We’re Back!

Jul 6

When “back” isn’t enough

In sports rehabilitation, we often think of being “back” as the moment an athlete steps onto the court again for their first game back. But many who have worked in high-performance environments knows that clearance is another step…a big step…but still just a step in the right direction.

This is part of the challenge that continues to interest me most about return to performance. The most difficult part of the process often begins after an athlete is technically “back.”

This is also the time when they often start to fall off the rehab list and sports medicine and performance team’s radar, we did our job… they’re back!

While we pat ourselves on the back for another successful return and cross our fingers and pray for no re-injury the athlete continues their journey. They may be available, practicing without issues, and even competing — yet still not moving the same, reacting the same, or impacting the game the same way they did before injury.

Sometimes it shows up physically through reduced explosiveness, tolerance, or rhythm. Other times it’s confidence, timing, decision-making, or simply the ability to consistently handle the demands of competition again. In basketball, those differences become visible quickly. Athletes and coaches can often feel the gap even when we’re happy with their isokinetic strength, CMJ symmetry, and our carefully planned load progression.

What do the numbers say?

The question, then, can’t simply be:

“Can the athlete play again?”

But rather:

“Can they return to meaningful impact in competition?”

A study by Garrett Bullock and colleagues in NBA athletes highlights this problem well. The authors examined return to performance following severe ankle, knee, and hip injuries in NBA players between 2008 and 2019. Using publicly available NBA data, they evaluated athletes who had sustained severe lower extremity injuries resulting in at least 14 missed games and compared player performance one year before injury to both one and two years after return to play.

Importantly, the study did not just look at whether players returned to competition. The authors examined multiple markers of basketball contribution and utilization including games played, games started, season minutes, points scored, points per game, and rebounds. In many ways, this is what makes the paper so interesting. It attempted to evaluate performance in a way that better reflects the realities of elite basketball rather than simply using participation alone as the endpoint.

What stood out most to me about the paper was not simply the decline in performance metrics, but the broader reality it reflects about elite basketball and high-performance sport.

The study found that only 69% of players were still participating in the NBA one year after severe lower extremity injury, and only 45% were still playing in the league two years later. Among those who did return, only 30% returned to a similar number of games played one year after injury, and only 37% returned to similar game participation two years later. Similar trends existed for scoring, minutes, and rebounding production. Even among athletes who successfully returned to the court, many were still performing below their pre-injury baseline.

Reframing the finish line

That distinction matters. This study is really what inspired my dissertation direction and my questions on what goes into performance outcomes in team sport.

We often celebrate the return date because it is visible and easy to define. But performance is more difficult. Performance in elite team sport involves sustaining workload over a season, regaining rhythm while navigating team systems, tolerating schedule density, adapting psychologically, and re-establishing trust in movement and decision-making under pressure. All of which ultimately influence an athlete’s ability to positively impact team outcomes and their future in the sport.

To me, this is where the conversation continues to evolve. The challenge is not simply getting athletes back onto the floor. The challenge is restoring the physical, psychological, and competitive qualities that drive meaningful impact once they return.

Stay tuned. We’ll continue to these discussions in the coming posts.

References:

Bullock GS, Ferguson T, Arundale AH, Martin CL, Collins GS, Kluzek S. Return to performance following severe ankle, knee, and hip injuries in National Basketball Association players. PNAS Nexus. Sep 2022;1(4):pgac176. doi:10.1093/pnasnexus/pgac176