Return to Play

Greg Canty, MD,* Laura Nilan, DO†

*The Center for Sports Medicine; Emergency Medicine, Children’s Mercy Hospital & Clinics; University of Missouri-Kansas City School of Medicine,
Kansas City, MO.
†
Pediatric Emergency Medicine, Children’s Mercy Hospital & Clinics, Kansas City, MO.

Practice Gaps
Clinicians caring for athletes and active individuals make return-to-play
recommendations regularly following an injury. Evidence suggests
a tremendous amount of variability in those decisions and very little
education about the process.

Objectives After completing this article, readers should be able to:

1. Establish a plan for returning athletes to play following musculoskeletal

injuries to the shoulder, knee, lower leg, and ankle.
2. Describe the criteria for returning athletes to play following injuries to
the head, neck, and eye.

INTRODUCTION

Return to play (RTP) is the process of deciding when an injured or ill athlete may
safely return to his or her desired sport or activity. Clinicians caring for young
athletes and active patients make these decisions every day based on a number of
different factors. The most important consideration for most physicians is part of
the Hippocratic oath to “first, do no harm.” Unfortunately, RTP scenarios are
rarely straightforward, and clinicians know there is substantial variability in the
rate of recovery for individual patients, so “one size does not fit all.” When
choosing criteria for RTP, erring on the side of safety is preferred, but being overly
conservative without merit can lead to unnecessary withholding of patients from
sports and activities.
Young patients are constantly encouraged to be physically active and
participate in youth sports due to the many benefits for overall health, quality of
life, improved academic performance, and decreased obesity. The benefits of
physical activity, however, can be tempered by an increased risk of injury that
cannot be ignored. Reinjury rates following initial injuries are high, averaging
between 15% and 32% and increasing with age. The primary predictor of future
injury risk is the presence of a prior injury. Most of the decisions that clinicians AUTHOR DISCLOSURE Drs Canty and Nilan
make when returning young athletes to play lack the support of strong have disclosed no financial relationships
relevant to this article. This commentary does
evidence-based research; rather, they are supported by clinical experience,
contain a discussion of an unapproved/
expert opinion, and a growing body of guidelines. The RTP decision is investigative use of a commercial product/
complicated by the involvement of not just patients and families, but also device.

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coaches, teammates, and extended members of the
health-care community, such as athletic trainers, physical
therapists, and other physicians. Ensuring that everyone
understands the risks, latest recommendations, and ex-
pectations when returning an athlete to play allows for
optimal care and acceptance by all the stakeholders in what
is hopefully a safe return to sport.
This article concentrates mostly on the medical compo-
nents of RTP, but a number of other components contrib-
ute to RTP decisions. Clinicians must factor in social
influences, economic considerations, and the political/
legal climate. Social influences on an athlete to return
from injury include both passive and direct pressure from
family, friends, coaching staff, and members of the com-
munity. These influences may carry over to the clinician, so
it is important to acknowledge such influences throughout
the process. When an athlete is returning to play at the high
school or elite level, an athletic trainer may be available to
aid in assessing the readiness to return, but at the recre-
ational and youth level, most decisions fall upon the
shoulders of volunteer coaches and parents who lack
any medical training. The economics of returning athletes
to play center around the large amount of money that
families spend on sports participation, including support-
ing traveling teams and pursuing possible collegiate schol-
arships. Finally, there are political and legal considerations
such as which person legally makes the final decision to
allow an athlete to return and the legal risk for that person.
The legal component has recently been in the spotlight,
with all 50 states adopting legislation concerning the role
of health-care providers in returning youth athletes to
participation following sports-related head injuries and
concussion.
Breaking down the RTP process into three steps, regard-
less of the type of injury, can aid in accounting for all these
factors while making RTP decisions more structured. The
first step, which involves the greatest amount of clinician
time, is evaluation of the overall health of the athlete related to
the recent injury. This step may address the athlete’s medical
history, current examination findings, and perceived severity
of injury. The second step in the process is to evaluate the risk
of sport participation. This includes considering factors such
as the sport being collision or noncontact, the injured ath-
lete’s role in the sport, the level of participation, and the
availability of protective equipment to aid in reducing injury
risk. The third step takes into account all the modifying
factors discussed previously. Acknowledging modifying
factors such as the time of season, pressure from the
athlete, conflicts of interest, and legal risks can help
clinicians make a better decision. Using this systematic
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approach should allow clinicians to feel confident that
young athletes are returning to the field safely and appro-
priately. (1)
MUSCULOSKELETAL CONDITIONS
A sports injury was traditionally believed to involve only
the musculoskeletal system. The following information
addresses a few of the more common nonoperative in-
juries and conditions that present to the clinician’s office
and require guidance on returning to play. Clinicians
should ask certain essential questions when considering
returning any injured athlete back to playing sports (Table 1).
The more specific the diagnosis, the more accurate a
treatment plan can be established and the better func-
tional criteria can be developed for RTP. A specific diag-
nosis involves understanding the anatomy and identifying
the potential risk and natural history of the injury while
creating a detailed rehabilitation program. Once a treat-
ment program is initiated, guidelines for RTP can be
considered if the athlete is responding to treatment as
anticipated.
Clinicians have traditionally taken into consideration joint
range of motion (ROM), swelling, pain, proprioception/balance,
strength, ability to perform sport-specific skills, and an
athlete’s psychological readiness for return when making RTP
decisions. A frequent recommendation is that no more than
a “minimal” amount of pain should be present with activity if
returning, but “minimal” has never been accurately defined.
Any pain that prevents an athlete from performing sport-
specific functional skills should be considered more than
minimal. The ability to demonstrate sport-specific skills
through standardized testing is ideal (eg, running, jumping),
TABLE 1. Essential Questions When
Considering Return to Play
• Has an accurate diagnosis been established?
• Is the injury resolved or rehabilitated to the point that pain has
resolved and full range of motion/function been re-established?
• Can the athlete perform functional activities without difficulty?
• What is the sport? Contact vs. noncontact? Position played? Level
of skill/competition?
• How high is the risk for further injury with return to play?
• Is equipment, bracing, or training available that might prevent
further injury?
• Does the athlete feel confident in returning to play?
Vol. 36 No. 10 OCTOBER 2015 439
 but testing may be challenging in some practice locations due
to space and facilities. Full ROM of the injured joint is
preferred and can best be measured by comparison with
the contralateral extremity. Traditionally, at least 90% of
strength with manual muscle testing has been preferred when
comparing to the uninjured extremity, but a return to normal
functional strength is preferable to prevent the risk of further
injury upon return. The presence of significant joint swelling
should also lead clinicians to consider delaying a return to
activity, but again, the degree of swelling that is “significant”
remains a question for debate. Determining normal function
after any injury is a challenge, but sports medicine physicians
frequently rely on comparison with the contralateral, or
uninjured, extremity. (2)
Assessing an athlete’s confidence is also an important
part of the decision. Among the numerous scoring sys-
tems, the easiest is a simple scale of 0 to 100%, with 100%
representing a return to baseline. If an athlete feels con-
fident about returning, has minimal or no swelling, and
shows full ROM, functional testing should be considered
to determine if the athlete is truly ready for a return to
sport.
Clinical Scenario #1
A 14-year-old basketball player presents to the office after an
inversion ankle injury 2 days ago. She has substantial lateral
swelling, persistent pain, and limitations in ROM, but the family
is eager to get her back on the court for a year-end tournament.
They would like to know the necessary criteria that she must
achieve to be allowed to return to play.
The Ankle
Ankle sprains are one of the most common injuries in
sports and affect athletes of all ages. Some running and
jumping sports, such as basketball and soccer, are associated
with a significant risk of ankle injuries. Once an ankle injury
occurs, up to 80% of athletes suffer recurrent sprains, and
basketball athletes have been found to be five times more
likely to reinjure an ankle once they have experienced an
initial injury. The frequency of ankle injuries and the high
risk for reinjury necessitates a good RTP strategy. Following
an accurate diagnosis and initiation of a functional rehabil-
itation program, clinicians should look for normalization of
swelling, pain, and ROM over 1 to 4 weeks. However, this
process can vary in duration, based on the degree of injury
and the response to rehabilitation.
A number of functional performance tests exist for the
lower extremity. Clinicians should become familiar with the
single-legged balance (Fig 1), single-legged hop, crossover
hops (Fig 2), shuttle run, agility T-test, vertical jump, and
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even formal programs such as the Star Excursion Balance
Test. Clinicians who are unfamiliar with any of these tests
can find illustrations of each in action on the Internet.
Taking into account individual office space and capabilities,
some form of functional performance testing with compar-
ison to the uninjured extremity should be required before
allowing any athlete to return to play. The athlete who can
demonstrate functional performance on these tests with
minimal or no pain may return to sport following an ankle
injury. (3)
The success of returning to sport after an ankle injury
can be improved with the use of protective equipment,
such as ankle-stabilizing orthotics with or without taping.
Such prophylactic measures have been shown to reduce
the risk of reinjury. However, even with bracing, athletes
must be able to perform functional activities before any
return. (4)
The Knee
The knee is another common site for musculoskeletal
injury in young athletes and often involves sprains, strains,
patellar instability, or apophysitis such as Osgood-Schlatter
disease. A very specific diagnosis is important because
some conditions such as sprains and strains are clearly
acute, while others such as apophysitis may be more
chronic. The RTP criteria are similar for both acute and
chronic conditions, but education about future expecta-
tions may differ significantly. Any acute traumatic knee
effusion should be evaluated cautiously because many
athletes with such injuries eventually are diagnosed with
a cruciate ligament tear, fracture, or patellar dislocation.
RTP guidelines for operative and nonoperative conditions
of the knee are similar, but the rate of progression during
rehabilitation is much slower and the risk of reinjury is
disproportionately higher with the surgically repaired
knee.
Criteria for RTP following a knee injury are similar to
those related to the ankle. Important factors include near
resolution of swelling, full ROM, minimal if any pain,
symmetric strength, psychological readiness, and success-
ful completion of functional performance testing. Any signs
of instability or asymmetry with functional testing should
prompt serious reconsideration of RTP due to the risk of
a more severe injury. Mild knee sprains and strains typically
recover in 1 to 3 weeks, but higher-grade injuries or patellar
instability may require up to 8 weeks, with intensive reha-
bilitation before athletes are ready for return. Unlike the
bracing evidence in ankle injuries, high-level studies have
not consistently supported the routine use of knee braces for
prevention of reinjury.
Figure 1. “Y” balance test. While balancing on one foot, the athlete reaches out as far as possible in three different directions (anterior, posterior-medial,
and posterior-lateral). Results are compared to those seen with the uninjured extremity.

Other Sports-related Lower Extremity Conditions
Other common sports-related injuries or conditions seen
in the lower extremity are stress fractures and medial
tibial stress syndrome (aka shin splints). These frequently
occur in running sports such as cross-country, but they
may develop in any sport that requires a significant
amount of running or jumping for competition and
conditioning. The presentation of pain along the tibia
is similar for both fractures and shin splints, but subtle
differences include point tenderness along the tibia with
stress fractures and broader discomfort along the postero-
medial tibia with shin splints. As mentioned previously,
proper diagnosis remains the key to guiding a successful
return. The functional performance tests of particular
emphasis for these conditions are single-leg hops and
progressive running activities without any evidence of
pain.
Stress-related fractures may require 6 to 12 weeks of
rehabilitation before a successful return to sport, depend-
ing upon the exact location of injury and the fracture
characteristics. Shin splints recover more quickly but often
recur. Low-risk stress fractures and shin splints should
undergo a prolonged period of walk/run progression once
they are pain-free with provocative maneuvers and show
signs of healing. Numerous running schedules and pro-
grams have been published to offer exact training regi-
mens, but none have significant scientific backing. (5) The
rule of thumb used by most sports physicians when
returning runners after stress-related injuries is to
increase total weekly mileage by no more than 10% and
scatter long and short runs throughout the week. The 10%
rule lacks strong scientific backing but appears to be an
excellent guide for most young athletes working their way
back into sport after a running injury.
The Shoulder and Upper Extremity
Injuries to the shoulder and upper extremity in young
athletes typically fall into one of two broad categories.
The first category is acute injuries, such as clavicle fractures,
distal radius fractures, and shoulder dislocations. The sec-
ond category is overuse injuries, such as humeral epiphy-
sitis and medial epicondyle apophysitis (aka “thrower’s
shoulder or elbow,” respectively). The RTP criteria for both
of these categories are similar, but rehabilitation is usually
more gradual for overuse injuries due to the high risk of
recurrent symptoms.

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 Figure 2. Crossover hop test. The athlete is asked to take three consecutive hops for distance on one foot, crossing over the line each time. The good
limb is tested first and then compared to the injured extremity.
Clavicle fractures are extremely common in young
athletes and usually involve the midshaft of the clavicle.
Healing potential for young athletes with clavicle fractures
is excellent, and many develop a significant callus that is
either visible or palpable on examination. Ideally, athletes
who have clavicle fractures demonstrate radiographic
evidence of healing, full ROM of the shoulder, comparable
strength, and symmetric functional ability when perform-
ing exercises such as push-ups and overhead motions
before returning to sports. This injury requires careful
consideration of the risk associated with specific sports
when contemplating a return. Noncontact sports can
usually be resumed by 6 weeks due to the lower risk of
reinjury, but contact and collision sports such as football
carry a much higher risk of reinjury. Due to this higher
risk, most experts require 2 to 4 months before allowing
a full return to contact or collision sports after a clavicle
fracture. (6)
Distal radial fractures are common acute injuries in
sports, and athletes frequently return to sport with little
complication if the fracture is minimally or not displaced.
The criteria for return after radius fractures is evidence of
radiographic healing, lack of tenderness on examination,
resolution of swelling, full ROM, and demonstration of
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functional weight-bearing activities such as push-ups.
Athletes in some sports, such as soccer, who rarely use
the wrist in competition, may be able to return more
quickly with use of a removable splint or cast for pro-
tection if everyone understands the risk for reinjury.
Clinicians should have a detailed discussion with the
family about the risk of reinjury or worsening injuries
if the athlete returns to play while the wrist is immobi-
lized. It is also important to emphasize that added equip-
ment may be a risk to other participants and should be
padded appropriately to decrease any such unnecessary
risk.
Overuse injuries of the shoulder, elbow, and wrist are
commonly associated with repetitive upper extremity
sports such as throwing a baseball, hitting a tennis ball,
or tumbling in gymnastics. Affected patients all present
with pain but may have varying degrees of other clinical
findings, such as radiographic changes and loss of ROM.
The first step in returning to sport following an overuse
injury is complete resolution of pain at rest and return of
full ROM. If radiographic changes were present, greater
caution is recommended; radiographs should show sub-
stantial improvement or normalization. Once this has been
achieved, a rehabilitation program emphasizing a gradual
return to the repetitive, causative activity is important to
gauge whether discomfort returns with more functional
activities. Examples include the interval throwing program
for baseball pitchers that involves a progressive amount of
short toss, long toss, and rest days over a period of weeks.
(7) Any reappearance of pain warrants further rest and
a delay of full return. Similar approaches can be translated
to repetitive activities in tennis, gymnastics, and other
sports.
Table 2 lists common musculoskeletal injuries and the
typical time to recovery with proper rehabilitation.
HEAD, NECK, AND EYE INJURIES
Along with musculoskeletal injuries, there is an increased
risk of injuries to the head during sports participation.
Injuries to the head may result in concussion, skull frac-
tures, neck injuries, or eye injuries. The Centers for
Disease Control and Prevention have reported more than
3.8 million sports-related concussions each year. The
increased incidence and recognition of concussion has
been reported in all sports, played by both male and female
athletes. Concussion now accounts for almost 10% of all
athletic injuries seen by physicians, but head injuries entail
more than just concussions. Head injuries include a large
proportion of eye injuries in youth that occur during sports
participation as well as an increasing proportion of cervical
spine injuries.
Clinical Scenario #2
A 16-year-old soccer player presents to the office after taking
a knee to the back of the head during a match and experiencing
subsequent headache, nausea, dizziness, and sensitivity to
light. She and her family are concerned about a possible
TABLE 2. Time to Recovery for Common Injuries
INJURIES OF MILD-TO-MODERATE SEVERITY
Lateral ankle sprains
Medial collateral ligament sprain
Stress fracture
Shin splints
Clavicle fracture
Overuse injuries of the upper extremity
*Severe or high-risk injuries may take longer.
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concussion but are pushing for a rapid return to play before
the state championships in 2 weeks. She is a candidate for
a college scholarship, so she and her family want to know what
must be done for her to return safely to the sport she loves.
Concussion
Over the past decade, general knowledge of and concern
about concussion has expanded. The concept of “grading
concussions” as a basis for RTP has been abandoned;
each case now is treated on an individual basis. RTP
protocols have received increasing recognition after insti-
tution of the “Lystedt Law” in the state of Washington in 2009
following a devastating head injury and premature return to
sport by a junior high school football player that resulted in
a lifelong neurologic impairment. Since 2009, laws regard-
ing concussion have passed in every state in the United
States, and concussion in sports has become a worldwide
issue. In May 2014, President Barack Obama hosted the
Healthy Kids and Safe Sports Concussion Summit, which
emphasized the nation’s need to expand knowledge about
concussions and provide better tools to prevent, identify, and
respond to concussions. Most state laws are similar and
mandate: 1) immediate removal from sports when a head
injury or concussion is suspected; 2) no return to practice or
play without written permission from a licensed health-care
provider; and 3) education of athletes, parents, coaches, and
physicians regarding concussion.
The current standard of care for returning to sports
following a suspected concussion centers around the
consensus statement commonly known as the Zürich
Guidelines. These guidelines are a consensus developed
by the Concussion in Sport Group, whose members are
international concussion experts from the fields of sports
medicine, neurology, neurosurgery, neuropsychology, and
TYPICAL RANGES FOR RETURN TO PLAY*
1 to 3 weeks
2 to 4 weeks
4 to 12 weeks, depending upon location
1 to 2 weeks with activity modification
6 to 12 weeks, depending upon sport
8 to 12 weeks
Vol. 36 No. 10 OCTOBER 2015 443
 various other fields involved in the care of sport-related
concussions. (8)
The cornerstone of the concussion protocol is requiring
athletes to become asymptomatic from their head injury or
return to their baseline physical and cognitive activity before
attempting any return. The best current method of quan-
tifying concussion symptoms during evaluation is to use
a symptom checklist. The most widely used and freely
available symptom checklist is derived from the Sideline
Concussion Assessment Tool (SCAT3), which was also
developed by the Concussion in Sport Group and updated
in 2013 to also offer a Child-SCAT3 for athletes between the
ages of 5 and 12 years. The subjective measure of being
asymptomatic can present challenges to athletes who may
be under internal or external pressure to “minimize symp-
toms” or athletes with comorbidities such as chronic head-
aches or learning disorders. For those athletes with
comorbidities, the physician must be comfortable that the
athlete has returned to baseline comorbidity and is no
longer experiencing symptoms from the head injury. An
additional method of assessing whether an athlete is at
“baseline” is to gather additional information about symp-
toms or cognitive performance from parents, teachers,
athletic trainers, and neuropsychologists before allowing
a young athlete to return to sport. In addition to following
symptom checklists such as the SCAT3, an athlete with
a head injury ideally should undergo balance and functional
testing such as the Balance Error Scoring System, the results
of which are compared to preinjury performance. A growing
number of commercial products, such as computerized
neurocognitive tests and vision tests, claim to aid in detecting
concussion, but their routine use for making RTP decisions
remains controversial. Clinicians may find that adding baseline
assessments to preparticipation examinations is extremely
helpful for later comparison in the event of an injury.
Once the head-injured athlete has returned to his or her
symptom-free physical and neuropsychological baseline,
clinicians should initiate a step-by-step RTP process. Each
step consists of an increasing level of activity and requires
a minimum of 24 hours before proceeding to the next step.
Some experts recommend an even more gradual progres-
sion, such as 48 hours between steps for younger athletes
and those with repeat concussions. Although this process
lacks significant scientific validity, the Zürich guidelines
have been adopted as a standard of care to encourage
a systematic approach for RTP following concussion. Table
3 outlines each step of the process and the specific purpose
of each step to allow modification for the sport played.
Patients whose symptoms return while trying to advance
through the steps should contact their doctors, rest for at
least 24 hours, and return to the last successfully completed
step before trying once again to proceed.
Another recent development is the concept of “return to
learn” following concussion. Youth athletes present
unique challenges because they are also returning to the
school environment where cognitive challenges may lead
to increased concussive symptoms. Much like the pro-
gressive steps employed with returning to sports, return-
to-learn protocols have been developed and emphasize
a gradual progression of cognitive activities based on the

TABLE 3. Zürich Guidelines for Return to Play Following Concussion

STAGE FUNCTIONAL EXERCISE OBJECTIVE

0 - No activity Physical and cognitive rest Recovery

1 - Light aerobic exercise
2 - Sport-specific exercise
3 - Noncontact training drills
4 - Full contact practice
5 - Return to play
Walking, swimming, stationary cycling to Increase heart rate
<70% of maximum predicted heart rate;
no weightlifting
Noncontact sporting activities (eg, skating Add movement
in hockey, running in soccer) to >70% of
maximum predicted heart rate
Progression to more complex training drills Advance coordination and increase exercise
(eg, passing drills in football, shooting drills
in basketball); may start weightlifting
Following medical clearance, may participate Restore confidence and assess functional skills
in normal training activities by coaching staff
Normal game play Full participation

Reprinted with permission from McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held
in Zurich, November 2012. Br J Sports Med. 2013;47:250–258.

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presence of symptoms, with increasingly more complex
tasks.
Clinical Scenario #3:
A high school football player comes into the office on Monday
after sustaining a neck injury in Friday night’s game. He was
immobilized at the game and transferred to the emergency
department where radiographs yielded negative findings. He
was eventually diagnosed with a “stinger.” Now he wants to
know when he can go back to playing football.
The Neck
Cervical spine injuries and spinal cord injuries are
uncommon, but they are some of the most feared in-
juries in sports. Sports-related cervical spine injuries
account for almost 10% of all cervical spine injuries in
the United States, and sports-related spinal cord injuries
represent almost 9% of all spinal cord injuries. Sports
are the second most common cause of spinal cord in-
juries in people younger than age 30 years. Among high
school and college athletes, the rates of quadriplegia
from cervical spine injury range from 0.5 to 2.5 per
100,000 cases. Football-related injuries are the most com-
mon cause of devastating cervical spine injuries in sports, but
other sports such as cheerleading, gymnastics, ice hockey,
lacrosse, and equestrian also have an increased risk. Most
injuries occur following an axial load on the spine as a result
of head-down contact or “spearing.”
Cervical spine injury with possible spinal cord injury
must be suspected in any athlete who has an altered level
of consciousness, midline bony tenderness, or neurologic
symptoms. Any athlete with these symptoms requires cer-
vical stabilization and must be transferred promptly to
a hospital for further evaluation.
Most cervical spine and neck injuries in athletics are
sprains and strains involving the ligaments and muscles of
the neck. These injuries present with neck pain that is not
midline and not associated with sensory or motor deficit. If no
bony or midline tenderness is present, the athlete may return
to sport once he or she is pain-free, has full ROM, has no
symptoms with Spurling’s test (laterally flexing the head to-
ward the affected arm produces pain down the arm, thereby
suggesting pressure on nerve root) or axial loading, and
demonstrates normal neck strength with manual testing.
“Burners” and “stingers” are brachial plexus neck inju-
ries that occur after acute trauma to the neck and shoulder
area and result in unilateral burning or stinging, with
transient weakness down one arm. Studies suggest that
50% to 65% of athletes involved in collision sports may
experience a stinger at some point in their playing careers.
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These injuries most often involve the C5-C6 nerve roots, and
symptoms usually last only seconds to minutes. However,
symptoms can last days to weeks or be recurrent, which
indicates the need for a more detailed evaluation. RTP after
a stinger requires resolution of all symptoms, full ROM, and
demonstrated normal strength of the neck and upper
extremity. If a patient has midline tenderness or bilateral
symptoms after a neck injury, it is not a burner or stinger.
Bilateral symptoms or midline tenderness should prompt
detailed evaluation while the athlete remains removed from
play until a safe return can be assured. Football players with
repeat injuries may warrant further radiographic or neuro-
logic testing and may benefit from protective equipment
such as a cowboy collar or shoulder pad lifter if returning to
football. (9)
The clinician should always carefully consider the
sport and position played before returning athletes
to play following a cervical spine or neck injury. If
there is any doubt, consultation with a sports medicine
specialist, neurosurgeon, or spine expert should be
considered.
The Eye
Visual trauma is common in sports and varies from
corneal abrasions to globe rupture. Blunt and penetrat-
ing traumas are the most common mechanisms of eye
injury in sports. Each year, more than 100,000 sports-
related eye injuries present to physicians. Permanent
loss of sight occurs in about 13,500 of these injuries per
year. Sports-related eye injuries account for 30% of all
eye injuries in children younger than age 16 years, and
the highest-risk sports are basketball, water sports,
baseball, and racquet sports. Baseball is the most com-
mon sport for eye injuries in children ages 5 to 14 years,
while basketball becomes the leading cause after age
15 years. (10)
The most common eye injuries with sports are corneal
abrasions and periorbital contusions. Many of these injuries
are minor and may not require much time away from sport.
Those with superficial abrasions may return immediately if
the abrasions are not central and not causing pain. The athlete
who is having pain should undergo a thorough ophthal-
mologic examination and not return until pain has
completely resolved, which may be as soon as 48 to 72
hours because the cornea regenerates rapidly.
Hyphemas are postinjury accumulations of blood
within the anterior chamber of the eye that frequently
follow blunt force trauma in sports. Hyphemas are one of
the more common serious eye injuries in sports. They
may result in increased intraocular pressure, and an athlete
Vol. 36 No. 10 OCTOBER 2015 445
 with a hyphema requires immediate removal from play,
protection such as gentle placement of a shield over the
affected eye, and prompt evaluation by an ophthalmologist.
Athletes with suspected hyphemas must be evaluated by an
ophthalmologist before any return to sport.
Any athlete with an eye injury requires detailed eval-
uation. They should never return to play until their
vision has completely returned to normal or there has
been a complete evaluation by an ophthalmologist. The
clinician should be extremely cautious with an athlete
who has any complaints of vision loss, foreign body
sensation, eye pain, or visual field changes after eye
trauma. Any concerns should prompt consultation with
an ophthalmologist.
The best news about ocular injuries in sports is that
more than 90% can be prevented through the use of
proper eye protection. Unfortunately, most athletes do
not use protective eyewear until after an injury has
occurred. Clinicians should encourage athletes in high-
risk sports to use protective eyewear that has been
approved by the American Society of Testing and Materials
and avoid the use of unapproved eyewear. Protective
eyewear should be mandatory for any athlete following
446 Pediatrics in Review
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a serious eye injury or any athlete with reduced vision in
one eye. (11)
Summary
• Based primarily on consensus and some research evidence,
young athletes with musculoskeletal and cervical spine injuries
should not return to play until they have full range of motion,
resolution of pain, normal strength, psychological readiness, and
the ability to demonstrate adequate sport-specific skills.
• Based primarily on consensus, young athletes with suspected
concussion should not return to sport until they have returned to
their baseline physical and cognitive activities and successfully
completed a return-to-play protocol.
• Based on consensus and some research evidence, any young athlete
with a significant eye injury, visual changes, or abnormal findings on
ophthalmologic examination results should not return to play until
evaluated by an ophthalmologist. A significant number of eye
injuries can be prevented by the use of approved protective eyewear.
References for this article are at http://pedsinreview.aappubli-
cations.org/content/36/10/438.full.
PIR Quiz
1. Reinjury rates for youth sports following initial injury are high. Which of the following is the REQUIREMENTS: Learners
primary predictor of future injury risk to youth athletes? can take Pediatrics in
A. Impaired cognitive ability at baseline. Review quizzes and claim
B. Inappropriate sport for Sexual Maturity Rating stage. credit online only at:
C. Increased age of athlete. http://pedsinreview.org.
D. Presence of a prior injury.
E. Pressure from coaches. To successfully complete
2. A female pitcher suffers a mid-shaft fracture of her right clavicle while sliding into second 2015 Pediatrics in Review
base. She heals and returns to play in 6 weeks. An important difference between return to articles for AMA PRA
play or after return to play with a clavicle fracture versus humeral epiphysitis of the same Category 1 CreditTM,
shoulder is that: learners must
A. Full resolution of pain is less important for humeral epiphysitis. demonstrate a minimum
B. Humeral epiphysitis rehabilitation is longer due to the high risk of recurrent performance level of 60%
symptoms. or higher on this
C. Rehabilitation is more gradual for a clavicle fracture. assessment, which
D. Reinjury is more common after a clavicle fracture. measures achievement of
E. Restoration of full range of motion at the shoulder is not required for a clavicle the educational purpose
fracture. and/or objectives of this
activity. If you score less
3. A star receiver is slammed to the ground when tackled in a football game. Dazed upon
than 60% on the
returning to the huddle, he is immediately removed from the game. He can return to play
assessment, you will be
when he has:
given additional
A. Clearance from his coach. opportunities to answer
B. Expressed a clear desire to resume participation. questions until an overall
C. Obtained written permission from his legal guardian. 60% or greater score is
D. Recovered preconcussion physical abilities and is symptom-free. achieved.
E. Successfully completed a step-by-step return-to-play process.
4. After making a block on a running play, a lineman feels a stinging sensation in his left arm.
This journal-based CME
The pain stops quickly after reaching the sideline. He does not need further evaluation if he
activity is available
has full range of motion and:
through Dec. 31, 2017,
A. A positive Spurling’s test result. however, credit will be
B. Normal strength in the neck and upper extremity. recorded in the year in
C. Only mild midline neck tenderness. which the learner
D. Only mild weakness of neck extension. completes the quiz.
E. Only slight tingling in the right arm.
5. An athlete with a superficial corneal abrasion may return to play if:
A. Blurring of vision is only in the periphery.
B. The corneal abrasion is not central in location.
C. There is only a mild foreign body sensation.
D. There is only minor associated pain.
E. There is only a small hyphema.

Parent Resources from the AAP at HealthyChildren.org

• https://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/When-is-an-Athlete-Ready-to-Return-
to-Play.aspx
• https://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/Sports-Injuries-Treatment.aspx
• https://www.healthychildren.org/English/health-issues/injuries-emergencies/sports-injuries/Pages/Sports-Related-Concussion-
Understanding-the-Risks-Signs-Symptoms.aspx

Vol. 36 No. 10 OCTOBER 2015 447

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 Return to Play
Greg Canty and Laura Nilan
Pediatrics in Review 2015;36;438
DOI: 10.1542/pir.36-10-438

Updated Information & including high resolution figures, can be found at:
Services http://pedsinreview.aappublications.org/content/36/10/438
References This article cites 15 articles, 5 of which you can access for free at:
http://pedsinreview.aappublications.org/content/36/10/438#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
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l_education_sub
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_cme
CME
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Sports Medicine/Physical Fitness
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medicine:physical_fitness_sub
Concussion
http://classic.pedsinreview.aappublications.org/cgi/collection/concus
sion_sub
Rehabilitation
http://classic.pedsinreview.aappublications.org/cgi/collection/rehabil
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edic_medicine_sub
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 Return to Play
Greg Canty and Laura Nilan
Pediatrics in Review 2015;36;438
DOI: 10.1542/pir.36-10-438

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/36/10/438

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
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