Making the game day ‘go’ or ‘no go’ decision

by Dr. Dev Mishra , Jul 28, 2018
The decision whether an athlete should be allowed to play or should sit out after injury is always an interesting one to observe from afar. These decisions are particularly difficult for team physicians at the professional level when there is a critical need for an athlete to compete.
I’d like to outline below the basic framework that a team physician would take when making this decision. These principles were nicely outlined in an article co-authored by my former Stanford partner, Dr. Gord Matheson.

There are three key aspects of the decision process, with multiple substeps. I find that physicians all over the world will use a similar set of steps.
1. Medical factors. In Gord’s methodology he calls this “evaluation of health status.” This would include: what’s the injury, what’s the athlete’s state of healing, pain, function, psychological readiness, etc. There needs to be adequate healing, negligible pain, and adequate function.
2. Sport-based risk evaluation. This step includes an assessment of the near-term and long-term risks of participation, a critical component of the discussion that the team physician will have with the athlete. The type of sport (e.g. collision, contact, non-contact), position, competitive level (e.g. pro, collegiate, rec), and ability to protect with devices such as braces or pads are important considerations.
3. Situation specific modifiers. These are often the trickiest and need quite a bit of experience and finesse to navigate. Some of the elements would include sport timing (e.g. World Cup, final round of US Open golf, or offseason), pressure from the athlete, pressure from the coach, financial factors, or fate of the hopes and dreams of an entire country.

Injured Player? Take Safe Steps in the Return-To-Play Decision
Where the physician places the emphasis with any given athlete is going to be highly individualized. And the decision on how hard to push the envelope is another tough one. My colleague Dr. Brian Cole at Midwest Orthopedics at Rush put it this way:

“The decision to push the envelope can be really complex. The player might feel like he needs more time — but the organization, in a situation like the NBA playoffs, will want him back as soon as possible. Or maybe the player is anxious to get back before he is ready, feeling the weight of his or her team and even career. Amid all of this, a team’s physician has to be clear-minded and focused on the best interest of the player. It takes an enormous amount of humility. You can never be a fan.”
Dr. Bert Mandelbaum, the longtime national team physician for U.S. Soccer and Advisor to Sideline Sports Doc told me this: “No matter the situation, whether it is a practice with very young players, a club team in a championship, or a professional in the World Cup there’s one thing we must do always: put the player first.”

Even I will watch and scratch my head sometimes when hearing about “go” or “no go” decisions, especially during super high pressure events. At the core I’m certain that no physician today would ever intentionally place an athlete at risk. I know that behind the scenes they are dealing with all of the information, pressure, and factors none of us have access to. What seems to an outsider like a simple decision often involves a heck of a lot of thought.

Key Points:
• The decision to allow an athlete to play or recommend sitting out is complex, and involves an assessment of medical factors, sport-based risk evaluation, and situation-specific modifiers
• The process for seemingly simple injuries can still be complex, especially in the high pressure environment of professional sports