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Closing The Return-To-Play Gap
Reinjury rates remain stubbornly high because structural healing doesn’t always equal functional readiness. Victor Donker is co-founder and CEO of Usono, a company based in Eindhoven, the Netherlands, which focuses on improving player care by understanding the function of the body in motion.
Why does return-to-play remain a challenge in football, particularly for hamstring injuries?
Return-to-play remains challenging because there is often a gap between structural recovery and functional readiness. In hamstring injuries, reinjury rates of around 20% indicate that we still lack consistent insight into how the muscle behaves during real sporting load. Hamstring injuries are also highly heterogeneous. Factors such as injury location, involvement of the musculotendinous junction (including T-junction injuries), and individual movement strategies mean that not all injuries behave the same way. As a result, return-to-play processes cannot be identical for every athlete. While this challenge exists across all levels of the game, it becomes especially visible in elite football due to higher physical demands, congested schedules and limited tolerance for reinjury risk.
Why might reinjury risk remain high even with advances in rehabilitation, imaging and load management?
Advances in rehabilitation strategies, imaging quality and load monitoring have been substantial. MRI and ultrasound continue to improve, while EMG, GPS data, force plates and performance metrics provide detailed insight into external load. What often remains missing is visibility into what actually happens inside the muscle during contraction and movement. A static scan may indicate that tissue is structurally healed, and clinical testing may appear positive, yet the functional behaviour of the muscle may not be ready for the next stage of rehabilitation. This mismatch between structure, load and function may help explain persistent reinjury risk.
What are the key limitations of relying on static imaging during later-stage rehabilitation?
Static imaging provides essential structural information, but it is typically performed at rest. As rehabilitation progresses, the key question shifts from whether tissue appears healed to how it behaves during movement. Football demands high-speed running, acceleration, deceleration and change of direction. Imaging that captures tissue only in a static position cannot fully reflect these functional demands, making it more difficult to judge readiness for real-world football actions.
How can dynamic and functional ultrasound assessment under movement and load provide insights that structural healing alone cannot?
Clinicians working with dynamic assessment have shown that observing tissue during controlled movement can reveal important functional behaviours that are not visible on static imaging. For example, Dr Marwan Al-Dawoud, Sport and Exercise Medicine Doctor working across elite football, has demonstrated how dynamic ultrasound during protocols such as the Askling hamstring exercises can provide insight into intermuscular coordination, intramuscular behaviour and the interaction between muscles and nerves. Similarly, Dr Colin Griffin (Dublin) applies comparable principles in calf and Achilles rehabilitation, focusing on functional sliding behaviour between structures such as the gastrocnemius and soleus. Both clinicians recently presented their applied work at the prestigious Isokinetic Conference in Athens (April), highlighting the growing interest in functional assessment among leading sports medicine experts.
How can functional information improve return-to-play discussions and alignment between medical, rehabilitation and performance staff?
Functional information supports clearer and more objective multidisciplinary discussions. Realtime visual feedback can help athletes understand how small changes in posture or movement affect tissue behaviour, while enabling clinicians to finetune exercise selection and progression. By understanding how muscles behave during relevant movements, medical staff can guide rehabilitation more precisely, informing performance and rehabilitation teams about which exercises can be progressed safely and where additional caution is required. This shared functional insight helps align medical, rehabilitation and performance staff around the same evidence, rather than relying solely on timelines or isolated test outcomes. Looking ahead, there is increasing interest in connecting and sharing this type of functional data across teams, and in exploring how advanced analysis tools may further support consistency and confidence in decision making.
