to this task. As a result, this ‘pain inhibition’ will create poor movement habits long beyond our injury.

It is also important to be exposed to previous levels of running with similar demands, such as high intensity, unanticipated actions before a safe return is certain. For successful return to sport to occur, the athlete must be able to execute movement patterns present in his or her sport without pain and without performance-limiting compensations.

Adequate fitness levels

Cardiovascular fitness refers to how well your body transports oxygen to the muscles during exercise. This is an essential component of a safe return to sport, as those who are able to perform activity at a higher rate for a longer time, fatigue less quickly, recover faster and have better reserve to continue exercising. Fatigue is detrimental, as it can alter movement patterns, putting stress on body parts that are unaccustomed, increasing the likelihood of injury.

Confidence

Confidence is the belief, or degree of certainty, that athletes have about their ability to be successful in sport. Scientific studies have shown that athletes who believe they will be successful, perform better in sports. Confidence is often gained from a high quality physical and mental preparation, which are key factors for return to sport.

Researchers discovered that if an athlete has fear during the rehabilitation process or return to play, the athlete could develop further injuries since they could be compensating or be hesitant to return to their sport. There are various questionnaires that can be completed to determine someone’s mental readiness to return to sport. It would be encouraged to speak to your physiotherapist about the appropriate questionnaire for your specific injury.

Chloe Wehbe

REFERENCES

– Christakou, A., Stavrou, N. A., Psychountaki, M., & Zervas, Y. (2022). Re-injury worry, confidence and attention as predictors of a sport re-injury during a competitive season. Research in Sports Medicine, 30(1), 19–29. https://www.researchgate.net/publication/345179039_Re-injury_worry_confidence_and_ attention_as_predictors_of_a_sport_re-injury_during_a_competitive_season
– Moseley G. Reconceptualising pain according to modern pain science. Physical Therapy Reviews. 2007;12(3):169-178.
– Smith B, Hendrick P, Smith T, Bateman M, Moffatt F, Rathleff M et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. British Journal of Sports Medicine. 2017;51(23):1679-1687.
– Thomas O and Thrower S (2022) Developing and Maintaining Sport-Confidence: Learning From Elite Athletes. Front. Young Minds. 10:675054. doi: 10.3389/frym.2022.675054

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