No evidence-based criteria exist to inform return to sport decisions after lateral ankle sprains

Just published in Sports Medicine, this systematic review was to identify prospective studies that used a criteria-based return to sport (RTS) decision-making process for patients with lateral ankle sprain (LAS) injury.

The PubMed (MEDLINE), Web of Science, PEDro, Cochrane Library, SPORTDiscus (EBSCO), ScienceDirect, and Scopus databases were searched to 23 November 2018. Studies were included if they prospectively applied a criteria-based RTS decision- making process for patients with LAS injury, but were excluded if they merely gathered outcome measures at the RTS time point. Studies were also excluded if patients were recovering from ankle fracture, high ankle sprain, medial ankle sprain, chronic ankle instability or complex ankle injury.

No studies were identified that used a criteria-based RTS decision-making process for patients with LAS injury. We were unable to conduct a quantitative synthesis or meta-analysis, therefore we provide a narrative synthesis of relevant questionnaires, as well as clinical and functional assessments commonly used in studies retrieved in the search.

Road to recovery along the RTS continuum. The  x -axis denotes ‘time’, and the  y -axis denotes the constant field of tension between rehabilitation/prevention and performance along the RTS continuum. While RTPf is a nonlinear process, Fig. 3 depicts a more or less ideal course. The progress curve emerges due to the dynamic RTS profile (see Fig. 2) over time. An example of the interpretation of minimal and maximal cut-offs for RTS decisions can be as follows: athletes with a lower re-injury risk but who are less advanced in their rehabilitation can possibly progress earlier to the next phase, while athletes with a higher re-injury risk could benefit from making further progress in their rehabilitation before being allowed to the next phase. Furthermore, (elite) athletes can benefit from pre-injury load moni- toring since this would yield additional information on the previous state of the system and help in determining goals for rehabilitation, prevention and training.  RTPa  return to participation,  RTS  return to sport,  RTPf  return to performance.

Road to recovery along the RTS continuum. The x-axis denotes ‘time’, and the y-axis denotes the constant field of tension between rehabilitation/prevention and performance along the RTS continuum. While RTPf is a nonlinear process, Fig. 3 depicts a more or less ideal course. The progress curve emerges due to the dynamic RTS profile (see Fig. 2) over time. An example of the interpretation of minimal and maximal cut-offs for RTS decisions can be as follows: athletes with a lower re-injury risk but who are less advanced in their rehabilitation can possibly progress earlier to the next phase, while athletes with a higher re-injury risk could benefit from making further progress in their rehabilitation before being allowed to the next phase. Furthermore, (elite) athletes can benefit from pre-injury load moni- toring since this would yield additional information on the previous state of the system and help in determining goals for rehabilitation, prevention and training. RTPa return to participation, RTS return to sport, RTPf return to performance.

We had to conclude that currently there are no published evidence-based criteria to inform RTS decisions for patients with an LAS injury. Based on our narrative synthesis, we propose a number of variables that could be used to develop a criteria-based RTS decision paradigm. Future research should aim to reach consensus on these variables and apply them to actual RTS decisions within prospective study designs. Furthermore, we suggest that complex systems theory and the RTS continuum could be used to inform the development of an RTS decision-making paradigm for athletes with LAS injury.

Key take home messages

  • No published evidence-based criteria exist to inform return to sport decisions for patients following lateral ankle sprain (LAS) injury.

  • Return to sport decisions following LAS injury are generally time-based.

  • We propose that complex systems theory and the return to sport continuum could be used to inform the development of a criteria-based return to sport paradigm to bridge the gap between research and clinical practice.

Tassignon B, Verschueren J, Delahunt E, Smith M, Vicenzino B, Verhagen E, et al. Criteria-Based Return to Sport Decision-Making Following Lateral Ankle Sprain Injury: a Systematic Review and Narrative Synthesis. Sports Med. 2019 Feb 11;44(1):1–19. 

The full paper can be accessed here