Parameters to Assess a Patient's Return to Sports

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by Amol Saxena, DPM

Basic guidelines to return an athlete to running sports include assessment of pain level, range-of-motion and strength. Basically, the patient must have no pain with daily activities. Some initial onset of activity stiffness or soreness may be present for long periods post-injury, and this is not uncommon to persist for up to a year. However, the soreness or stiffness should get better with activity.

Pain accompanied by swelling is never normal. There can be mild pain with palpation to either the Achilles tendon or the insertion. Ankle range-of-motion should be within 5° of the contra-lateral limb's ankle but adequate to perform the necessary activities. Atrophy should be less than 6 mm on the affected limb. (Saxena, A. Return to athletic activity after foot and ankle surgery: a preliminary report on select procedures. J Foot Ankle Surg 39(2): 114-119, 2000)

Strength assessment includes pain-free hopping and 20 single-leg heel raises. Generally, 45 seconds of consistent activity repeated five times, is a good guideline for allowing a patient to return to sport. A typical regimen has the patient progress to being able to perform five sets of 25 single-leg heel raises on the affected limb as a barometer. Standard vertical leap testing, a single-leg three hop test and a 20-yard lateral shuttle test should be assessed in the athletic population without return to sport unless all limitations are within 80 percent of the non-affected extremity. (Guillet & Saxena, “Rehabilitation of the Achilles Tendon”, submitted for publication.) A patient should always get clearance to return to running or sports from his or her doctor, therapist or trainer.

A typical return to a running program would involve the patient doing the following:

1. Alternate walking and jogging for two minutes each, completing four cycles (16 minutes of total activity).
2. Take a rest day and reassess two days later.
3. If the walking and jogging cycles were challenging, repeat this every other day for a week. If it was far too easy, alternate three minutes jogging with one minute walking, again for four cycles.
4. Reassess and repeat this every other day for a week.
5. Then, begin with the following running schedule outlined in the table below.

Gradual Progression of Running After Injury or Surgery

Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
15 min	Rest	15 min	Rest	20 min	Rest	20 min
20 min	Rest	25 min	Rest	25 min	Rest	30 min
20 min	Rest	30 min	Rest	40 min	Rest	40 min
20 min	Rest	40 min	Rest	50 min	Rest	50 min
20 min	Rest	50 min	30 min	Rest	60 min	20 min

Often, patients with purely soft-tissue problems fare better with activity more often, versus those with bony involvement that may need to maintain activity every other day for longer periods of time. It is recommended that the patients maintain their flexibility and strengthening regimen, along with any other therapy modalities such as heat prior and ice after, until they are up to their typical activity level, which can take up to one year.