Integrating functional performance, load tolerance, psychological readiness, and contextual factors in return-to-sport decision-making: a conceptual and practical framework

Return-to-sport decision-making is a central responsibility in sports physiotherapy, yet athletes may appear clinically recovered while remaining underprepared for the physical, psychological, and contextual demands of sport. This critical narrative review synthesizes key considerations relevant to return-to-sport decision-making and proposes a practical four-domain framework integrating functional performance, load tolerance, psychological readiness, and contextual sport demands. The framework describes an iterative process beginning with minimum clinical readiness, followed by development of a domain-based readiness profile, action-oriented interpretation, shared progression decision-making, and reassessment over time. It is intended to help clinicians identify readiness gaps, communicate progression decisions, and select graded progression strategies. Rather than serving as a validated prediction model, the framework is presented as a clinical reasoning aid to support individualized and context-sensitive return-to-sport decisions. Future research should evaluate its feasibility, reliability, and clinical utility across different sports, injury types, competitive levels, and resource settings.