Skip to main
Share this page:

Return to Play Decision-Making: Balancing Athlete Health and Competitive Goals

By Matthew S. Fury, MD, Meghan E. Bishop, MD

    • Industry Insights
    • Early Career Engagement

Sports medicine team physicians navigate a complex landscape where they must support athletes in the pursuit of excellence while safeguarding their health.

Balancing the competitive goals of athletes with their long-term well-being is a multifaceted endeavor that demands strong interpersonal relationships, medical expertise, clear communication, empathy, and foresight. These qualities and attributes serve as the foundation for successfully navigating what can be the most challenging decision in the training room—return to play.

Return to sport decisions require a multidisciplinary approach between the athlete, physician, coach, athletic trainers, and physical therapists. Establishing an early trusting relationship between the physician and athlete can help alleviate fear surrounding the injury and instill trust in the plan. However, building a trusting relationship begins long before the time of injury. Preseason physicals, training room rounds, and routine post-game interactions provide opportunities for the physician to develop an honest and approachable reputation where the health of the player–not the needs of the team–is paramount. While the physician-athlete relationship is important, establishing a clear line of communication with the physical therapists and athletic trainers that are caring for the athletes on a much more frequent basis is key. Return to play decisions should be made involving all parties and consider postsurgical timelines, the patient’s individual progression through rehab, as well as psychological readiness factors.

Past AOSSM President Mark Miller has previously stated that “you can’t reassure the player until you are sure yourself.” However, expertise in medical decision making is not acquired in passing. Physicians should explore the literature, draw on the experience of colleagues and mentors, and collaborate with trainers, therapists, and coaches to obtain a holistic assessment of the athlete. Objective measures are critical. Validated measures or questionnaires, like the ACL Return to Sport after Injury (ACL-RSI) or the Shoulder Instability-Return to Sport after Injury (SIRSI), may be helpful in assessing readiness during the final stages of rehabilitation. Newer tools also allow clinicians to assess psychological readiness. A systematic review by Nwachukwu et al. found that of those who did not return to play status post ACL reconstruction 64.7% cited a psychological reason for not returning with fear of reinjury being the most common reason (76.7%) (Nwachukwu et al. OJSM 2019). Additionally, functional movement assessments that include dual cognitive-motor tasks are critical in determining both physical and mental readiness to return to play.

One of the most rewarding aspects of being a sports medicine surgeon is being able to help an athlete through an injury and to get them back on the field successfully. It is essential to always keep the athlete’s best interest in mind, communicate clearly, and assess the athlete as a whole when determining return to play decision-making.


  1. Nwachukwu BU, Adjei J, Rauck RC, et al. How Much Do Psychological Factors Affect Lack of Return to Play After Anterior Cruciate Ligament Reconstruction? A Systematic Review. Orthopaedic Journal of Sports Medicine. 2019;7(5). doi:
Back to top