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Injured Player? Take Safe Steps in the Return-To-Play Decision
by Dev Mishra, April 28th, 2017 2:09PM
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TAGS:  youth, youth boys, youth girls, youth soccer

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By Dev Mishra, M.D.

One of the toughest decisions in youth sports is determining when a player who has suffered an injury is ready to return to action. It's very easy to get caught up in the moment of competition and perhaps put an injured player back in the game before he or she is really ready. The emphasis on the sideline should always be directed toward athlete or child safety.

Returning to play prematurely can lead to a more serious injury. In my clinical practice over the last 23 years I see one or two kids each week with a significant injury that started out as some kind of minor injury. For whatever reason they kept playing and that minor injury turned into something more significant.

Sometimes it was because they were put back in the game too soon. Sometimes it was because they failed to report it to the coach. Sometimes they played for weeks with a chronic, nagging pain.

If you think a kid’s not really ready, it’s better to sit them -- maybe lose them for a few days -- rather than to let them get back in before they’re ready and lose them for weeks or months.

Ideally the real decision on return to play is not in the hands of the coach, it is in the hands of a trainer or physician -- someone who’s really trained and qualified to make that decision. This would certainly be the case when returning from a serious injury such as a fracture, concussion, or injury that required surgery.

But there are many settings where someone who is professionally qualified isn’t there to make a remove-from-play or return-to-play decision. This is common in competition on the field of play. In that case it’s really going to come down to the coach to make a reasonable decision.

When players insist they are ready to play

Players want to play and this means that they will often insist they are ready to play when perhaps they are not. This is where the decision becomes really tough. You really need to be their advocate -- to be their voice.

As the kids get older they’re going to have better reasoning abilities. They’re also going to have other motivations to stay in the game -- and perhaps not tell you everything.

With kids, you’ll often have to make the tough decision for their own good. What if you’re at an away tournament? What if it’s your star player? What if you have to play a man-down? You still want to err on the side of safety. Here are two simple observational tactics to help you determine safe return to play for in-game situations:

Pregame: Watch closely when they don’t think you’re watching

You might have a situation where a player was injured during practice midweek and you’ll have an opportunity to observe them in pregame warmup on the weekend. If you can see them limp, favor one side, or appear in pain with warmup movements -- those are red flags indicating an injury that may not be healed well enough to allow safe return to play. Your best course of action would be to hold the player from play.

In-game: Do a functional test

In many movement-based sports you’ll be dealing with injuries to the lower extremities -- hip, knee, ankle, foot.

You’ll need to confirm that the player is really pain free. If you can be reasonably confident they are really pain free and have no visible swelling then you’ll need to put them through a functional test.

On the sideline ask the player to jog, cut, sprint and jump and observe closely. If the player can do that comfortably and with no visible problems that is a very good indicator of return to play. That’s basically saying if a kid gets back to “normal” -- they can play.

In a game situation there are of course many grey areas, decisions are rarely black and white. If you follow the advice above for the functional test you’ll generally be safe, but if you have any doubts don’t take a chance and risk turning the mild injury into something serious. Hold them out and advise them to consult a medical professional.

Key Points:
* The coach will often have to make a decision on return-to-play during competition.
* One tactic would be to observe the player in pregame warmup for any pain or poor movement.
* A second in-game method is to make sure the player is pain-free, has no swelling, and can pass a sideline functional test of jog, cut, sprint, and jump.

(Dr. Dev K. Mishra, a Clinical Assistant Professor of orthopedic surgery at Stanford University, is the creator of the SidelineSportsDoc.com online injury-recognition course, now a requirement for US Club Soccer coaches and staff members. Mishra writes about injury management at SidelineSportsDoc.com Blog. This article previously appeared in the Youth Soccer Insider in April of 2015).



7 comments
  1. Jay Wall
    commented on: April 28, 2017 at 4 p.m.
    One of the hardest things to do as a coach is to convince many of those parents who are convinced their child is God's gift to the sport, that their child is not yet ready to safely return to play at the same competitive level. > Parents who protest their child says their is no pain, that they want to play and they feel great. > And when you list specific functional areas their player has issues with these parents often refuse to accept that you are being honest and that their child really does need the additional time to recover. > And if you draw the line and they won't play until they are fully recovered, the parents who tell you in no uncertain terms they will play or they will take their player to another club where they will be a star. > Often the greater problem in having players sit until they have recovered from an injury is the parents refusal to accept the extent of their players injury.
  1. Quarterback TD
    commented on: April 28, 2017 at 5:31 p.m.
    Some injuries kids can play through, some you need a doctor's clearance. There are times where I am totally confuse about where the line is being drawn because I see kids with braces on their knees, casting for shin splints and medical bandages saying they have doctors clearance and playing full contact. Personally I put this squarely on the parents once a doctor prognosis is made and the parents are informed. Parents can tell the coach the kid is not playing because of injury and that's the end of that.
  1. Nick Daverese
    commented on: April 29, 2017 at 10:38 a.m.
    A parent can get their family doctor to give any kind of letter they want. So it is better to have a fitness test with all parts of the body before the season starts. Then again after the season starts. To pass coming back from an injury you the player has to be at least well enough before the start of the season.
  1. Nick Daverese
    commented on: April 30, 2017 at 7:43 a.m.
    Does this doctor ever read this publication. If so I would like to hear what she would do to releave the pain associated with players who get Osgood-Schlatter after a growth spurt. So they can continue playing without the pain associated with this.
  1. Jay Wall
    commented on: April 30, 2017 at 10:55 a.m.
    An ortopedic group explained the condition as pain when the connecting tissue below the knee cap was being pulled away from the bone and suggested a simple strap brace to keep the connecting tissue in place while the connecting tissue grew to the new length of the lower leg bone. Braces were about 3/8th inch wide. We referred players to doctors at first and they all suggested the same brace so that became standard. When a player first had the pain in a game we found they creating a temporary brace with prewrap was a temporary solution that worked well. Take a double thickness of prewrap, twist and tie at the point where the connecting tissue reached the bone. A temporary brace works if you don't have a simpe strap brace in the first aid kit.
  1. Jay Wall
    commented on: April 30, 2017 at 12:51 p.m.
    Due to family affair rushed answer above. > Osgood Slatters comes from rapid growth and often with too much activity for rate of growth (overuse injury). > If there is pain rest, ice with leg raised above heart for 20 minutes every 3-4 hours to reduce swelling, anti-inflammatory (like Ibuprofen Advil or Motrin type products), brace or taping for activities, quad and hamstring stretching in moderation, exercise in moderation to give body time to recover, avoiding all overuse and highly repetitive training. Playing in games only if completely without pain and with brace until body growth catches up and can play with full range of motion and no pain. > Practice focus on no overuse and a very limited number of slow perfect repetitions to make a habit out of perfect technique, but wait until can play with no pain or brace before return to repetitions under pressure and match conditions. > Focus on mental aspects of everything to convert overuse time into a quality learning experience. For example, 2 simple moves that have no stress and are done in slow motion repetitions that are best to beat a passive opponent on the sideline, 2 more slow motion moves to split 2 passive opponents, etc. Using slow motion games with throwing the ball instead of kicking it and walking instead of running are also great for learning. A throws to B and then walks to the best supporting position to receive a pass back. B throws the ball to A, in the air, to arrive just as they get to the best possible position. Make the focus on what movement to use where on the field and to accomplish what. When fully recovered step practice up to practicing everything learned with passive opposition to real game like learning with active opponents. > If player has pain at lower walk through level refer to a medical practitioner to determine if they must have treatment and cease play for a term determined by the doctor. >>> Best xray showing the condition can be found at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063719/figure/FIG3/ >>> Published in an artice at: https://www.ncbi.nlm.nih.gov/pubmed/27752406
  1. Nick Daverese
    commented on: May 1, 2017 at 1 a.m.
    That is a big problem for a lot of players especially young players. You not going to make the condition worse by playing with it. But you have to find ways to making playing with it less painful. The strap is the best you want to minimize the pain before you play. After you start playing it is too late to help the player. Anti inflammatory is only good for players over 18 not under. It is dangerous for a young player to take. We give anti inflammatory to adult players a couple of hours before a match for those just coming back from an injury to minimize swelling during the match. I Agee with iceing and leg raised over the heart after the match. Remember ice baths articles do they work they do if the player is used to taking them. That bump under the knee gets bigger with age. It can be reduced with surgery, but that pesky bump never goes away completely it can come back.

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