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Almost all patients in the office or on the field ask their clinician when they can return to play (RTP). These decisions are based on a large number of factors including the history of the injury, physical examination, type of injury, rehabilitation, type of activity, psychological state, competitive level and ability to protect the injury. In addition, the athlete may receive conflicting opinions from other clinicians, family, friends, coaches and agents. Such conflicts can lead to (1) miscommunication, (2) loss of trust, (3) potential litigation, (4) declines in sport participation rates as some individuals never 'get back in the game' due to fear of reinjury (despite acceptable levels of risk) and (5) even more serious medical complications as some athletes return to activity while still at unacceptable levels of risk for subsequent sport-related injury. 1-4
One important factor that may minimise the development of such conflict is to have a formal structure or process that makes the RTP decision reasoning more transparent. This would be expected regardless of who has the decision-making authority (eg, clinician, athlete, shared decision-making). In 2010, we adapted a decision theoretic model for RTP decision-making 5 ( figure 1 ) that separates the decision-making process into three steps. The first two steps, Medical Factors and Sport Risk Modifiers, assess risk, and the third step evaluates the effect of Decision Modifiers. The model evolved out of a literature review, discussions among three experienced sport medicine physicians, a student and staff, and feedback from colleagues. Later research showed that it is consistent with clinicians' beliefs independent of country of practice or clinician specialty, 6 and serves as a framework to help organise complex information.
In presenting the framework at three different conferences to several hundred participants, questions arose concerning how particular factors fit or do not fit within the model. For example, the factor 'ability to protect' is included in step 2, although it is clearly not a medical factor or a decision modifier and is not directly related to sport. Other challenges expressed include the framework's ability to account for very serious conditions such as concussion, or when there are simultaneous risks (eg, short-term risk of reinjury, long-term risk of osteoarthritis). The reason for these difficulties may simply lie in the fact...