Return-to-Play in Sports & Exercise Medicine across Upper-, Low- and Middle-Income Countries: A Scoping Review of Athlete Outcomes.

Abstract

Introduction: Organized sport is expanding across low- and middle-income countries (LMICs), but structures for safe, well-governed return-to-play (RTP) remain poorly described. RTP underpins the entire process of care across Sports and Exercise Medicine (SEM) phases of intervention and return to competition. Objectives: To examine how RTP is practiced within elite and sub-elite athletes engaged in organised sport among OECD classified UMICs (Upper Middle Income Countries), LMICs (Lower Middle Income Countries) and LICs (Lower Income Countries) the structures and content of RTP processes, criteria and timelines, the use and documentation of shared decision-making (SDM), integration of mental-health assessment and referral, and record-keeping, alongside athlete outcomes and process indicators where available. Methods: A scoping review of publications from six databases identified studies reporting RTP processes for athletes in LMICs; two reviewers independently screened and extracted data. Results: Searches yielded 4,396 publications. 117 studies were included, mostly from upper-middle-income countries and focused on musculoskeletal injury (N= 65%), especially ACL (N= 28.2%). Few studies reported formal, phase-based RTP protocols (N= 34.2%), graded progression, or systematic psychological assessment, and many decisions relied on clinician judgment without clear documentation. Conclusion: RTP in LMICs is often clearance-focused, and rarely phase-based or biopsychosocial. Comprehensive yet simple, context-adapted RTP frameworks, better documentation, and integration of mental-health assessment across the entire RTP continuum are needed to support safer, more consistent returns to sport.