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Publication

Return to sport and performance after lower extremity injuries in athletes practicing high-impact sports

Book - Dissertation

Participating in sports is considered a vital component of an active and healthy lifestyle. Nevertheless, physical activity and participation in sports carries considerable risk of musculoskeletal injury. Lower extremity injuries frequently occur among athletes, particularly in athletes practicing high-impact sports. For most athletes, it is important to return to performance after injury. However, there is no guarantee of return to performance for approximately half of injured athletes, and when athletes do return to performance, there is a high risk of re-injury and one third of athletes report not performing as well as before their injury.
Return to sport decision-making that aims toward the level of performance before an injury and minimises risk of re-injury is important. To make structured and transparent return to sport decisions, the StARRT framework can be used. Measuring functional performance is one of the steps in this framework, and single-legged hop tests are commonly used to assess athletes’ ability to perform components of sport-specific actions. Although hop tests were designed to support return to sport decision-making after anterior cruciate ligament injury or reconstruction, these hop tests are also used in clinical practice to make return to sport decisions after other lower extremity injuries of the hip, ankle, or hamstring(s).
However, even if an athlete meets hop test criteria, there is no guarantee of return to performance or a decreased risk of re-injury. There are also concerns regarding the use of the non-injured leg as an index measurement in return to sport decision-making and measuring hop tests in controlled and non-fatigued conditions. In addition, the focus of rehabilitation is the restoration of physical functions, but one of the most common reasons for not returning to sport or performance is fear of re-injury or lack of confidence. Measuring and monitoring an athlete’s psychological readiness to return to sport is fundamental, and interventions targeting psychological readiness to return to sport may help to facilitate a safe return to sport after injury. This doctoral thesis aimed to contribute to the knowledge on the use of hop tests and psychological readiness in the criterion-based return to sport decision-making process after lower extremity injuries in athletes practicing high-impact sports.
In the systematic review in Chapter 2, we identify, critically appraise, and analyse published evidence on the association between functional performance and return to performance after lower extremity injuries in athletes participating in high-impact sports. Though functional performance tests are often used to make return to sport decisions, it is unknown whether functional performance is associated with return to performance after lower extremity injuries. Eight studies reported an association between functional performance and return to performance, but these only involved athletes after anterior or posterior cruciate ligament reconstruction. We found a high risk of bias in all studies and only low-quality evidence suggesting small associations between functional performance and return to performance after anterior and posterior cruciate ligament reconstruction. No evidence exists for lower extremity injuries other than after anterior or posterior cruciate ligament reconstruction. Thus, this systematic review concludes that there is no high-quality evidence that functional performance is associated with return to performance after lower extremity injuries in athletes practicing high-impact sports. High-quality prospective cohort studies on the association between functional performance and return to performance are recommended in athletes with various types of lower extremity injury.
Although the association between hop tests and return to performance cannot be established based on available studies, hop tests can be used as one of the elements substantiating return to sport decision-making and to provide feedback regarding the rehabilitation process. In the study in Chapter 3, we compared the single-legged hop test performance of the non-injured leg of athletes returning to high-impact sports after lower extremity injury and the matched leg of healthy athletes. No previous studies investigated differences in hop tests among athletes who were ready to return to sport after various types of lower extremity injuries and matched healthy athletes. Our study indicates that at the criterion-based point of return to high-impact sports after a lower extremity injury, clinicians can use the outcomes of the non-injured leg as a reference for the outcomes of the injured leg in hop tests in the return to sport decision-making process. However, although athletes can achieve symmetry between the injured and non-injured leg, they might fail to meet pre-injury performance levels. To avoid a premature or unsuccessful return to sport, it is recommended that both legs are tested regularly to obtain an athlete-centred benchmark. As hop tests are usually assessed under non-fatigued conditions, the objective of Chapter 4was to assess differences in hop test outcomes before and after a match in and between soccer players returning to performance after a lower extremity injury and non-injured teammates. Soccer players returning to performance after a lower extremity injury and their non-injured teammates yielded similar scores on hop tests before and after a match, with comparably reduced outcomes following the match. Returning to sport is influenced by more factors than only the outcomes of closed skill, controlled, and straightforward hop tests, which may not accurately represent the sport context. More demanding sport-specific performance tests and measuring movement quality are also recommended for safe return to sport decision-making. Finally, it is preferable to compare the outcomes of these tests with pre-injury outcomes. In the return to sport-decision-making process, both physical and psychological factors are important. Lower fear of re-injury and greater psychological readiness favour return to sport. No questionnaire in the Dutch language existed for measuring psychological readiness to return to sport after lower extremity injuries. Hence, the aim of the study presented in Chapter 5 was to translate and validate the I-PRRS scale into the Dutch language. The Dutch I-PRRS scale produced can be used in clinical practice to measure and monitor psychological readiness in athletes returning to high-impact sports after lower extremity injuries. To create a positive rehabilitation environment that can improve the likelihood of returning to sport and performance, techniques addressing fear and athletic confidence should be incorporated into rehabilitation, possibly in collaboration with a sport psychologist. The prognostic value of the I-PRRS scale in athletes who return to performance (or not) should be investigated in future research. We conclude that although hop tests cannot guide clinicians’ predictions of the successful return to performance, they can be used to guide treatment progression and to support return to sport decision-making. Pre-injury outcomes should be compared with post-injury outcomes. However, since pre-injury scores are oftentimes unavailable,clinicians can use the outcomes of the non-injured leg as a reference for the outcomes of the injured leg in hop tests to decide on return to sport after lower extremity injuries at the criterion-based point of return to sport. Because biomechanical deficits can exist despite achieving symmetrical or pre-injury hop test outcomes, movement quality should also be measured in the return to sport decision-making process. To administer tests that accurately reflect the sport context, tests should be used in which possibly fatigued athletes need to respond to unanticipated and less-controlled tasks in open environments. In addition to physical rehabilitation, consideration of fear of re-injury and confidence of the athlete regarding return to sport are essential. The Dutch I-PRRS scale can be used to measure and monitor psychological readiness to return to sport or performance. Future research on how sport-specific performance tests and psychological factors relate to and predict return to performance after lower extremity injuries may help inform clinicians’ decision-making for optimal assessment timing and their understanding of an athlete’s ability to return to sport. In summary, the findings of this doctoral thesis are as follows:• We found no high-quality evidence that functional performance is associated with return to performance after lower extremity injuries in athletes practicing high-impact sports.• At the criterion-based point of return to high-impact sport after lower extremity injury, clinicians can use the non-injured leg as a reference for the injured leg in hop tests.• Soccer players returning to performance after a lower extremity injury and their non-injured teammates showed similar scores on hop tests before and after a match with comparably reduced outcomes following the match.• The I-PRRS scale was successfully translated to the Dutch language and can be used in clinical practice to measure and monitor psychological readiness in athletes returning to high-impact sports after lower extremity injuries.
Number of pages: 156
ISBN:978-94-6423-658-3
Publication year:2022
Keywords:lower extremity injuries, Athletes, high-impact sports
Accessibility:Open