Often sports injuries occur and come with a timetable, an estimate for how many days, weeks or months for an athlete to return to play. Timothy Hewitt, an expert in ACL injuries and director of Sports Medicine Research at Ohio State, has advocated that timetables aren’t useful, and says, “Time to return to play has no association with athletes’ health outcomes.”
Athletes who peg their return to play to calendar dates don’t improve their chances of returning to peak athleticism and, if they aren’t competition-ready upon their return to play, they are more likely to hurt themselves. There’s really no upside, just downside.
Injury and re-injury risk remain extremely high for athletes who accelerate their rehabilitation schedules. Earlier returns to play go hand in hand with increased risks, says Hewett, “With an ACL reconstruction, it’s two years to recovery.”
The paradigm shift isn’t really a change in injury timetables. The change is in how organizations and players manage risk, and use the best available evidence and data to inform those risk decisions.
To minimize risk associated with return from injury the one essential timetable is how long it will take for full recovery. That’s at least full two years for an ACL reconstruction, according to Hewett. Any shorter timeframe should come from clear headed analysis of risks and opportunities, with all of the player health and player/team economic considerations in play.
How would that work in practice? Decision trees are one method. They’re an analytical tool used in both healthcare and business analysis. They compare and predict future decision outcomes based on present-time decision options.
The basic form of decision trees are if-this-then-that check and do lists. Probabilities can be attached to decision outcomes. These are the branches that follow out from the nodes that are the decision points. The probabilities add mathematical rigor to the decision-making, even though the probability numbers vary widely, ranging from strong evidence-based data to outright guesses.
Clinicians use decision trees to determine a best course of treatment given a range of options and the scope of a patient’s age and health condition. MBAs see decision trees in their first year coursework when they cover Expected Value analysis; that’s where they learn how to predict financial gains and losses for business decisions.
The point is: Health outcomes are expected value decisions when it comes to NBA athletes, who in many cases have guaranteed multi-year contracts. It’s something that should be reflected in the return to play decision-making process, especially with high value, elite talents.
Hewett and collaborators at other U.S. medical research centers have been working with the NBA and WNBA to improve the risk factors data and the analysis to improve return to play decisions. The work is part of the Multi center Orthopedic Outcomes Network (MOON), a National Institutes of Health funded group that includes clinician-scientists at Ohio State, Vanderbilt, Washington University at St. Louis, the Cleveland Clinic, the University of Iowa, the Hospital for Special Surgery and the University of Colorado.
Advanced analysis and improving the body of evidence are only part of the decision-making process, the easy part really. The hard part is the communication and collaboration required for teams and players to navigate the risks and sort out the best interests of everyone involved.
“You’ve got sports medicine, physical therapy, athletic trainers, strength coaches, all in their own silos working on the same athletes,” said Art Horne, the well-known Director of Sports Performance at Northeastern University who also organizes the leading sports science conference in the Northeast U.S., the Boston Sports Medicine and Performance Group Summer Seminar. “It’s like an assembly line” and each group needs to keep its own channel of communication to coaches and to management.
At each step in the assembly line the different professions do their own work, often without input, coordination or oversight from other stakeholders in the athlete return to play process, be they coaching, front office or medical staff. The division of labor muddles decision-making. Sports medicine might make the clinical return to play decision but the coaches or sports trainers or physical therapists might have useful information that fails to come into play.
Notable exceptions in the NBA are Indiana and Oklahoma City, according to Horne. The two teams have coordinated their sports medicine and training, something that Horne has done at Northeastern. Last year the Boston school literally removed the concrete wall separating the two departments (replacing it with a door and glass partition). “The biggest thing about all this, it comes down to communication. Now it’s easier. Everyone sees what’s going on,” said Horne.
Ian Shrier is a research sports medicine physician at McGill University in Montreal who collaborates with Ohio State’s Hewett. He made the point at an American College of Sports Medicine symposium in May, 2013, that “Return to play decisions really require a skill set that is greater than any one stakeholder’s.”
Shrier is seeking government grant funding to research the issue of who, from all the participants, has the right skills to provide the proper inputs for an evidence-based return to play decision process, one that also treats the injured athlete as a person and not a body part.
Fergus Connolly is the San Francisco 49ers’ athlete performance director and he has worked for Liverpool FC, Wales Rugby, the New York Knicks and the Jacksonville Jaguars, among others. The severe time pressure on decision makers, mostly due to the heavy game schedule and the time it takes to prepare, causes less than ideal decision processes, he feels.
“In many professional sports there’s often not time to do it right, but there’s money to do it twice. It’s the same in the NBA,” he said. “In my experience, of all the professional sports leagues, NBA people work the hardest under the most time pressure. 82 games a season is unheard of in any sport in Europe.”
This workload compromises communication and cripples efforts to integrate information inputs, things like recovery, data collection and analysis, strength and endurance training, nutrition, physical therapy – all of which would help reduce injury risks.
Collaboration under pressure makes the hiring decisions for these jobs a challenge for teams. “I tell GM’s, ‘You don’t necessarily want to bring in the best doctor, sports scientist, trainer or strength coach. You want to bring in the right person,'” says Connolly. “The right person knows that 80% of their job is knowing what not to do, given all of the options that are out there. The other 20% is knowing how to deliver them.”
During the summer in 2013 the Portland Trail Blazers hired Chris Stackpole to be the team’s Director of Player Health. Stackpole is both a physical therapist and a sports trainer. The Blazers’ press release described his job as something more like 10 jobs, “He will work closely with the team’s athletic trainers, physicians, strength and conditioning specialists, nutritionists, psychologists and therapeutic specialists to integrate rehabilitative concepts into performance training.” Good thing Stackpole is just 26 years old.
Since the summer before the 2013-14 NBA season a number of NBA hires will work across their organizations on athlete performance. Jennifer Swanson became the Bulls’ new director of sports performance. Gersson Rosas moved from Houston to Dallas and back to Houston to oversee sports science for the organizations. The Warriors, Spurs, Cavaliers, Grizzlies, Mavericks, Lakers, Magic, 76ers, Kings and Wizards have all announced new hires to upgrade athlete performance and/or sports science.
Connolly thinks of returning to play after injury in four distinct, gradual levels of attainment: return to train, return to play, return to perform, return to win. Athletes who’ve had severe injuries often never return to past levels of performance (though there are a few who actually elevate their performance.)
Athletes are naturally anxious to return, even though the risk of re-injury increases when the focus is on “return to play” and not on “return to perform” or another, higher level of recovery. “Even at high school or junior high level there’s so much pressure from themselves, from peers, parents and coaches to return to play in a specific timetable and not one minute longer,” says Ohio State’s Hewett. “It’s tied to their identity.”
Hewett’s fully outfitted lab can run three-dimensional motion test, ergonomic tests, motor- and motion control tests for athletes undergoing injury rehabilitation. He expects to use the data he’s gathering to develop decision trees to guide a trainer or clinician through a set of multi-modal tests for strength, agility, force production and proprioception that accurately reflect the athlete’s progress to full recovery, where full recovery is actually a better place physically than before the athlete’s injury took place.
In the case of ACL reconstruction, athletes who return to the game when they have only attained “return to play” condition routinely say that the repaired knee “doesn’t feel right.” The sad news is that it never will feel the same as before surgery. ACLs aren’t loaded with mechano receptors the way other, touchier parts of your body are, but they are there – “3-5% of the total tissue volume of the ligament,” says Hewett.
Evidence strongly indicates, according to Hewett, that those mechano-receptors aren’t coming back post surgery. Again, it’s the two-year window for an athlete to develop similar neural feedback mechanisms that compensate for the lost feeling.
Hewett presented his research in February at the 2013 All Star Game in Houston and again in May at the Chicago draft combine, both times at events organized by NBA team physicians. The new norms show that NBA teams have been listening. It’ll take longer for new, improved norms for return to play decisions to gain adoption at the game’s lower levels however. From Hewett’s collaborator Ian Shrier, “I consider this a ten year or twenty year project. We’re making sociological changes.”