Return to activity criteria

Return-to-Activity Criteria

Time-based clearance is popular because it is easy and defensible-sounding, and it is neither safe nor accurate. Criteria-based return asks a different question: what must this person demonstrate before this exposure is reasonable? This builds that battery, sets thresholds in advance — before anyone is under pressure — and stages the return so the first day back is not the full demand.

What This Skill Produces

• Criteria by stage — what must be demonstrated to progress from each stage to the next
• The test battery with thresholds — specific tests, with pass criteria set in advance
• The graded exposure plan — how demand is reintroduced, in what increments, over what period
• The residual-risk conversation — what remains uncertain even when criteria are met, communicated honestly
• The decision record — who decided, on what evidence, with what the patient understood
• The monitoring plan — what is watched after return, and what would pause it

Required Inputs

Ask for these if not provided:

• The injury or condition — what happened, what was done, and the tissue-healing or condition constraints
• The activity being returned to — its actual physical demands, not the label
• Current status — objective measures, symmetry, capacity, and symptom behaviour under load
• The pressures — a season, a job, a deadline, or a patient's own impatience, named openly
• The team — the surgeon, physician, coach or employer involved, and who holds the clearance decision

Framework: Criteria Set in Advance, Demonstrated Under Load, Reintroduced Gradually

1. Define the demand precisely. 'Return to work' means nothing; 'lifting 20 kg from floor to waist, forty times a shift' is testable. Test against the real demand.
2. Set thresholds before the decision is live. Criteria written under pressure bend. Written at week two, they hold at week twelve.
3. Test under representative load and fatigue. Capacity when fresh tells you little about the fortieth lift or the eightieth minute.
4. Use symmetry and capacity together. Symmetry alone can be achieved by both sides being poor.
5. Grade the reintroduction. Full demand on day one is where re-injury concentrates. Stage it, and define what triggers a step back.
6. Be honest about residual risk. Meeting criteria reduces risk; it does not remove it. The patient is entitled to know that before deciding.
7. Record the decision and its basis. Who decided, on what evidence, what was explained, and what the patient chose — particularly where the patient elects to return early against advice.

Deeper Material

• references/worked-example.md — an ACL return three weeks before a play-off, declined against criteria written 24 weeks earlier. Read it when the shape of a good output is unclear, or to calibrate how specific the entries should be.

Output Format

Return-to-activity plan: [patient] · [injury/condition] · [target activity] · [date]

Target demand: [the specific physical demands of the activity, quantified] Constraints: [tissue healing, surgical protocol, medical restrictions — and who set them] Pressures: [named openly — season, employment, deadline, patient impatience]

Stages

Stage	Activity permitted	Criteria to progress	Tested how
1
2
3
Return

Test battery

Test	Threshold	Under fatigue?	Result	Date	Pass

Graded reintroduction

Week	Volume	Intensity	Contact/load	Step back if

Residual risk discussed: [what remains uncertain, what the evidence does and does not support, what would raise risk] · Patient's understanding: [recorded]

Decision: [cleared / not cleared / cleared with restrictions] · By: [who holds this decision] · Evidence relied on: [which criteria met] · Not met: [any, and the reasoning for proceeding]

Monitoring after return: [what is watched · by whom · what pauses the return]

The clearance decision belongs to the treating clinician, made with the patient and the relevant medical team, against the constraints set by the treating surgeon or physician. This structures the reasoning and the record; it sets no threshold, clears no individual, and replaces no clinical judgement or governing-body protocol.

Quality Checks

• The target demand is quantified, not named
• Thresholds were set before the decision became live
• Testing includes performance under fatigue and representative load
• Symmetry is assessed alongside absolute capacity
• Return is graded, with explicit step-back triggers
• Residual risk was discussed and the patient's understanding recorded
• The decision, its evidence, and any unmet criteria are documented
• The clearance decision sits with the clinician who holds it

Anti-Patterns

• Time-based clearance. Weeks since surgery say nothing about capacity.
• Testing fresh only. Re-injury happens tired, and so should testing.
• Symmetry as the sole criterion. Both sides can be equally deconditioned.
• Setting criteria during the decision. They bend to the pressure in the room.
• Full demand on day one. The single highest-risk moment in the whole process.
• Skipping the risk conversation. The patient cannot consent to a risk nobody described.
• No record of who decided. Matters enormously if something goes wrong.
• Letting the pressure hold the decision. Name it, and keep the decision where it belongs.

Example Trigger Phrases

• "Set return to sport criteria after ACL reconstruction"
• "Is this patient ready to go back to work?"
• "The coach wants them back this week — how do I handle that?"
• "Design a graded return to running programme"
• "What should I test before clearing someone to return?"