Editorial Commentary: Return-to-Play and Return-to-

Sport Metrics Require Standardization

Matthew T. Rasmussen, M.D., Dustin R. Lee, M.D., and
David E. Hartigan, M.D., Editorial Board

It is commonly accepted that a primary goal of orthopaedic surgeries is to restore function for our patients, and to achieve
this goal, many research studies aim to define outcomes that set a benchmark for knowing whether this mark is achieved.
Unfortunately, return-to-play (RTP) and return-to-sport (RTS) metrics are often used without any strict definition or
standardization. They often rely on patient recall, which could be biased, and often fail to distinguish level of performance
after return to activity. Moreover, different patients have different activity levels and goals; RTP or RTS in a professional is
obviously different than in someone who walks in a pool for exercise. The reasons that a patient does not RTS also bear
consideration. Reasons could include physical sensations, psychological experiences, lifestyle and social factors, injury at
another site, and other causes. It is important that wedas both surgeons and researchersdbecome aware of the in-
consistencies created with RTP/RTS metrics and ensure we are monitoring the right outcomes, so our patients achieve the
best results possible. In the end, we must establish a trusting relationship with our patients to help manage their
expectations and get them back into the game safely.

See related article on page XXX

F irst, we would like to applaud Shirinskiy, Rutgers,

Sierevelt, Priester-Vink, Ring, van den Bekerom,
and Verweij in undertaking a research inquisition into
competition/performance level and a 21% RTS in the
same sport at the same or higher competition/perfor-
mance level.2 The only benefit in using the first
the common metrics, return to sport (RTS) and return instance as the primary outcome is to make us feel
to play (RTP) that many of us take for granted, and better as surgeons and does nothing to improve the
highlighting how difficult this measurement can be in overall well-being of the athlete. O’Connor et al.
“Ill-Defined Return to Sport Criteria and Inconsistent concluded in their systematic review and meta-analysis
Unsuccessful Return Rates Caused by Various Reasons of RTP after hip arthroscopy that there is significant
not Necessarily Related to Treatment After Superior variability among RTP protocols, which is mainly due to
Labral Treatment: A Systematic Review.”1 Just like a lack of standardization, as many rehabilitation pro-
one’s memory can be extremely subjective, so can the tocols rely on dogma and expert opinion.3 These find-
criteria used to define RTS and RTP protocols. Often- ings carry over to the knee literature as well. Recent
times, the question of whether the individual RTS or studies have attempted to evaluate common metrics
RTP is simplified down to a binary question of either used in RTS protocols. Their findings? Certain tests,
“yes” or “no.” This has led to incredibly varied RTP and such as the individual hop and strength tests that are
RTS outcomes across the literature. For example, routinely used in ACLR RTS protocols, appear to have
Wörner et al. reported 89% RTS after hip arthroscopy limited and inconsistent value.4 Return to preinjury
for FAI when patients were asked in a more general level of play is even more ludicrous, given patients
and traditional way (return to participation in some sort indicated for a biceps tenodesis/tenotomy are often
of sport or exercise). However, they reported only a weekend warriors who are on the back nine of their
28% RTS in the same preinjury sport at a lower careers. Unless we can offer our patients a ride in a time
machine or a sip from the fountain of youth, we are
better off discovering a more effective means of
Bloomington, Minnesota measuring our success.
Ó 2024 by the Arthroscopy Association of North America
0749-8063/242018/$36.00
However, in light of all this, we would like to
https://doi.org/10.1016/j.arthro.2024.12.003 commend Shirinskiy et al. on taking the time to not

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2024: pp 1-3 1
2 EDITORIAL COMMENTARY

only investigate this topic but to also spend the time to advancements in surgical techniques and updated
screen the full texts of 106 articles to identify the 45 treatment algorithms since older studies have been
studies that were included in their systematic review.1 published. Clinical outcome measures are instrumental
The authors strove to focus on a very specific topic in guiding treatment approaches and certainly relevant
being superior labral pathology but opened up a Pan- here as we continue to lack clear high-level evidence
dora’s box, as they looked to determine whether for surgical best practice treatment. Unfortunately, as
patients achieved relevant outcomes following different highlighted by the authors, some of the main challenges
treatment modalities. Their primary hypothesis was are determining the best clinical outcome measure to
there would be discrepancies in the criteria for RTS gauge surgical response (clearly, RTP is flawed and may
between studies, substantial variability in the rates of no not be it) and honing in on specific indications in future
return to sport (nRTS), and no return to preinjury level studies to limit wide variability in recorded outcome
(nRTPL) within and between treatments, and that measures (e.g., young vs old; throwing athletes vs
reasons for nRTS would be related to both physical and nonthrowing athletes).9
psychological factors. The biggest finding was that not Many advancements have been made in arthroscopic
even 1 of those studies provided a definition for surgery, which has led to increased opportunities to
determining RTS and only 2 defined RTPL. Rates for enhance quality of life metrics for our patients. How-
nRTS and nRTPL were just as inconsistent, ranging ever, we have fallen short when it comes to measuring
from 0 to 100% for different treatment modalities. The our success via RTP metrics.10,11 This should come as no
authors built a strong methodology in accordance with surprise as surgeons are certainly the type to be quick to
PRISMA and use of the MINORS tool to assess for bias. pull out a tape measure. However, before we brandish
They thoroughly reviewed the literature and tried to our pocket rulers, we need to first define what it is that
create categories of reasons why patients did not RTS: we are actually measuring and then determine how
physical sensations, psychological experiences, lifestyle best to quantify it. Lastly, we need to ask ourselves the
and social factors, injury at another site, and other most important question of all: are we making our
causes. patients better by allowing them to step off the sidelines
Essentially when interpreting the data from the cur- and back into the game of life? We should continue to
rent study and applying it to our practices, we need to make steady progress as long as we stick to the fun-
be wary of results that may not be measuring the cor- damentals by establishing a clear diagnosis, utilizing
rect outcome and that we are sometimes trying to multidisciplinary collaboration with physical therapy
compare apples to oranges and treating vastly different colleagues to maximize nonoperative management12
cohorts the same. It may be that we have not found the and reserve operative management for those who
correct indications yet or we just need to treat every- have persistent symptoms after comprehensive
body the same (i.e., biceps tenodesis for all).5 Looking nonsurgical management.
closely at the studies analyzed within the systematic
review, one will find that some had predominantly
overhead athletes, some had patients with mean ages of
Disclosures
The authors declare the following financial interests/
30 or 40 years old (which is the intersection between
personal relationships which may be considered as
indications for repair vs tenodesis),6 and some where
potential competing interests: D.E.H. reports consulting
patients were predominantly competitive/professional
versus others where the majority was recreational. Yogi or advisory work for Arthrex and serves on the editorial
board of the Journal of Arthroscopic and Related Surgery.
Berra was either onto something or on something
All other authors (M.T.R., D.R.L.) declare that they
when he said baseball is 50% physical and 90% mental.
have no known competing financial interests or per-
Returning to sport after injury is no different7 and
sonal relationships that could have appeared to influ-
requires surgeons first to be physicians and establish a
ence the work reported in this article.
trusting doctor-patient relationship to help manage
patient expectations and ultimately get them off the
bench and back into the game.
Studies as old as 1993 were included, and both in- References
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return to sport criteria and inconsistent unsuccessful
changed, as emerging evidence has shown a relatively
return rates caused by various reasons not necessarily
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we must take some responsibility to improve in- following hip arthroscopy is a matter of definition? Br J
dications and surgical techniques. There have been Sports Med 2018;52:1475-1476.
 EDITORIAL COMMENTARY 3

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