Return-to-Play Protocols for Various Injuries in Skeletally Immature Athletes: A Systematic Review

Sports-related injuries are a commonly encountered orthopedic complaint in the United States. Return-to-play (RTP) protocols are in place to guide safe progression through injury recovery and offer a stepwise timeline for resuming athletic activity. In pediatric athletes, this is increasingly important in the context of disrupted growth, muscular and skeletal imbalances, and heightened social importance of team-based activities. Despite this, there is limited literature defining a concise RTP protocol for pediatric athletes suffering from various common sports-related injuries. The primary aim of this investigation was to systematically review and synthesize existing RTP protocols for the most commonly encountered pediatric athletic injuries based on the currently available literature at this time. The literature search for this analysis was performed in the Biomedical Reference Collection, Cochrane Library, CINAHL, and MEDLINE. After inclusion criteria were met and article screening was performed, a total of 36 articles were selected for further qualitative analysis. This review reaffirmed the lack of standardized RTP protocols for pediatric sports injuries. A total of 51% of the protocols analyzed involved anterior cruciate ligament (ACL) tears and concussions, both of which hold highly variable RTP guidelines. For ACL injuries, this review determined an average of 9-12 months of recovery is the most commonly utilized timeframe; however, younger athletes may require upwards of 14-16 months depending on physeal maturation. While concussion protocols are relatively accepted across athletic disciplines, there are possible improvements available, including sport-specific testing such as the Gapski-Goodman Test, provocation tests, or ImPACT scoring. RTP protocols are highly variable depending on a variety of factors such as the type of provider performing the assessment, age of the patient, and the sport involved. Further research is necessary to further delineate the nuanced differences in safe RTP guidelines for injuries seen in each sport.