European Journal of Sport Science

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tejs20

Return to play protocols for musculoskeletal

upper and lower limb injuries in tackle-collision
team sports: A systematic review

A. Grethe Geldenhuys, Theresa Burgess, Stephen Roche & Sharief Hendricks

To cite this article: A. Grethe Geldenhuys, Theresa Burgess, Stephen Roche & Sharief
Hendricks (2022) Return to play protocols for musculoskeletal upper and lower limb injuries
in tackle-collision team sports: A systematic review, European Journal of Sport Science, 22:11,
1743-1756, DOI: 10.1080/17461391.2021.1960623

To link to this article: https://doi.org/10.1080/17461391.2021.1960623

View supplementary material

Published online: 13 Aug 2021.

Submit your article to this journal

Article views: 1544

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=tejs20
EUROPEAN JOURNAL OF SPORT SCIENCE
2022, VOL. 22, NO. 11, 1743–1756
https://doi.org/10.1080/17461391.2021.1960623

REVIEW

Return to play protocols for musculoskeletal upper and lower limb injuries in
tackle-collision team sports: A systematic review
a b,c d a,e
A. Grethe Geldenhuys , Theresa Burgess , Stephen Roche and Sharief Hendricks
a
Division of Exercise Science & Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town,
Newlands, South Africa; bDivision of Physiotherapy, Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University
of Cape Town, Cape Town, South Africa; cCentre for Medical Ethics and Law, Faculty of Medicine and Health Sciences, Stellenbosch University,
Cape Town, South Africa; dOrthopaedic Research Unit, Department of Orthopaedic Surgery, Groote Schuur Hospital, Faculty of Health
Sciences, University of Cape Town, Cape Town, South Africa; eCarnegie Applied Rugby Research (CARR) centre, Institute for Sport Physical
Activity and Leisure, Leeds Beckett University, Leeds, England

ABSTRACT KEYWORDS
Athletes in tackle-collision teams are at high risk of musculoskeletal injuries resulting in absence Return to sport;
from play due to the high impact nature of the sport. There is a paucity of research to guide management; assessment;
the management and assessment methods needed to facilitate the return to play (RTP) process. rugby; American football;
Australian rules football
This review aimed to describe, synthesise and evaluate RTP protocols implemented for
musculoskeletal injuries in tackle-collision teams. A systematic search of Scopus, PubMed, Web
of Science and Ebsco Host was conducted for RTP management protocols and assessment
modalities following upper and lower limb musculoskeletal injuries in tackle-collision team
athletes. Prospective and retrospective quantitative controlled trials, cohort, case–control, case-
series and cross-sectional observation studies published between January 2000 and March 2020
were considered. The main outcome measures were the proportion of athletes to RTP,
associated time-loss and reinjury risk. 5265 articles were screened. 34 studies met the eligibility
criteria of which 23 involved management and 11 assessment modalities. Management involved
surgical or conservative strategies along with exercise-based rehabilitation. Assessment
modalities included radiographic assessment, clinical evaluation and subjective ratings.
Promising RTP management included progressive weight-bearing and exercised-based
rehabilitation for ankle sprains as well as surgery, the use of a sling and exercise-based
rehabilitation for shoulder instability. MRI scans showed promise in predicting time-loss
following hamstring and calf strains in tackle-collision athletes. There are currently no clear
guidelines for RTP after musculoskeletal injuries in tackle-collision sports. Future research should
investigate efficient management strategies evaluated through valid and reliable assessment
methods to better guide clinicians.

Introduction
Rugby football (union, league and sevens), American
football and Australian rules football are popular team
sports characterised by repeated cycles of high-intensity
running and physical-technical contesting of the tackle
and other collisions (Johnston, Gabbett, & Jenkins,
2014; Naughton et al., 2020). For example, in rugby
union, the tackle is contested approximately 10–20
times per match depending on playing position
(Burger, Lambert, & Hendricks, 2020). To meet the
demands of the sport and compete successfully,
tackle-collision sport athletes require well-developed
physical qualities (aerobic fitness, speed, muscular
strength, power, and agility), and high levels of technical
proficiency (Burger et al., 2016; Johnston et al., 2014).
The nature of tackle-collision team sports presents an
above-average overall risk of injury (Scase et al., 2012;
Williams, Trewartha, Kemp, & Stokes, 2013) compared
to other popular team sports such as football (Junge,
Cheung, Edwards, & Dvorak, 2004). For example, in
rugby union players 72–80% of injuries occurred due
to contact mechanisms (Bitchell, Mathema, & Moore,
2020).
Upper and lower limb musculoskeletal injuries rep-
resent the highest burden (i.e. injury incidence x mean
days absent per injury) with high rates of primary and
subsequent injuries resulting in absence from training
and matches (i.e. time-loss) (Scase et al., 2012; Williams
et al., 2013). For example, in Australian rules football,
knee and shoulder injuries were significantly associated

CONTACT A. Grethe Geldenhuys aldagrethegeldenhuys@gmail.com Division of Exercise Science & Sports Medicine, Department of Human Biology,
Faculty of Health Sciences, University of Cape Town, PO Box 115, Boundary Road, Newlands, Cape Town, 7725, South Africa
Supplemental data for this article can be accessed online at https://doi.org/10.1080/17461391.2021.1960623.
© 2021 European College of Sport Science
1744 A. G. GELDENHUYS ET AL.
with missing on average four to five matches with a rein-
jury rate of 12.8% reported per club (Scase et al., 2012).
Time-loss due to injury may affect athletes physically,
psychologically and financially and has the potential to
negatively impact team performance (Williams et al.,
2013, 2016). Returning athletes to play as safely and
efficiently as possible while promoting optimal perform-
ance is therefore crucial in these sports (Ardern et al.,
2016).
To improve the practice of returning athletes to sport,
a number of protocols and a consensus statement have
been published (Ardern et al., 2016; Shrier, 2015). In the
consensus statement, return to play (RTP) is described as
the continuum of multi-factorial decisions that facilitates
athletes’ re-integration into the sporting environment
(Ardern et al., 2016). The RTP process requires effective
injury management with different treatment modalities
and exercise-based rehabilitation (Ardern et al., 2016;
Orchard, Best, & Verrall, 2005). Moreover, valid and
reliable assessment techniques are essential to guide
decisions during the RTP process through monitoring
progress and potentially predicting re-injury risk
(Ardern et al., 2016; Orchard et al., 2005).
Given the potential long-term damage a mismanaged
head injury may cause, RTP research of management
and assessment in tackle-collision sports have largely
focused on concussions (Kerr et al., 2016). Musculoskele-
tal injuries in tackle-collision sports represent a very high
over-all burden, as described above, with relatively less
research in comparison to concussion (Scase et al.,
2012; Williams et al., 2013). Although studies on RTP fol-
lowing musculoskeletal injuries have been conducted,
management and assessment methods have not been
synthesised to allow clinical guidance during the RTP
process.
Therefore, the purpose of this review is to describe and
synthesise management protocols (Part One) and assess-
ment modalities (Part Two) implemented during RTP fol-
lowing upper and lower limb musculoskeletal injuries in
tackle-collision team athletes and to determine its
impact on the RTP rate, time-loss and reinjury risk.
Methods
Protocol and registration:
The review was conducted in accordance with the Pre-
ferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines (Moher, Liberati,
Tetzlaff, & Altman, 2009). The protocol is registered on
the International Prospective Register of Systematic
Reviews (PROSPERO) with the registration number:
CRD42020173352.
Search strategy:
The databases of PubMed/Medline, Web of Science,
Ebsco Host and Scopus were searched for relevant articles
published between January 2000 and March 2020. The
following key search terms were used: (“return to play”
OR “return to sport” OR “return to performance” OR
“return to participation” OR “return to training” OR
“return to function” OR “return to competition”) AND
(“collision sport” OR “contact sport” OR “impact sport”
OR “tackl*” OR “rugby” OR “rugby union” OR “rugby
league” OR “rugby sevens” OR “American football” OR
“Gaelic football” OR “Australian rules football” OR “Cana-
dian football”). Results from all four databases were com-
bined into an Excel sheet. After removal of duplicates, all
titles and abstracts were screened according to the eligi-
bility criteria stipulated below by one author (GG).
Eligibility criteria
Considering that this is the first systematic review on RTP
management protocols and assessment modalities for
musculoskeletal injuries in tackle-collision sports, we
decided to be inclusive in terms of the study design cri-
teria. Studies were included if they met the following
criteria:
(1) Quantitative controlled trials, cohort, case–control,
case-series and cross-sectional observational (retro-
spective and prospective) studies published
between January 2000 and March 2020.
(2) The population considered was tackle-based col-
lision team sport athletes including rugby union,
rugby league, rugby sevens, American football,
Gaelic football, Australian rules football and Cana-
dian football (athletes of any age, sex or level of
experience included) who experienced a musculos-
keletal injury to the upper or lower limb (including
injuries or damage to bone, cartilage, ligaments,
tendons or muscles).
(3) Interventions involved management protocols with
a rehabilitation component (Part One) or assessment
modalities (Part Two) to facilitate RTP decisions.
(4) The primary outcome measures were the proportion
of athletes who returned to play, time-loss prior to
RTP and reinjury rates. Secondary outcome measures
included associated symptomatic, functional,
psychological and performance characteristics.
Studies were excluded for the following reasons:
(1) Unavailability in English.
(2) Inability to retrieve full text (after all avenues for
access investigated).

(3) Single case studies and reviews.
(4) Studies with combined sport populations where data
for one or more of the sporting populations could not
be differentiated from the reported results.
The full texts of all remaining articles were indepen-
dently reviewed by two authors (GG & SH) for eligibility.
Manual cross-checking of the reference lists of included
articles were performed to identify further studies for
potential inclusion. Any differences in opinion were
resolved through discussion including third party invol-
vement as required.
Data extraction
Data extraction was documented in Microsoft Excel. The
following data were captured for all identified articles:
authors, year of publication, journal of publication, title
and source. After full text screening, the following
data were captured: study design, sample size, partici-
pant characteristics (age and sex), sporting code(s),
level of competition, body region and injury, interven-
tion, outcome measures and the effect of the
intervention.
Data synthesis
Studies were categorised as either management strat-
egies (Part One) or assessment techniques (Part Two) uti-
lised during the RTP process. Studies were further
divided by the location of injuries with broad divisions
between the upper and lower limbs. Due to the
heterogeneity of data meta-analysis could not be
performed.
Quality appraisal
Quality analyses of each cohort, case–control and other
observational studies were performed with the Downs &
Black Quality assessment tool (Downs & Black, 1998).
This scale was modified slightly by changing the weight-
ing of item 27 to one instead of five points, which is in
line with previous literature (O’Connor et al., 2015).
Studies were rated as “excellent” for scores of 24–28,
“good” for scores of 19–23, “fair” for scores of 14–18
and “low” for any scores lower than 14 out of a total of
28 (O’Connor et al., 2015).
Quality analysis of each case series was conducted
through an instrument developed and validated
specifically for this study design (Yang et al., 2009).
Studies were rated as “excellent” for scores from 12–
13, “good” for scores from 9–11, “fair” for scores from
five to eight and “low” for scores under five (Yang
et al., 2009).
EUROPEAN JOURNAL OF SPORT SCIENCE 1745
Results
Study selection
The initial electronic search of the four databases pro-
duced 6503 studies. An additional 18 studies were ident-
ified through manual cross-checking. After removal of
duplicates 5265 studies remained. Title screening
reduced the list to 922 articles. After screening abstracts,
144 studies remained. Following full text screening, 34
articles were included for the final review. The main
reasons for exclusion of articles during full text screening
were combined sport populations, lack of rehabilitation
components in management and/or non-musculoskele-
tal injuries. The screening and selection processes are
presented in a PRISMA flow diagram (Figure 1).
Description of included studies
The final 34 studies involved athletes from American
football (n = 14), Australian rules football (n = 7), rugby
union (n = 5) and rugby league (n = 2) with the remain-
der unspecified or combined rugby codes (n = 6). The
vast majority (n = 28) of studies included professional
athletes either exclusively or as part of a combined
population. No studies performed in Canadian football,
Gaelic football or rugby sevens met the eligibility criteria.
In total, 2140 male, 6 female (from two mixed samples)
and 376 athletes of unknown sex were included.
Management strategies were investigated in 23
studies with a total of 702 participants. The majority of
studies were case series (n = 14), followed by cohort (n
= 7) and case–control (n = 2) designs. These manage-
ment strategies included either surgical or conservative
modalities followed by exercise-based rehabilitation.
The mean follow-up period ranged from 3 months to
15 years when reported.
Assessment methods were investigated in 11 studies
with a total of 1820 participants. The majority were
cohort designs (n = 6) followed by observational (n = 3)
and case series (n = 2) designs. Assessment modalities
included radiographic techniques, clinical assessment
and subjective ratings. Many of these were retrospective
studies providing data-collection periods rather than
follow-up periods which ranged from three weeks to
15 years.
Return to play criteria utilised across studies varied
widely. In general, this included one or more of the fol-
lowing factors: achievement of specific ROM, strength
and other rehabilitation goals, healing based on
imaging techniques, set time-frames and/or discussion
among management team members (Badge, Tambe, &
Funk, 2009; Cardone, Brown, Roberts, Saies, & Hayes,
1746 A. G. GELDENHUYS ET AL.
Figure 1. PRISMA flow diagram.
Table 1. Characteristics of studies investigating RTP protocols following musculoskeletal injuries in tackle-collision team sports.
Management protocols for
lower limb musculoskeletal
injuries
Number of studies 13
Total participants 293
Distribution of joints Ankle and foot: 53.8%
(%) Knee: 23.1%
Hip: 15.4%
Thigh: 7.7%
Distribution of sexes Male: 84.0%
(%) Unspecified: 16.0%
Mean age range (in 19.3–27.2 years
years)
Distribution of American football: 61.5%
different sports (%) Rugby codes: 38.5%
Distribution of level Professional: 61.5%
of competition (%) Combined: 30.8%
Unknown: 7.7%
Distribution of Fair: 38.5%
quality ratings (%) Good: 30.8%
Low: 23.1%
Excellent: 7.7%
Management protocols for Assessment protocols for
upper limb musculoskeletal Assessment protocols for lower upper limb musculoskeletal
injuries limb musculoskeletal injuries injuries
10 10 1
409 1758 62
Shoulder: 90.0% Thigh muscles: 60.0% Shoulder: 100.0%
Thumb: 10.0% Lower leg muscles: 20.0%
Ankle: 10.0%
Knee: 10.0%
Male: 60.1% Male: 90.5% Male: 91.9%
Unspecified: 39.9% Unspecified: 9.4% Female: 8.1%
Female: 0.001%
17.7–27.9 years 16–27.2 years 26.0–26.0 years
Rugby codes: 60.0% Australian rules football: 60.0% Rugby codes: 100.0%
American football: 30.0% American football: 30.0%
Australian rules football: Rugby league: 10.0%
10.0%
Combined: 60.0% Professional: 80.0% Professional: 100.0%
Professional: 40.0% High school: 10.0%
Competitive/
unspecified: 10.0%
Good: 70.0% Good: 80.0% Good: 100.0%
Excellent: 20.0% Excellent:10.0%
Low: 10.0% Fair: 10.0%

2002; Latham, Goodwin, Stirling, & Budgen, 2017;
Moorman et al., 2003; Neyton et al., 2012; Osbahr
et al., 2013; Ranalletta et al., 2018; Samra et al., 2015;
Takazawa et al., 2016; Toritsuka, Horibe, Hiro-oka, Mit-
suoka, & Nakamura, 2004; Yagishita, Enomoto, Takazawa,
Fukuda, & Koga, 2019).
The quality ratings of studies ranged from “low” to
“excellent” with the majority (n = 19) rated as “good”.
The main reasons for lower ratings in cohort and observa-
tional studies were lack of randomisation (all studies) fol-
lowed by lack of blinding, convenience sampling and/or
unrepresentative management centres in some studies.
The main reasons for lower ratings in case series were
inappropriate sampling (often non-consecutive cases),
assessment subject to bias (mostly due to lack of blind-
ing) or insufficient information to assess other criteria.
Combined study characteristics are presented in
Table 1. (The details of each study are captured in Sup-
plementary Files).
Part One
Return to play protocols following lower limb
injuries
Management protocols for ankle sprains
Protocol description. Surgical repair (Latham et al.,
2017), single platelet rich-plasma (PRP) injections
(Samra et al., 2015) and conservative management
with taping (Osbahr et al., 2013) were investigated to
facilitate RTP following ankle syndesmosis injuries
(Latham et al., 2017; Osbahr et al., 2013; Samra et al.,
2015) and lateral ligament sprains (Osbahr et al., 2013).
Pain and swelling were managed through rest, ice, com-
pression and elevation (RICE) in all cases (Latham et al.,
2017; Osbahr et al., 2013; Samra et al., 2015).
Each modality was accompanied by a rehabilitation
protocol initially involving immobilisation (Latham
et al., 2017; Samra et al., 2015) where indicated
(Osbahr et al., 2013) followed by progressive weight-
bearing (WB) (Latham et al., 2017; Osbahr et al., 2013;
Samra et al., 2015). Two studies included exercises for
ankle range of motion (ROM) and strengthening of adja-
cent muscle groups (Latham et al., 2017; Osbahr et al.,
2013). Later phases involved sport specific drills
(Latham et al., 2017; Samra et al., 2015), proprioception
(Latham et al., 2017; Osbahr et al., 2013), functional
and plyometric exercises (Latham et al., 2017) in selected
studies. Manual therapy and subtalar mobilisations were
also included in one study (Latham et al., 2017).
Return to play rates, time-loss and reinjury. All ath-
letes successfully returned to play in these studies
EUROPEAN JOURNAL OF SPORT SCIENCE 1747
(Latham et al., 2017; Osbahr et al., 2013; Samra et al.,
2015). The average time-loss was shortest for lateral liga-
ment sprains (Osbahr et al., 2013), followed by conserva-
tively managed (Osbahr et al., 2013) and surgically
managed (Latham et al., 2017) syndesmosis injuries.
The only study to include a control group for compari-
son reported that the addition of a PRP injection to
usual care resulted in significantly shorter RTP times
(Samra et al., 2015). This was accompanied by signifi-
cantly lower pain ratings, better power and agility test
performance and lower fear-avoidance behaviours
(Samra et al., 2015). A syndesmosis sprain reinjury rate
of 5% and a lateral ankle sprain reinjury rate of 7%
were reported in athletes in the same season (Osbahr
et al., 2013). None of the remaining studies reported
recurrence (Latham et al., 2017; Samra et al., 2015).
Management protocols for other ankle and foot
injuries
Protocol description. Surgical repair followed by pro-
gressive WB and rehabilitation were investigated in ath-
letes presenting with anterior ankle impingement
(McCrum, Arner, Lesniak, & Bradley, 2018), superficial
deltoid complex avulsion and fracture (Hsu, Lareau, &
Anderson, 2015), hallux valgus (Smith & Waldrop,
2018), and Jones fracture (Lareau, Hsu, & Anderson,
2016) respectively. Rehabilitation protocols involved
similar components to the above studies with ROM,
mobilisations, strengthening, balance, power, agility,
running and sport-specific drills included (Hsu et al.,
2015; Lareau et al., 2016; McCrum et al., 2018; Smith &
Waldrop, 2018).
Return to play rates, time-loss and reinjury. All ath-
letes with anterior ankle impingement (McCrum et al.,
2018) and Jones fractures (Lareau et al., 2016) returned
to play at a competitive level, compared to 86% of
those with deltoid avulsions and fractures (Hsu et al.,
2015) and 73% of those with hallux valgus (Smith &
Waldrop, 2018). The majority of those who failed to
RTP were reportedly due to unrelated reasons (Hsu
et al., 2015; Smith & Waldrop, 2018). Reinjury rates
were only reported for athletes with Jones fractures
with 12% suffering refractures (Lareau et al., 2016).
Management protocols for knee injuries
Protocol description. In the knee, hyperbaric oxygen
therapy for grade 2 medial collateral ligament (MCL)
sprains (Yagishita et al., 2019), surgical reconstruction
of anterior cruciate ligament (ACL) sprains (Takazawa
et al., 2016) and conservative management of posterior
cruciate ligament (PCL) sprains were investigated to
facilitate RTP in tackle-collision sport athletes (Toritsuka
1748 A. G. GELDENHUYS ET AL.
et al., 2004). The rehabilitation protocols involved pro-
gressive WB and quadriceps strengthening (Takazawa
et al., 2016; Toritsuka et al., 2004; Yagishita et al.,
2019). In addition, knee ROM, strengthening of sur-
rounding areas (Toritsuka et al., 2004; Yagishita et al.,
2019), functional training and sport specific drills (Taka-
zawa et al., 2016) were included in selected studies.
Return to play rates, time-loss and reinjury. All ath-
letes with MCL injuries and the majority (88.5%) of ath-
letes with ACL reconstruction and conservatively
managed PCL injuries (75%) could RTP at the same
level as pre-injury (Takazawa et al., 2016; Toritsuka
et al., 2004; Yagishita et al., 2019). Time-loss was lowest
for athletes with MCL injuries and longest for athletes
with ACL injuries (Takazawa et al., 2016; Toritsuka
et al., 2004; Yagishita et al., 2019). Furthermore, athletes
with MCL injuries receiving hyperbaric oxygen therapy
in addition to rehabilitation could RTP significantly
faster with lower pain ratings during walking and
running compared to controls (Yagishita et al., 2019).
Only one study reported recurrence rates with ACL
graft rupture reported in 15.4% of cases (Takazawa
et al., 2016).
Management protocols for hamstring injuries
One study investigated the use of PRP injections along-
side rehabilitation compared to rehabilitation only for
hamstring strains in American football players (Rettig,
Meyer, & Bhadra, 2013). No significant differences in
time-loss prior to RTP were detected and no reinjuries
occurred in either group (Rettig et al., 2013).
Management protocols for hip injuries
Protocol description. Return to play was investigated in
American football players with two hip related con-
ditions namely femoroacetabular impingement (FAI)
managed with surgical repair and posterior hip subluxa-
tion managed with aspiration and protected WB
(Menge, Bhatia, McNamara, Briggs, & Philippon, 2017;
Moorman et al., 2003). The post-operative rehabilitation
protocol involved passive ROM progressed to active-
assisted ROM (AAROM) and finally active ROM (AROM)
as well as strengthening and endurance training,
similar to those previously described for the knee and
ankle (Menge et al., 2017). A progressive return to
activity (details unavailable) was performed following
hip aspiration (Alonso, Hekeik, & Adams, 2000).
Return to play rates, time-loss and reinjury. 87% of
athletes with FAI and 75% of athletes with posterior sub-
luxation returned to competitive American football
(Menge et al., 2017; Moorman et al., 2003). This was
possible after 13 weeks for the latter study with the
time-loss unspecified in the prior study. Reinjury rates
were not reported (Menge et al., 2017; Moorman et al.,
2003).
Return to play following upper limb injuries
Management protocols for shoulder instability
Protocol description. Six studies investigated RTP fol-
lowing glenohumeral joint (GHJ) instability with surgical
management followed by a sling (Arner, McClincy, &
Bradley, 2015; Calvisi, Goderecci, Rosa, & Castagna,
2019; Kawasaki et al., 2018; Neyton et al., 2012;
Pagnani & Dome, 2002; Ranalletta et al., 2018). Each
study involved variants of shoulder stabilisations
namely arthroscopic Bankart repair, Bristow procedure
with Bankart repair, arthroscopic stabilisation, modified
Latarjet and Latarjet-Patte surgery (Arner et al., 2015;
Calvisi et al., 2019; Kawasaki et al., 2018; Neyton et al.,
2012; Pagnani & Dome, 2002; Ranalletta et al., 2018).
The rehabilitation protocols in the majority of studies
started with PROM (Arner et al., 2015; Kawasaki et al.,
2018; Neyton et al., 2012; Pagnani & Dome, 2002; Ranal-
letta et al., 2018) (83.3% of studies) followed by AAROM
and strengthening (66.7% of studies) (Arner et al., 2015;
Kawasaki et al., 2018; Pagnani & Dome, 2002; Ranalletta
et al., 2018). AROM were included in all studies (Arner
et al., 2015; Calvisi et al., 2019; Kawasaki et al., 2018;
Neyton et al., 2012; Pagnani & Dome, 2002; Ranalletta
et al., 2018). Activities of daily living (ADL) (Kawasaki
et al., 2018; Neyton et al., 2012), proprioceptive neuro-
muscular facilitation (PNF) (Calvisi et al., 2019; Pagnani
& Dome, 2002), plyometrics (Pagnani & Dome, 2002),
stretching (Calvisi et al., 2019) as well as open and
closed chain exercises (Badge et al., 2009) were included
in selected protocols. In addition, most protocols pro-
gressed to include running (Neyton et al., 2012;
Pagnani & Dome, 2002; Ranalletta et al., 2018) and/or
sport specific drills (Badge et al., 2009; Kawasaki et al.,
2018; Pagnani & Dome, 2002).
Return to play rates, time-loss and reinjury. The ability
to RTP at pre-injury level was possible for over 90% of
rugby players after 5–6 months with GHJ instability in
three studies respectively (Calvisi et al., 2019; Kawasaki
et al., 2018; Ranalletta et al., 2018). Likewise, 89.7% of
American football players could RTP at competitive
level (Pagnani & Dome, 2002), although the time-loss
prior to return was not described. In contrast, lower pro-
portions of rugby union (64.7%) (Neyton et al., 2012) and
American football players (78.6%) (Arner et al., 2015)
returned at the same level of play after a range of 5–7
months. Reinjury rates varied from none (Neyton et al.,
 EUROPEAN JOURNAL OF SPORT SCIENCE 1749

2012; Ranalletta et al., 2018) to minimal (Kawasaki et al., subjective stability ratings during the post-operative
2018; Pagnani & Dome, 2002) with one study reporting period in selected studies (Arner et al., 2015; Calvisi
that 13.6% of athletes suffered recurrences of shoulder et al., 2019; Kawasaki et al., 2018; Ranalletta et al., 2018).
instability (Calvisi et al., 2019). The remaining study did
not report recurrence (Arner et al., 2015). Management protocols for other shoulder injuries
Protocol description. Similar to instability conditions,
rotator cuff (RC) tears and isolated posterior labral inju-
Additional findings
ries in rugby players were managed with arthroscopic
Significant improvements were reported in average
surgical repair followed by a sling (Badge et al., 2009;
visual analogue scale (VAS) pain, Rowe, Constant, Amer-
Tambe, Badge, & Funk, 2009). The rehabilitation protocol
ican Shoulder and Elbow Surgeons (ASES), Western
for both included closed and open chain exercises and
Ontario Shoulder Instability index (WOSI) scores and
resistance training followed by sport specific drills
(Badge et al., 2009; Tambe et al., 2009). In addition,
Table 2. Assessment modalities used during management core and scapular stabilisation and proprioception
protocols for acute diagnosis, evaluating progress or readiness
retraining were included for RC tear management
to return to play.
Clinical Functional Imaging Psychological
(Tambe et al., 2009). Simulated impact and tackle bag
assessment testing (lab tests) state training were initiated once ROM, strength, isokinetic
Cardone X O and proprioception parameters were deemed adequate
et al., 2002 in both cases (Badge et al., 2009; Tambe et al., 2009).
Pagnani & XO X
Dome,
2002 Return to play rates, time-loss and reinjury. Return to
Moorman X XO
et al., 2003 competitive rugby was possible after 4–5 months for all RC
Toritsuka XO X O athletes except one (who retired due to unrelated reasons)
et al., 2004
Tambe et al., O O X as well as following labral repair (Badge et al., 2009; Tambe
2009 et al., 2009). One player with previous labral damage sus-
Badge et al., XO XO X
2009
tained a recurrent injury to the same shoulder in the sub-
Neyton et al., XO X XO sequent season, whereas another player required repeat
2012 surgery after making insufficient progress with RC rehabi-
Osbahr et al., XO O X
2013 litation (Badge et al., 2009; Tambe et al., 2009).
Rettig et al., X O X
2013
Samra et al., X XO X O Management protocols for acromioclavicular
2015 conditions
Arner et al., XO X O
2015
Protocol description. Return to Australian rules football
Hsu et al., X X following Grade III acromioclavicular joint (ACJ) injuries
2015
Takazawa X O X O
was investigated in one study (Cardone et al., 2002).
et al., 2016 Slightly more than half of these athletes chose conserva-
Lareau et al., X XO tive management involving RICE and sling immobilis-
2016
Latham XO O X ation, whereas the remaining athletes selected surgical
et al., 2017 management involving open reduction and ACJ stabilis-
Menge et al., X X
2017 ation surgery (Cardone et al., 2002). A risk-based RTP
McCrum XO protocol was followed starting with return to non-
et al., 2018
Smith & X O X contact training, followed by return to contact training
Waldrop, and finally return to matches (Cardone et al., 2002). All
2018 athletes received physiotherapy mobilisation (Cardone
Ranalletta XO XO X
et al., 2018 et al., 2002), although further details were unavailable.
Kawasaki XO
et al., 2018
Yagishita X O Return to play rates, time-loss and reinjury. Only
et al., 2019 33.3% of the surgical management group compared to
Calvisi et al., XO X
2019 50.0% of the conservative management group were
Bernstein, XO X still participating in competitive Australian rules football
et al., 2020
at the final follow-up (Cardone et al., 2002). Although the
“X” indicates that the specified assessment method was included for acute diag-
nosis whereas “O” indicates that the specified assessment method was conservative management group could return to train-
included for evaluating progress or readiness to return to play. ing earlier, the surgical group could return to
1750 A. G. GELDENHUYS ET AL.
competitive play faster (Cardone et al., 2002). None of
these differences were statistically significant, which
may relate to the small sample size (Cardone et al.,
2002). Reinjury rates were unreported (Cardone et al.,
2002).
Management protocols in the hand
One case series investigated RTP after thumb ulnar col-
lateral ligament (UCL) ruptures managed surgically fol-
lowed by gradually reduced levels of splinting as well
as ROM and strengthening exercises (Bernstein, McCul-
loch, Winston, & Liberman, 2020). RTP was achieved in
all athletes after an average of 13.3 days (Bernstein et
al., 2020). No further management protocols for upper
limb injuries in tackle-collision sports were identified.
Assessment modalities in management
Assessment modalities used during management proto-
cols varied widely, as shown in Table 2. Certain methods
were used to assist diagnosis after acute musculoskeletal
injuries, whereas others assessed progress or readiness
to RTP. These methods were broadly categorised as clini-
cal assessment (e.g. signs and symptoms, ROM and
strength), functional testing (e.g. symmetry during
hopping), imaging (e.g. X-rays) and psychological assess-
ment (e.g. fear of reinjury). Acute injuries were assessed
predominantly through imaging (91.3% of studies) and
clinical assessments (87.0% of studies) with functional
testing performed in selected studies (17.4%). Progress
was assessed predominantly through clinical assessment
methods (52.2% of studies), followed by functional
testing (43.5% of studies), psychological assessment
(21.8% of studies) and imaging (17.4% of studies).
Part Two
Assessment modalities in the lower limb
Assessment of hamstring injuries
Five studies focused on hamstring injuries assessed
through MRI and/or clinical assessment to predict RTP
and/or reinjury risk in professional athletes (Comin, Mal-
liaras, Baquie, Barbour, & Connell, 2013; Eggleston,
McMeniman, & Engstrom, 2019; Koulouris, Connell,
Brukner, & Schneider-Kolsky, 2007; Verrall, Slavotinek,
Barnes, Fon, & Esterman, 2006; Warren, Gabbe, Schnei-
der-Kolsky, & Bennell, 2008). Using MRI, it was found
that hamstring injuries with central tendon disruption
and those classified as more severe on a modified
grading system were significantly associated with
greater time-loss prior to RTP (Comin et al., 2013; Eggle-
ston et al., 2019). One study found that greater sizes of
hamstring injuries on MRI were significantly associated
with recurrent injuries in the subsequent season
(Verrall et al., 2006), whereas another study found a
non-significant association between the length of ham-
string strains on MRI and reinjury risk in the same season
(Koulouris et al., 2007).
Clinical assessments detecting painful walking for
more than a day following hamstring strains in Austra-
lian rules football players were associated with signifi-
cantly longer time-loss prior to RTP (Warren et al.,
2008). In addition, a history of a previous hamstring
injury in the past year was significantly associated with
recurrence to the lateral hamstring within the first
three weeks after RTP (Warren et al., 2008). Other clinical
assessment methods were unable to predict time to RTP
or reinjury incidence within the follow-up period
(Warren et al., 2008). Likewise, another study was
unable to detect any significant associations between
any clinical assessment methods and RTP (Verrall et al.,
2006).
Assessment of calf strains
Two studies investigated RTP assessment methods fol-
lowing calf strains with MRI scans utilised in both cases
(Waterworth, Wein, Gorelik, & Rotstein, 2017; Werner
et al., 2017). The involvement of more than one
muscle, musculotendinous locations, greater size of
fascial defects and the presence of fluid were all associ-
ated with longer time-loss prior to RTP (Waterworth
et al., 2017; Werner et al., 2017). One study also included
a physical examination and player history, however this
was not significantly associated with time-loss (Werner
et al., 2017).
Assessment of quadriceps injuries
One study investigated clinical tests administered by
physiotherapists for quadriceps contusions in pro-
fessional rugby league players (Alonso et al., 2000). Stat-
istically significant associations were detected between
time-loss prior to RTP (with standardised treatment)
and positive findings on the following clinical evalu-
ations: passive knee flexion ROM, firmness ratings,
brush swipe tests, palpation and thigh circumferences
(Alonso et al., 2000). Reinjury rates were unavailable
(Alonso et al., 2000).
Assessment of ankle injuries
Clinical assessment and diagnostic ultrasound were
compared in American football players with grade I syn-
desmosis sprains managed with standardised conserva-
tive methods to predict time-loss prior to RTP (Miller
et al., 2012). A significant association was detected
between the height of the injury zone based on tender-
ness to palpation on clinical assessment and time-loss

(Miller et al., 2012). In addition, a clinical suspicion of syn-
desmosis sprains and normal lateral ankle ligaments on
ultrasound were associated with significantly faster
times to RTP compared to ultrasound-detected com-
plete tibiofibular ligament sprains (Miller et al., 2012).
Assessment of knee injuries
One study considered the ability of various factors
related to assessment of knee injuries in American foot-
ball players to predict time-loss prior to RTP (Baker,
Browning, Charnigo, Bunn, & Sanderson, 2018). Signifi-
cant associations were detected between longer time-
loss and the need for an MRI, surgical management,
assessment by physicians and injury occurrence during
preseason (Baker et al., 2018).
Assessment modalities in the upper limb
Only one study investigating assessment tools used in
RTP decisions following upper limb musculoskeletal
injuries in tackle-collision sports was identified (Gero-
metta, Klouche, Herman, Lefevre, & Bohu, 2018). This
study investigated the use of the Shoulder Instability
Return to Sport Injury Scale (SIRSI) following shoulder
surgery for instability in rugby players (Gerometta
et al., 2018). Higher scores on the SIRSI questionnaire
was significantly associated with the ability to RTP (Ger-
ometta et al., 2018). In addition, high validity and
reliability was reported (Gerometta et al., 2018). Reinjury
rates were unavailable (Gerometta et al., 2018).
Discussion
Overview
This review described, synthesised and evaluated man-
agement and assessment modalities implemented
during RTP after upper and lower limb musculoskeletal
injuries in tackle-collision team sports. Management
strategies included conservative and surgical strategies
accompanied by exercise-based rehabilitation. Assess-
ment modalities included imaging, clinical evaluation
and subjective ratings. Moreover, the review aimed to
investigate the efficacy of these methods. The designs
and quality of the available studies, however, could
only provide a low level of evidence regarding the
value thereof for RTP. As a result, it is not possible to
provide clear guidelines for clinicians to facilitate RTP
decisions following musculoskeletal injuries in tackle-
collision athletes. Nonetheless, there is moderate evi-
dence that progressive WB and exercise-based rehabili-
tation may add value to ankle sprain RTP management
protocols. Surgical management followed by a sling
EUROPEAN JOURNAL OF SPORT SCIENCE 1751
and exercise-based rehabilitation may be useful for
shoulder instability RTP management protocols. The dis-
crepancies identified should help to direct future
research. The most noteworthy findings are discussed
below.
Return to play management protocols after ankle
sprains
Each management protocol described for ankle sprains
enabled all athletes to return to tackle-collision sport
(Latham et al., 2017; Osbahr et al., 2013; Samra et al.,
2015). The RICE protocol implemented in each case
may, however, be outdated with a recent review recom-
mending the POLICE (i.e. protection, optimal loading,
ice, compression, elevation) protocol for acute manage-
ment of lateral ankle sprains (D’Hooghe, Cruz, & Alkhe-
laifi, 2020). The efficacy of progressive WB and
exercise-based rehabilitation for ankle sprains have
been established previously in other sports (Doherty,
Bleakley, Delahunt, & Holden, 2017; D’Hooghe et al.,
2020). This preliminary data indicates that the same
may apply in tackle-collision sports.
Return to play management protocols for
shoulder instability
GHJ instability conditions managed through surgical
interventions followed by a sling and rehabilitation
allowed the majority of athletes to RTP after half a year
(Arner et al., 2015; Calvisi et al., 2019; Kawasaki et al.,
2018; Neyton et al., 2012; Pagnani & Dome, 2002; Ranal-
letta et al., 2018). Shoulder injury RTP rates in the current
review were not consistent with other sports (Abdul-
Rassoul, Galvin, Curry, Simon, & Li, 2019; Ialenti, Mulvihill,
Feinstein, Zhang, & Feeley, 2017; Pagnani & Dome,
2002). For example, after arthroscopic Bankart repairs
in a general sporting population RTP rates of 71.0%
(Ialenti et al., 2017) and 97.5% (Abdul-Rassoul et al.,
2019) were reported, compared to the RTP rate of
95.5% in rugby players (Calvisi et al., 2019). Pooled RTP
rates after Latarjet procedures ranged from 84.0–97.0%
in general sporting populations (Abdul-Rassoul et al.,
2019; Ialenti et al., 2017), compared to the range of
64.0–92.0% reported in tackle-collision athletes
(Neyton et al., 2012; Ranalletta et al., 2018). While high
forces experienced on shoulders during collisions may
impact the ability to RTP in tackle-collision sports
(Usman, McIntosh, & Fréchède, 2011), clinicians
working with athletes through a RTP protocol, irrespec-
tive of the sport, should ideally understand the
demands of the sport and structure RTP protocols to
cope with these demands.
1752 A. G. GELDENHUYS ET AL.
No conservative management strategies were included
in this review. However, in all except one study (Neyton
et al., 2012), the proportion of players who were able to
RTP was higher than in a general sports population
where GHJ instability was managed conservatively
through an accelerated rehabilitation programme only
(Arner et al., 2015; Calvisi et al., 2019; Pagnani & Dome,
2002; Ranalletta et al., 2018). In terms of RTP rates, surgical
management of GHJ instability appears to be superior to
conservative management (Zaremski et al., 2017).
Assessment methods of musculoskeletal injuries
A limited number of studies (n = 11) were identified that
investigated assessment methods utilised to aid RTP in
tackle-collision sports, allowing for minimal data syn-
thesis. One notable finding was that MRI scans may
have value in predicting time-loss following calf and
hamstring injuries in tackle-collision athletes (Comin
et al., 2013; Eggleston et al., 2019; Waterworth et al.,
2017; Werner et al., 2017). Although this may be useful
in well-resourced professional settings, the high cost
associated with MRI’s may hinder its feasibility in other
(for example, amateur) settings. Conversely, MRI’s
value for RTP has been disputed in other sports
(Ekstrand et al., 2012). Moreover, it is unclear which
muscle strain classification system should be used and
how long after the injury the scan should be performed.
Selected studies provided preliminary evidence for
the potential value of palpation and ultrasound after
ankle sprains (Miller et al., 2012), the SIRSI questionnaire
after shoulder injuries (Gerometta et al., 2018) and
selected clinical assessment methods (including painful
walking and previous injury) following muscle strains
(Alonso et al., 2000; Warren et al., 2008).
Return to tackle-collision sport focused protocol
required
None of the management protocols described specifi-
cally followed existing models or guidelines such as
the 2016 RTP consensus statement and the Strategic
Assessment of Risk and Risk Tolerance (StARRT)
(Ardern et al., 2016; Shrier, 2015). In addition, none of
the studies met the best practice recommendations for
musculoskeletal pain published in 2020 (Lin et al.,
2020). Many of the reviewed studies, however, predated
these publications. Moreover, RTP frameworks such as
the StARRT framework (Shrier, 2015) were not specifi-
cally formulated for the unique risks imposed within
tackle-collision team environments. The absence of
tackle-collision specific guidelines may partially explain
the heterogeneity of the protocols reviewed. For
example, a risk-adjusted phased approach has been rec-
ommended (Ardern et al., 2016), yet only one study
differentiated between return to non-contact training
and return to contact-training (Cardone et al., 2002)
during RTP despite the different levels of risk imposed
by these activities. These findings highlight the need
to include tackle and collision skill training within RTP
protocols. In 2017, the need for a contact-skill pro-
gramme was raised (Hendricks, Till, Brown, & Jones,
2017), and in 2018, a tackle contact-skill training frame-
work and skill load measurements for collision sport was
published (Hendricks et al., 2018). The framework
describes measurements that can be used to monitor
and progress tackle training to ensure optimum transfer
to matches (Hendricks et al., 2019). The tackle framework
and skill load measurements can also be used for a more
targeted approach in facilitating return to tackle-col-
lision sports. In rugby union, Burger et al. (2020)
described this approach as “return to contact” (Burger
et al., 2020). The physical-technical demands of repeat-
edly contesting tackles and collisions are highly fati-
guing, which may affect technique (Davidow et al.,
2020) and subsequently increase players risk of injury if
they are not optimally prepared. Future research
should differentiate between return to non-contact
and contact training and return to matches with RTP
protocols focusing on physical-technical capacities to
resist fatigue.
The RTP criteria utilised in reviewed studies varied
widely. A survey conducted among team management
(including physicians, physiotherapists, trainers and
coaches) to investigate RTP practices and criteria in
New Zealand rugby union clubs reported that standar-
dised criteria were not commonly utilised in practice
(Beardmore, Handcock, & Rehrer, 2005). The majority of
participants, however, agreed that physiotherapy clear-
ance, physician clearance, participation in team running
and training and completion of fitness testing (in order
of perceived importance) should be considered as criteria
to facilitate RTP decisions (Beardmore et al., 2005). There
is an urgent need to formulate RTP criteria to evaluate the
readiness of tackle-collision athletes to RTP.
Specific exercise-based rehabilitation strategies also
require further investigation to determine the value and
appropriate dosing of each physiological construct. None
of the studies mentioned psychological management
strategies, although psychological readiness is an impor-
tant construct for RTP decisions (Ardern et al., 2014).
Limitations and future directions
Studies varied particularly with regard to different level
of play, types of injuries, injury definitions, RTP

definitions, assessment and management interventions,
follow-up periods and RTP criteria thus meta-analysis
could not be performed. While the majority (n = 20) of
studies involved professional athletes, the current
review also included studies that consisted of different
levels of competition (n = 10), non-professional athletes
(n = 2) and studies that did not specify the level of com-
petition or a range of athletes from different levels of
play grouped as one cohort (n = 10). Including these
different competition levels may be considered a
caveat of the current review, as professional athletes
may have better access to resources, diagnostic tools,
and medical professionals during RTP. With that said,
how access to resources, diagnostic tools, and/or
medical professionals affect RTP practice at these
various levels is yet to be investigated.
Since only six females were mentioned in two mixed
sample studies, female specific recommendations could
not be extrapolated from the reviewed studies. The
increased participation of females in tackle-collision
sports and the potential for different RTP outcomes
between males and females, for example after ACL’s
(Lin, Casey, Herman, Katz, & Tenforde, 2018), highlights
the need for research in females populations in these
sports.
Cohort, case–control and observation studies gener-
ally provide level III evidence, whereas case-series
provide level IV evidence. The retrospective nature of
many studies could have resulted in selection bias and
missing information. A lack of control groups and non-
randomisation may have introduced selection and
placebo bias. However, considering the intricate and
multi-factorial nature of RTP in the sporting environ-
ment, implementing a prospective randomised con-
trolled trial may be difficult.
Most of these studies were rated as “good” or “excel-
lent”, however, others were of insufficient quality,
further limiting the generalisability of results. Only four
studies included some form of blinding. Lack of blinding
in the majority of studies was one of the main reasons
for lower quality ratings as this may have led to observer
and/or participant bias. In the absence of higher quality
studies providing stronger evidence, the research dis-
cussed provides limited evidence for management pro-
tocols and assessment strategies.
To improve the quality of future studies in tackle-col-
lision teams standardised outcome measures with valid
and reliable assessment modalities should be used to
evaluate the efficacy of RTP protocols. Moreover,
future studies should provide clearer definitions for
RTP and time-loss injuries considered along with more
thorough descriptions of the protocols followed to
allow for reproducibility.
EUROPEAN JOURNAL OF SPORT SCIENCE 1753
The review was limited by restricting articles to those
available in English. Studies only available in other
languages may have shed further light on the objectives
investigated.
Conclusion
Based on the current literature, it is not possible to
provide clear guidelines for clinicians to facilitate RTP
decisions following musculoskeletal injuries in tackle-
collision athletes. There is, however, moderate evidence
that progressive WB and exercise-based rehabilitation
may add value to ankle sprain RTP management proto-
cols and that surgical management followed by a sling
and exercise-based rehabilitation may be useful for
shoulder instability RTP management protocols. Future
high-quality studies should be conducted to determine
clinicians’ RTP knowledge and current practice following
musculoskeletal injuries in tackle-collision teams. More-
over, efficient management strategies evaluated
through valid and reliable assessment methods to facili-
tate return to tackle-collision team sport should be
established.
Disclosure statement
No potential conflict of interest was reported by the author(s).
ORCID
A. Grethe Geldenhuys http://orcid.org/0000-0001-8938-3105
Theresa Burgess http://orcid.org/0000-0001-9796-2182
Stephen Roche http://orcid.org/0000-0002-5695-2751
Sharief Hendricks http://orcid.org/0000-0002-3416-6266
References
Abdul-Rassoul, H., Galvin, J. W., Curry, E. J., Simon, J., & Li, X.
(2019). Return to sport after surgical treatment for anterior
shoulder instability: A systematic review. The American
Journal of Sports Medicine, 47(6), 1507–1515. doi:10.1177/
0363546518780934
Alonso, A., Hekeik, P., & Adams, R. (2000). Predicting recovery
time from the initial assessment of a quadriceps contusion
injury. Australian Journal of Physiotherapy, 46(3), 167–177.
doi:10.1016/S0004-9514(14)60326-3
Ardern, C. L., Glasgow, P., Schneiders, A., Witvrouw, E., Clarsen,
B., Cools, A., … Bizzini, M. (2016). Consensus statement on
return to sport from the first world congress in sports phys-
ical therapy, Bern. British Journal of Sports Medicine, 50(14),
853–864. doi:10.1136/bjsports-2016-096278
Ardern, C. L., Österberg, A., Tagesson, S., Gauffin, H., Webster, K.
E., & Kvist, J. (2014). The impact of psychological readiness to
return to sport and recreational activities after anterior cruci-
ate ligament reconstruction. British Journal of Sports
1754 A. G. GELDENHUYS ET AL.
Medicine, 48(22), 1613–1619. doi:10.1136/bjsports-2014-
093842
Arner, J. W., McClincy, M. P., & Bradley, J. P. (2015). Arthroscopic
stabilization of posterior shoulder instability is successful in
American football players. Arthroscopy: The Journal of
Arthroscopic & Related Surgery, 31(8), 1466–1471. doi:10.
1016/j.arthro.2015.02.022
Badge, R., Tambe, A., & Funk, L. (2009). Arthroscopic isolated
posterior labral repair in rugby players. International
Journal of Shoulder Surgery, 3(1), 4–7.
Baker, C., Browning, S., Charnigo, R., Bunn, T., & Sanderson, W.
(2018). Factors related to return to play after knee injury in
high school football athletes. Annals of Epidemiology, 28(9),
629–634.e1. doi:10.1016/j.annepidem.2018.06.008
Beardmore, A. L., Handcock, P. J., & Rehrer, N. J. (2005). Return-
to-play after injury: Practices in New Zealand rugby union.
Physical Therapy in Sport, 6(1), 24–30. doi:10.1016/j.ptsp.
2004.04.002
Bernstein, D. T., McCulloch, P. C., Winston, L. A., & Liberman, S.
R. (2020). Early return to play with thumb spica gauntlet
casting for ulnar collateral ligament injuries complicated
by adjacent joint dislocations in collegiate football
linemen. Hand, 15(1), 92–96. doi:10.1177/1558944718788644
Bitchell, C. L., Mathema, P., & Moore, I. S. (2020). Four-year
match injury surveillance in male Welsh professional
Rugby Union teams. Physical Therapy in Sport, 42, 26–32.
doi:10.1016/j.ptsp.2019.12.001
Burger, N., Lambert, M., & Hendricks, S. (2020). Lay of the land:
Narrative synthesis of tackle research in rugby union and
rugby sevens. BMJ Open Sport & Exercise Medicine, 6(1), 1–
13. doi:10.1136/bmjsem-2019-000645
Burger, N., Lambert, M. I., Viljoen, W., Brown, J. C., Readhead, C.,
& Hendricks, S. (2016). Tackle technique and tackle-related
injuries in high-level South African Rugby Union under-18
players: Real-match video analysis. British Journal of Sports
Medicine, 50(15), 932–938. doi:10.1136/bjsports-2015-
095295
Calvisi, V., Goderecci, R., Rosa, F., & Castagna, A. (2019).
Arthroscopic anatomic repair of bankart lesion in rugby
players. Journal of Biological Regulators and Homeostatic
Agents, 33(1), 15–20.
Cardone, D., Brown, J. N., Roberts, S. N. J., Saies, A. D., & Hayes,
M. G. (2002). Grade III acromioclavicular joint injury in
Australian rules football. Journal of Science and Medicine in
Sport, 5(2), 143–148. doi:10.1016/S1440-2440(02)80035-4
Comin, J., Malliaras, P., Baquie, P., Barbour, T., & Connell, D.
(2013). Return to competitive play after hamstring injuries
involving disruption of the central tendon. The American
Journal of Sports Medicine, 41(1), 111–115. doi:10.1177/
0363546512463679
Davidow, D., Redman, M., Lambert, M., Burger, N., Smith, M.,
Jones, B., & Hendricks, S. (2020). The effect of physical
fatigue on tackling technique in Rugby Union. Journal of
Science and Medicine in Sport, 1–6. doi:10.1016/j.jsams.
2020.04.005
D’Hooghe, P., Cruz, F., & Alkhelaifi, K. (2020). Return to play
after a lateral ligament ankle sprain. Current Reviews in
Musculoskeletal Medicine, 13, 281–288. doi:10.1007/s12178-
020-09631-1
Doherty, C., Bleakley, C., Delahunt, E., & Holden, S. (2017).
Treatment and prevention of acute and recurrent ankle
sprain: An overview of systematic reviews with meta-
analysis. British Journal of Sports Medicine, 51(2), 113–125.
doi:10.1136/bjsports-2016-096178
Downs, S. H., & Black, N. (1998). The feasibility of creating a
checklist for the assessment of the methodological quality
both of randomised and non-randomised studies of health
care interventions. Journal of Epidemiology & Community
Health, 52(6), 377–384. doi:10.1136/jech.52.6.377
Eggleston, L., McMeniman, M., & Engstrom, C. (2019, August).
High-grade intramuscular tendon disruption in acute ham-
string injury and return to play in Australian Football
players. Scandinavian Journal of Medicine & Science in
Sports, 2020, 1–10. doi:10.1111/sms.13642
Ekstrand, J., Healy, J. C., Waldén, M., Lee, J. C., English, B., &
Hägglund, M. (2012). Hamstring muscle injuries in pro-
fessional football: The correlation of MRI findings with
return to play. British Journal of Sports Medicine, 46(2),
112–117. doi:10.1136/bjsports-2011-090155
Gerometta, A., Klouche, S., Herman, S., Lefevre, N., & Bohu, Y.
(2018). The shoulder instability-return to sport after injury
(SIRSI): a valid and reproducible scale to quantify psycho-
logical readiness to return to sport after traumatic shoulder
instability. Knee Surgery, Sports Traumatology, Arthroscopy,
26(1), 203–211. doi:10.1007/s00167-017-4645-0
Hendricks, S., Till, K., Brown, J. C., & Jones, B. (2017). Rugby
union needs a contact skill-training programme. British
Journal of Sports Medicine, 51(10), 829–830. doi:10.1136/
bjsports-2016-096347
Hendricks, S., Till, K., Oliver, J. L., Johnston, R. D., Attwood, M.,
Brown, J., … Jones, B. (2018). Technical skill training frame-
work and skill load measurements for the rugby union
tackle. Strength & Conditioning Journal, 40(5), 44–59.
doi:10.1519/SSC.0000000000000400
Hendricks, S., Till, K., Oliver, J. L., Johnston, R. D., Attwood, M. J.,
Brown, J. C., … Jones, B. (2019). Rating of perceived chal-
lenge as a measure of internal load for technical skill per-
formance. British Journal of Sports Medicine, 53(10), 611–
613. doi:10.1136/bjsports-2018-099871
Hsu, A. R., Lareau, C. R., & Anderson, R. B. (2015). Repair of acute
superficial deltoid complex avulsion during ankle fracture
fixation in national football league players. Foot & Ankle
International, 36(11), 1272–1278. doi:10.1177/
1071100715593374
Ialenti, M. N., Mulvihill, J. D., Feinstein, M., Zhang, A. L., &
Feeley, B. T. (2017). Return to play following shoulder
stabilization: A systematic review and meta-analysis.
Orthopaedic Journal of Sports Medicine, 5(9), 1–6. doi:10.
1177/2325967117726055
Johnston, R. D., Gabbett, T. J., & Jenkins, D. G. (2014). Applied
sport science of rugby league. Sports Medicine, 44(8),
1087–1100. doi:10.1007/s40279-014-0190-x
Junge, A., Cheung, K., Edwards, T., & Dvorak, J. (2004). Injuries in
youth amateur soccer and rugby players - comparison of
incidence and characteristics. British Journal of Sports
Medicine, 38(2), 168–172. doi:10.1136/bjsm.2002.003020
Kawasaki, T., Hasegawa, Y., Kaketa, T., Shiota, Y., Gonda, Y.,
Sobue, S., … Kaneko, K. (2018). Midterm clinical results in
rugby players treated with the bristow procedure. The
American Journal of Sports Medicine, 46(3), 656–662. doi:10.
1177/0363546517740567
Kerr, Z. Y., Zuckerman, S. L., Wasserman, E. B., Covassin, T.,
Djoko, A., & Dompier, T. P. (2016). Concussion symptoms
and return to play time in youth, high school, and college

American football athletes. JAMA Pediatrics, 170(7), 647–653.
doi:10.1001/jamapediatrics.2016.0073
Koulouris, G., Connell, D. A., Brukner, P., & Schneider-Kolsky, M.
(2007). Magnetic resonance imaging parameters for asses-
sing risk of recurrent hamstring injuries in elite athletes.
The American Journal of Sports Medicine, 35(9), 1500–1506.
doi:10.1177/0363546507301258
Lareau, C. R., Hsu, A. R., & Anderson, R. B. (2016). Return to play
in national football league players after operative jones frac-
ture treatment. Foot & Ankle International, 37(1), 8–16.
doi:10.1177/1071100715603983
Latham, A. J., Goodwin, P. C., Stirling, B., & Budgen, A. (2017).
Ankle syndesmosis repair and rehabilitation in professional
rugby league players: A case series report. BMJ Open Sport
& Exercise Medicine, 3(1), 1–6. doi:10.1136/bmjsem-2016-
000175
Lin, C., Casey, E., Herman, D., Katz, N., & Tenforde, A. (2018). Sex
differences in common sports injuries. PMC, 176(1), 1073–
1082. doi:10.1016/j.pmrj.2018.03.008
Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., …
O’Sullivan, P. P. B. (2020). What does best practice care for
musculoskeletal pain look like? Eleven consistent rec-
ommendations from high-quality clinical practice guide-
lines: Systematic review. British Journal of Sports Medicine,
54(2), 79–86. doi:10.1136/bjsports-2018-099878
McCrum, C. L., Arner, J. W., Lesniak, B., & Bradley, J. P. (2018).
Arthroscopic anterior ankle decompression is successful in
National Football League players. American journal of ortho-
pedics (Belle Mead NJ), 47(1), 1–10. doi:10.12788/ajo.2018.
0001
Menge, T. J., Bhatia, S., McNamara, S. C., Briggs, K. K., &
Philippon, M. J. (2017). Femoroacetabular impingement in
professional football players: Return to play and predictors
of career length after hip arthroscopy. The American
Journal of Sports Medicine, 45(8), 1740–1744. doi:10.1177/
0363546517700118
Miller, B. S., Downie, B. K., Johnson, P. D., Schmidt, P. W.,
Nordwall, S. J., Kijek, T. G., … Carpenter, J. E. (2012). Time
to return to play after high ankle sprains in collegiate foot-
ball players: A prediction model. Sports Health: A
Multidisciplinary Approach, 4(6), 504–509. doi:10.1177/
1941738111434916
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009).
Preferred reporting items for systematic reviews and meta-
analyses: The PRISMA statement. PLoS Medicine, 6(7),
e1000097. doi:10.1371/journal.pmed.1000097
Moorman, C., Russel, W., Hershman, E., Crowe, J. F., Potter, H.
G., Barnes, R., … Guettler, J. H. (2003). Traumatic
posterior hip subluxation in American football. The Journal
of Bone and Joint Surgery-American Volume, 85-A(7),
1190–1196.
Naughton, M., Jones, B., Hendricks, S., King, D., Murphy, A., &
Cummins, C. (2020). Quantifying the collision dose in
rugby league: A systematic review, meta-analysis, and criti-
cal analysis. Sports Medicine-Open, 6(1), doi:10.1186/
s40798-019-0233-9
Neyton, L., Young, A., Dawidziak, B., Visona, E., Hager, J.-P.,
Fournier, Y., & Walch, G. (2012). Surgical treatment of
anterior instability in rugby union players: Clinical and radio-
graphic results of the Latarjet-Patte procedure with
minimum 5-year follow-up. Journal of Shoulder and Elbow
Surgery, 21(12), 1721–1727. doi:10.1016/j.jse.2012.01.023
EUROPEAN JOURNAL OF SPORT SCIENCE 1755
O’Connor, S. R., Tully, M. A., Ryan, B., Bradley, J. M., Baxter, G. D.,
& McDonough, S. M. (2015). Failure of a numerical quality
assessment scale to identify potential risk of bias in a sys-
tematic review: A comparison study. BMC Research Notes, 8
(1), 1–7. doi:10.1186/s13104-015-1181-1
Orchard, J., Best, T. M., & Verrall, G. M. (2005). Return to play fol-
lowing muscle strains. Clinical Journal of Sport Medicine, 15
(6), 436–441. doi:10.1097/01.jsm.0000188206.54984.65
Osbahr, D. C., Drakos, M. C., O’Loughlin, P. F., Lyman, S., Barnes,
R. P., Kennedy, J. G., & Warren, R. F. (2013). Syndesmosis and
lateral ankle sprains in the National Football league.
Orthopedics, 36(11), 1378–1384. doi:10.3928/01477447-
20131021-18
Pagnani, M. J., & Dome, D. C. (2002). Surgical treatment of trau-
matic anterior shoulder instability in American football
players. The Journal of Bone and Joint Surgery-American
Volume, 84(5), 711–715+Adv30. doi:10.2106/00004623-
200205000-00002
Ranalletta, M., Rossi, L. A., Bertona, A., Tanoira, I., Hidalgo, I. A.,
Maignon, G. D., & Bongiovanni, S. L. (2018). Modified Latarjet
without capsulolabral repair in rugby players with recurrent
anterior glenohumeral instability and significant glenoid
bone loss. The American Journal of Sports Medicine, 46(4),
795–800. doi:10.1177/0363546517749586
Rettig, A. C., Meyer, S., & Bhadra, A. K. (2013). Platelet-rich
plasma in addition to rehabilitation for acute hamstring inju-
ries in NFL players: Clinical effects and time to return to play.
Orthopaedic Journal of Sports Medicine, 1(1), 1–5. doi:10.
1177/2325967113494354
Samra, D. J., Sman, A. D., Rae, K., Linklater, J., Refshauge, K. M., &
Hiller, C. E. (2015). Effectiveness of a single platelet-rich
plasma injection to promote recovery in rugby players
with ankle syndesmosis injury. BMJ Open Sport & Exercise
Medicine, 1(1), 1–7. doi:10.1136/bmjsem-2015-000033
Scase, E., Magarey, M. E., Chalmers, S., Heynen, M., Petkov, J., &
Bailey, S. (2012). The epidemiology of injury for an elite
junior Australian Football cohort. Journal of Science and
Medicine in Sport, 15(3), 207–212. doi:10.1016/j.jsams.2011.
12.002
Shrier, I. (2015). Strategic Assessment of Risk and Risk Tolerance
(StARRT) framework for return-to-play decision-making.
British Journal of Sports Medicine, 49(20), 1311–1315.
doi:10.1136/bjsports-2014-094569
Smith, K., & Waldrop, N. (2018). Operative outcomes of grade 3
turf toe injuries in competitive football players. Foot & Ankle
International, 39(9), 1076–1081. doi:10.1177/
1071100718775967
Takazawa, Y., Nagayama, M., Ikeda, H., Kawasaki, T., Ishijima, M.,
Saita, Y., … Kaneko, K. (2016). Anterior cruciate ligament
injuries in elite and high school rugby players: A 11-year
review. The Physician and Sportsmedicine, 44(1), 53–58.
doi:10.1080/00913847.2016.1116362
Tambe, A., Badge, R., & Funk, L. (2009). Arthroscopic rotator cuff
repair in elite rugby players. International Journal of Shoulder
Surgery, 3(1), 8. doi:10.4103/0973-6042.50876
Toritsuka, Y., Horibe, S., Hiro-oka, A., Mitsuoka, T., & Nakamura,
N. (2004). Conservative treatment for rugby football players
with an acute isolated posterior cruciate ligament injury.
Knee Surgery, Sports Traumatology, Arthroscopy, 12(2), 110–
114. doi:10.1007/s00167-003-0381-8
Usman, J., McIntosh, A. S., & Fréchède, B. (2011). An investi-
gation of shoulder forces in active shoulder tackles in
1756 A. G. GELDENHUYS ET AL.
rugby union football. Journal of Science and Medicine in
Sport, 14(6), 547–552. doi:10.1016/j.jsams.2011.05.006
Verrall, G. M., Slavotinek, J. P., Barnes, P. G., Fon, G. T., &
Esterman, A. (2006). Assessment of physical examination
and magnetic resonance imaging findings of hamstring
injury as predictors for recurrent injury. Journal of
Orthopaedic & Sports Physical Therapy, 36(4), 215–224.
doi:10.2519/jospt.2006.36.4.215
Warren, P., Gabbe, B. J., Schneider-Kolsky, M., & Bennell, K. L.
(2008). Clinical predictors of time to return to competition
and of recurrence following hamstring strain in elite
Australian footballers. British Journal of Sports Medicine, 44
(6), 415–419. doi:10.1136/bjsm.2008.048181
Waterworth, G., Wein, S., Gorelik, A., & Rotstein, A. H. (2017).
MRI assessment of calf injuries in Australian Football
league players: Findings that influence return to play.
Skeletal Radiology, 46(3), 343–350. doi:10.1007/s00256-016-
2564-7
Werner, B. C., Belkin, N. S., Kennelly, S., Weiss, L., Barnes, R. P.,
Potter, H. G., … Rodeo, S. A. (2017). Acute gastrocnemius-
soleus complex injuries in national football league athletes.
Orthopaedic Journal of Sports Medicine, 5(1), 1–6. doi:10.
1177/2325967116680344
Williams, S., Trewartha, G., Kemp, S. P. T., Brooks, J. H. M., Fuller,
C. W., Taylor, A. E., … Stokes, K. A. (2016). Time loss injuries
compromise team success in Elite Rugby Union: A 7-year
prospective study. British Journal of Sports Medicine, 50(11),
651–656. doi:10.1136/bjsports-2015-094798
Williams, S., Trewartha, G., Kemp, S., & Stokes, K. (2013). A meta-
analysis of injuries in senior men’s professional Rugby
Union. Sports Medicine, 43(10), 1043–1055. doi:10.1007/
s40279-013-0078-1
Yagishita, K., Enomoto, M., Takazawa, Y., Fukuda, J., & Koga, H.
(2019). Effects of hyperbaric oxygen therapy on
recovery acceleration in Japanese professional or semi-
professional rugby players with grade 2 medial collateral
ligament injury of the knee: A comparative non-
randomized study. Undersea and Hyperbaric Medicine, 46
(5), 647–654.
Yang, A. W., Li, C. G., Da Costa, C., Allan, G., Reece, J., & Xue, C. C.
(2009). Assessing quality of case series studies: Development
and validation of an instrument by herbal medicine CAM
researchers. The Journal of Alternative and Complementary
Medicine, 15(5), 513–522. doi:10.1089/acm.2007.0806
Zaremski, J. L., Galloza, J., Sepulveda, F., Vasilopoulos, T.,
Micheo, W., & Herman, D. C. (2017). Recurrence and return
to play after shoulder instability events in young and adoles-
cent athletes: A systematic review and meta-analysis. British
Journal of Sports Medicine, 51(3), 177–184. doi:10.1136/
bjsports-2016-096895