Semin Musculoskelet Radiol 2024; 28(02): 107-118
DOI: 10.1055/s-0043-1778028
Review Article

Return to Play in the Professional Athlete

Aishwarya Gulati
1   Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
Vishal Desai
1   Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
› Author Affiliations


The management of any injury in elite athletes poses unique challenges distinct from the general population because the goal is rapid recovery and return to play (RTP) while simultaneously managing residual symptoms and minimizing risk of reinjury. The time required for treatment, recovery, and return to peak performance can have consequences for both the athlete and his or her team: financial implications, psychological stressors, team dynamics, and future performance. RTP after an injury in the professional athlete requires a complex decision-making process with many stakeholders. Several factors influence this decision, not the least of which is the type and mechanism of injury. This article provides an overview of the RTP process including nonmedical factors that may influence this decision, common injuries seen in professional athletes, injury patterns particular to certain popular sports, and imaging guidelines for such injuries.

Publication History

Article published online:
14 March 2024

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  • References

  • 1 Herring SA, Kibler WB, Putukian M. The team physician and the return-to-play decision: a consensus statement—2012 update. Med Sci Sports Exerc 2012; 44 (12) 2446-2448
  • 2 Gimigliano F, Resmini G, Moretti A. et al. Epidemiology of musculoskeletal injuries in adult athletes: a scoping review. Medicina (Kaunas) 2021; 57 (10) 1118
  • 3 Delos D, Maak TG, Rodeo SA. Muscle injuries in athletes: enhancing recovery through scientific understanding and novel therapies. Sports Health 2013; 5 (04) 346-352
  • 4 Barroso GC, Thiele ES. Muscle injuries in athletes. Rev Bras Ortop 2015; 46 (04) 354-358
  • 5 Wong S, Ning A, Lee C, Feeley BT. Return to sport after muscle injury. Curr Rev Musculoskelet Med 2015; 8 (02) 168-175
  • 6 Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001; 29 (04) 521-533
  • 7 Palisch A, Zoga AC, Meyers WC. Imaging of athletic pubalgia and core muscle injuries: clinical and therapeutic correlations. Clin Sports Med 2013; 32 (03) 427-447
  • 8 Haider H, Montgomery JR, Spicer PJ. Rectus abdominus tear in a collegiate cheerleader. Radiol Case Rep 2022; 18 (01) 37-39
  • 9 Halabchi F, Hassabi M. Acute ankle sprain in athletes: clinical aspects and algorithmic approach. World J Orthop 2020; 11 (12) 534-558
  • 10 Miller BS, Downie BK, Johnson PD. et al. Time to return to play after high ankle sprains in collegiate football players: a prediction model. Sports Health 2012; 4 (06) 504-509
  • 11 Wood AM, Robertson GAJ, MacLeod K, Porter A, Court-Brown CM. Epidemiology of open fractures in sport: one centre's 15-year retrospective study. World J Orthop 2017; 8 (07) 545-552
  • 12 Lam KC, Marshall AN, Welch Bacon CE, Valovich McLeod TC. Cost and treatment characteristics of sport-related knee injuries managed by athletic trainers: a report from the Athletic Training Practice-Based Research Network. J Athl Train 2021; 56 (08) 922-929
  • 13 Nicolini AP, de Carvalho RT, Matsuda MM, Sayum JF, Cohen M. Common injuries in athletes' knee: experience of a specialized center. Acta Ortop Bras 2014; 22 (03) 127-131
  • 14 Jones M, Ball S, Williams A, Borque K. Multi-ligament knee injuries in elite athletes: return to play rates, timing, and complications. Orthop J Sports Med 2020; 8 (7 Suppl 6): 23 25967120S00366
  • 15 Lavoie-Gagne OZ, Korrapati A, Retzky J. et al. Return to play and player performance after meniscal tear among elite-level European soccer players: a matched cohort analysis of injuries from 2006 to 2016. Orthop J Sports Med 2022; 10 (01) 23 259671211059541
  • 16 Pfirrmann D, Herbst M, Ingelfinger P, Simon P, Tug S. Analysis of injury incidences in male professional adult and elite youth soccer players: a systematic review. J Athl Train 2016; 51 (05) 410-424
  • 17 Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: a comprehensive overview. J Orthop Surg Res 2018; 13 (01) 309
  • 18 Petraglia F, Ramazzina I, Costantino C. Plantar fasciitis in athletes: diagnostic and treatment strategies. A systematic review. Muscles Ligaments Tendons J 2017; 7 (01) 107-118
  • 19 Matusak ME, Yau CC, Fibel KH. Medical sports injuries in American football players. HSS J 2023; 19 (03) 277-284
  • 20 Bailowitz Z, Visco CJ, Christen K, Ahmad CS. Diagnostic musculoskeletal ultrasound for the acute evaluation and management of soccer players. Curr Sports Med Rep 2021; 20 (10) 525-530
  • 21 Breukers M, Haase D, Konijnenberg S, Klos TVS, Dinant GJ, Ottenheijm RPG. Diagnostic accuracy of dynamic ultrasound imaging in partial and complete anterior cruciate ligament tears: a retrospective study in 247 patients. BMJ Open Sport Exerc Med 2019; 5 (01) e000605
  • 22 Flores DV, Bohyn C, Murray TE, Murphy DT, Cresswell M. Dynamic US of musculoskeletal disorders: a pictorial review with emphasis on techniques. Radiographics 2023; 43 (08) e220130
  • 23 Ciccotti MG, Atanda Jr A, Nazarian LN, Dodson CC, Holmes L, Cohen SB. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med 2014; 42 (03) 544-551
  • 24 Ciccotti MC, Hammoud S, Dodson CC, Cohen SB, Nazarian LN, Ciccotti MG. Medial elbow instability resulting from partial tears of the ulnar collateral ligament: stress ultrasound in a cadaveric model. Am J Sports Med 2020; 48 (11) 2613-2620
  • 25 Hall MM. Return to play after thigh muscle injury: utility of serial ultrasound in guiding clinical progression. Curr Sports Med Rep 2018; 17 (09) 296-301
  • 26 Maffulli N, Del Buono A, Oliva F. et al. Muscle injuries: a brief guide to classification and management. Transl Med UniSa 2014; 12: 14-18
  • 27 Pollock N, James SL, Lee JC, Chakraverty R. British athletics muscle injury classification: a new grading system. Br J Sports Med 2014; 48 (18) 1347-1351
  • 28 Crema MD, Yamada AF, Guermazi A, Roemer FW, Skaf AY. Imaging techniques for muscle injury in sports medicine and clinical relevance. Curr Rev Musculoskelet Med 2015; 8 (02) 154-161
  • 29 Isern-Kebschull J, Pedret C, Mechó S. et al. MRI findings prior to return to play as predictors of reinjury in professional athletes: a novel decision-making tool. Insights Imaging 2022; 13 (01) 203
  • 30 Abbott A, Bird ML, Wild E, Brown SM, Stewart G, Mulcahey MK. Part I: epidemiology and risk factors for stress fractures in female athletes. Phys Sportsmed 2020; 48 (01) 17-24
  • 31 Kakouris N, Yener N, Fong DTP. A systematic review of running-related musculoskeletal injuries in runners. J Sport Health Sci 2021; 10 (05) 513-522
  • 32 Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg 2000; 8 (06) 344-353
  • 33 Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med 1987; 15 (01) 46-58
  • 34 Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17 (05) 309-325
  • 35 Robertson GA, Wood AM, Heil K, Aitken SA, Court-Brown CM. The epidemiology, morbidity and outcome of fractures in rugby union from a standard population. Injury 2014; 45 (04) 677-683
  • 36 Robertson GA, Wood AM. Fractures in sport: optimising their management and outcome. World J Orthop 2015; 6 (11) 850-863
  • 37 Morgan RJ, Bankston Jr LS, Hoenig MP, Connor PM. Evolving management of middle-third clavicle fractures in the National Football League. Am J Sports Med 2010; 38 (10) 2092-2096
  • 38 Robertson GA, Wood AM, Aitken SA, Court Brown C. Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population. Foot Ankle Int 2014; 35 (11) 1143-1152
  • 39 Cotton MO, Sliepka III JM, Klavas DM, McCulloch PC, Harris JD, Jack II RA. Performance and return to sport after open fracture in National Football League players. Orthop J Sports Med 2021; 9 (09) 23 259671211027862
  • 40 Giza E, Mithöfer K, Farrell L, Zarins B, Gill T. Injuries in women's professional soccer. Br J Sports Med 2005; 39 (04) 212-216 ; discussion 212–216
  • 41 Forsythe B, Knapik DM, Crawford MD. et al. Incidence of injury for professional soccer players in the United States: a 6-year prospective study of major league soccer. Orthop J Sports Med 2022; 10 (03) 23 259671211055136
  • 42 Brophy RH, Stepan JG, Silvers HJ, Mandelbaum BR. Defending puts the anterior cruciate ligament at risk during soccer: a gender-based analysis. Sports Health 2015; 7 (03) 244-249
  • 43 Forsythe B, Lavoie-Gagne OZ, Forlenza EM, Diaz CC, Mascarenhas R. Return-to-play times and player performance after ACL reconstruction in elite UEFA professional soccer players: a matched-cohort analysis from 1999 to 2019. Orthop J Sports Med 2021; 9 (05) 23 259671211008892
  • 44 The female ACL: why is it more prone to injury?. J Orthop 2016; 13 (02) A1-A4
  • 45 Griffin LY, Agel J, Albohm MJ. et al. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 2000; 8 (03) 141-150
  • 46 USA Pickleball Association. History of the game. Available at: Accessed December 12, 2023
  • 47 Kekelekis A, Nikolaidis PT, Moore IS, Rosemann T, Knechtle B. Risk factors for upper limb injury in tennis players: a systematic review. Int J Environ Res Public Health 2020; 17 (08) 2744
  • 48 Weiss H, Dougherty J, DiMaggio C. Non-fatal senior pickleball and tennis-related injuries treated in United States emergency departments, 2010–2019. Inj Epidemiol 2021; 8 (01) 34
  • 49 Rice RP, Roach K, Kirk-Sanchez N. et al. Age and gender differences in injuries and risk factors in elite junior and professional tennis players. Sports Health 2022; 14 (04) 466-477
  • 50 Minghelli B, Cadete J. Epidemiology of musculoskeletal injuries in tennis players: risk factors. J Sports Med Phys Fitness 2019; 59 (12) 2045-2052
  • 51 Fu MC, Ellenbecker TS, Renstrom PA, Windler GS, Dines DM. Epidemiology of injuries in tennis players. Curr Rev Musculoskelet Med 2018; 11 (01) 1-5
  • 52 Dines JS, Bedi A, Williams PN. et al. Tennis injuries: epidemiology, pathophysiology, and treatment. J Am Acad Orthop Surg 2015; 23 (03) 181-189
  • 53 Chung KC, Lark ME. Upper extremity injuries in tennis players: diagnosis, treatment, and management. Hand Clin 2017; 33 (01) 175-186
  • 54 Goes PK, Flores DV, Damer A, Huang BK. Shoulder and elbow injuries in adult overhead throwers: imaging review. Radiographics 2023; 43 (12) e230094
  • 55 Alrabaa RG, Lobao MH, Levine WN. Rotator cuff injuries in tennis players. Curr Rev Musculoskelet Med 2020; 13 (06) 734-747
  • 56 Bullock GS, Faherty MS, Ledbetter L, Thigpen CA, Sell TC. Shoulder range of motion and baseball arm injuries: a systematic review and meta-analysis. J Athl Train 2018; 53 (12) 1190-1199
  • 57 Posner M, Cameron KL, Wolf JM, Belmont Jr PJ, Owens BD. Epidemiology of Major League baseball injuries. Am J Sports Med 2011; 39 (08) 1676-1680
  • 58 Marigi EM, Conte S, Reinholz AK. et al. Shoulder injuries in professional baseball batters: analysis of 3,414 injuries over an 8-year period. Arthrosc Sports Med Rehabil 2022; 4 (03) e1119-e1126
  • 59 Carr II JB, McElheny KD, Corrigan A, Rowe D, Ma K, Curriero FC. The most common type, severity, and expected frequency of injuries vary by defensive position in professional baseball players. Am J Sports Med 2022; 50 (09) 2534-2541
  • 60 Douglas L, Whitaker J, Nyland J. et al. Return to play and performance perceptions of baseball players after isolated SLAP tear repair. Orthop J Sports Med 2019; 7 (03) 23 25967119829486
  • 61 Vo AM, Rogers KM, Bonner KF. Arthroscopic resection of symptomatic Bennett lesions. Arthrosc Tech 2019; 8 (12) e1463-e1467
  • 62 Thomas SJ, Paul RW, Rosen AB. et al. Return-to-play and competitive outcomes after ulnar collateral ligament reconstruction among baseball players: a systematic review. Orthop J Sports Med 2020; 8 (12) 23 25967120966310
  • 63 Desai SS, Dent CS, El-Najjar DB, Swindell HW, Popkin CA. Musculoskeletal injury in American football: a bibliometric analysis of the most cited articles. Orthop J Sports Med 2023; 11 (06) 23 259671231168875
  • 64 Kluczynski MA, Kelly WH, Lashomb WM, Bisson LJ. A systematic review of the orthopaedic literature involving National Football League players. Orthop J Sports Med 2019; 7 (08) 23 25967119864356
  • 65 Logan CA, Murphy CP, Sanchez A. et al. Medial collateral ligament injuries identified at the National Football League scouting Combine: assessment of epidemiological characteristics, imaging findings, and initial career performance. Orthop J Sports Med 2018; 6 (07) 23 25967118787182
  • 66 Doughtie M. Syndesmotic ankle sprains in football: a survey of National Football League athletic trainers. J Athl Train 1999; 34 (01) 15-18
  • 67 Kirsch JM, Burrus MT, Bedi A. Common injuries in professional football quarterbacks. Curr Rev Musculoskelet Med 2018; 11 (01) 6-11
  • 68 Cabri J, Sousa JP, Kots M, Barreiros J. Golf-related injuries: a systematic review. Eur J Sport Sci 2009; 9 (06) 353-366
  • 69 Moon H-W, Kim J-S. Golf-related sports injuries of the musculoskeletal system. J Exerc Rehabil 2023; 19 (02) 134-138
  • 70 Robinson PG, Murray IR, Duckworth AD. et al. Systematic review of musculoskeletal injuries in professional golfers. Br J Sports Med 2019; 53 (01) 13-18
  • 71 McCarroll JR. Overuse injuries of the upper extremity in golf. Clin Sports Med 2001; 20 (03) 469-479
  • 72 McHardy A, Pollard H, Luo K. One-year follow-up study on golf injuries in Australian amateur golfers. Am J Sports Med 2007; 35 (08) 1354-1360
  • 73 Gosheger G, Liem D, Ludwig K, Greshake O, Winkelmann W. Injuries and overuse syndromes in golf. Am J Sports Med 2003; 31 (03) 438-443
  • 74 Nielsen RO, Nohr EA, Rasmussen S, Sørensen H. Classifying running-related injuries based upon etiology, with emphasis on volume and pace. Int J Sports Phys Ther 2013; 8 (02) 172-179
  • 75 van der Worp MP, ten Haaf DS, van Cingel R, de Wijer A, Nijhuis-van der Sanden MW, Staal JB. Injuries in runners; a systematic review on risk factors and sex differences. PLoS One 2015; 10 (02) e0114937
  • 76 Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36 (02) 95-101
  • 77 Thijs Y, De Clercq D, Roosen P, Witvrouw E. Gait-related intrinsic risk factors for patellofemoral pain in novice recreational runners. Br J Sports Med 2008; 42 (06) 466-471
  • 78 Macintyre JG, Taunton JE, Clement DB, Lloyd-Smith DR, McKenzie DC, Morrell RW. Running injuries: a clinical study of 4,173 cases. Clin J Sport Med 1991; 1 (02) 81-87
  • 79 Vajapey S, Matic G, Hartz C, Miller TL. Sacral stress fractures: a rare but curable cause of back pain in athletes. Sports Health 2019; 11 (05) 446-452
  • 80 Rogers DL, Tanaka MJ, Cosgarea AJ, Ginsburg RD, Dreher GM. How mental health affects injury risk and outcomes in athletes. Sports Health 2023; 19 417381231179678
  • 81 van Niekerk M, Matzkin E, Christino MA. Psychological aspects of return to sport for the female athlete. Arthrosc Sports Med Rehabil 2023; 5 (04) 100738
  • 82 Poucher ZA, Tamminen KA, Sabiston CM, Cairney J, Kerr G. Prevalence of symptoms of common mental disorders among elite Canadian athletes. Psychol Sport Exerc 2021; 57: 102018
  • 83 Sarmento H, Frontini R, Marques A. et al. Depressive symptoms and burnout in football players: a systematic review. Brain Sci 2021; 11 (10) 1351
  • 84 Daley MM, Griffith K, Milewski MD, Christino MA. The mental side of the injured athlete. J Am Acad Orthop Surg 2021; 29 (12) 499-506
  • 85 Chen Y, Buggy C, Kelly S. Winning at all costs: a review of risk-taking behaviour and sporting injury from an occupational safety and health perspective. Sports Med Open 2019; 5 (01) 15
  • 86 Conti C, di Fronso S, Pivetti M, Robazza C, Podlog L, Bertollo M. Well-come back! Professional basketball players perceptions of psychosocial and behavioral factors influencing a return to pre-injury levels. Front Psychol 2019; 10: 222
  • 87 Gianakos AL, Abdelmoneim A, Kerkhoffs G, Mulcahey MK. Rehabilitation and return to sport of female athletes. Arthrosc Sports Med Rehabil 2022; 4 (01) e247-e25
  • 88 Secrist ES, Bhat SB, Dodson CC. The financial and professional impact of anterior cruciate ligament injuries in National Football League athletes. Orthop J Sports Med 2016; 4 (08) 23 25967116663921
  • 89 Eliakim E, Morgulev E, Lidor R, Meckel Y. Estimation of injury costs: financial damage of English Premier League teams' underachievement due to injuries. BMJ Open Sport Exerc Med 2020; 6 (01) e000675
  • 90 Mayer J, Burgess S, Thiel A. Return-to-play decision making in team sports athletes. A quasi-naturalistic scenario study. Front Psychol 2020; 11: 1020
  • 91 Shrier I, Charland L, Mohtadi NG, Meeuwisse WH, Matheson GO. The sociology of return-to-play decision making: a clinical perspective. Clin J Sport Med 2010; 20 (05) 333-335