Envision the following scenario: A player injures his knee (knee sprain), and has swelling and loss of function. He goes to his physician, and is told to rest it for a few days, and then return to a second assessment and a possible MRI, and other tests. The player’s knee feels better after a few days and does not go back to the doctor, and shows up at practice and tells the coach he wants to play. Since this player is the star midfielder, the coach says, “great, we have an important game this Saturday”. The coach notices the player is still “limping” a bit, but figures he will do fine. The player plays in the game, re injures the knee, more severely this time and ends up having surgery and is out for the season. There were several things done wrong here. First, the player and family did not follow through with the physician’s advice. Second, the coach should have required the player to bring a note from the physician releasing him to play without restrictions. Thirdly, the coach should have run the player through a series of skill and agility drills to determine if he could play without any signs of limitations. Fourth. Since the player was a minor, a parent had to be with the player at the first doctor visit, and should have been aware of the doctor’s recommendations. Had the coach discussed this with the parents, he/she would have known that the player had not completed the medical management of his problem.
No one was the winner here. The coach lost a good player for the season, and may have some liability associated with returning the player too soon. The player aggravated an injury to the point surgery was required, when more rest and some rehab might have fixed the original problem.
Knowing when to return to player to activity does not require a “crystal ball”, but it is a decision that is not made easily, but can be made safely if certain factors are taken into consideration. Following a few basic guidelines will improve the chances of a safe return to playing soccer for anyone who sustains an injury where time away from activity is required.
Minor Injuries: Most injuries sustained by players are minor in nature, and often the coach, parent, and player can make the decision regarding return to activity. Bumps, bruises, minor sprains and strains may result in limited time away from sports, and in some cases a safe return can be the same day. Medical evaluation is often not required here. When minor injuries occur in a game or practice, the player must be able to demonstrate to the coach that they can perform all needed skills prior to returning the same day. Concussions are an exception to this, and require a different approach. See the section on concussions in this website. When a “minor” injury does not respond with rest and general first aid management (ice) within a couple of weeks, it should be classified as a moderate injury and steps should be taken as noted below.
Moderate to Severe Injuries: These are injuries where there is a clear loss of ability to perform the skills and functions required in soccer. Pain, swelling, limited joint mobility, weakness, and “guarded” function may all present to some degree. In some cases, physician evaluation is necessary. The player should be held out of all practices and games until evaluated by an MD.
When there is Physician involvement: Anytime the player seeks advice of a medical professional, then that person will be the one to regulate what the player is permitted to do, and when the player may return to sports. Coaches need to be in direct contact with the parents and be aware of what the physician has instructed the player and family to do regarding their injury. The coach should not, under any circumstances, permit the player to return to activity of any kind, without the written consent of the MD. The coach needs to inform the parent and player that when they return to their physician for follow up visits that if the physician says the player may return to sports, there must be a written note or prescription stating as much. If there is a return with restrictions (may drill, but no contact, etc), then the note must state this. This communication needs to be written, and the coach should maintain this written authorization in their files for future reference.
When having a written OK to play is not enough: Simply having a note from the doctor that a player may return to play is just the first step. Once that OK is received, the coach then needs to begin the process of progressively working the player back into the routine, with graduated drills, skills, and conditioning. If a player has been off for say, 4 weeks with a knee sprain, it is obviously not wise to throw them back into the game as though nothing had ever happened. A progressive, gradual return, will ensure the player makes a safe “re-entry” into soccer with less risk of re-injury.
Three main rules to follow:
- If a player sees a medical professional for their injury, they may NOT return to activity until released by the physician. A written note should be required.
- With all injuries, minor to severe, with or without MD involvement, players must be gradually worked back into practices and games slowly through a progression of skill drills, running, agility work and game-like situations. If a player demonstrates the inability to perform needed skills and tasks without pain, swelling or guarding (protecting), then they are not yet ready to play in a game.
- The decision to return to play must be one that is coordinated and discussed by the coach, parents and player. Physicians included if involved.
Note: Concussions are managed differently than typical strains, sprains, bruises. See the section on concussions to determine return to play guidelines for this problem.
