Beyond Multidimensional Assessment: A Sequential Framework for Return-to-Play Decision-Making—A Narrative Review

Return-to-play (RTP) decision-making after musculoskeletal injury is increasingly recognized as a multidimensional process integrating clinical recovery, physical capacity, sport-specific performance, psychological readiness, and workload tolerance. However, current guidelines remain heterogeneous in how these domains are assessed, sequenced, and integrated into progression decisions. This narrative review synthesizes current evidence on RTP assessment and proposes a sequential multidimensional framework to address this implementation gap. The framework is based on four principles: prerequisite capacity, complementary assessment, progressive specificity, and multidomain integration. Assessments are sequenced when meaningful biological or functional dependencies exist, while psychological readiness and workload tolerance are evaluated longitudinally throughout rehabilitation. Rather than prescribing a universal test battery or clearance threshold, the framework emphasizes selecting the smallest set of valid, complementary, and non-redundant assessments needed to answer stage-specific clinical questions. Discordant findings are used to identify limiting capacities and guide reassessment rather than being reduced to a global pass/fail decision. As RTP approaches, assessment progresses toward increasingly representative sport exposure, with final clearance integrating all relevant domains, sport-specific demands, and contextual risk tolerance. The proposed framework should be considered a clinical reasoning model rather than a validated predictive algorithm. Prospective studies are required to determine whether this approach improves RTP decision-making and subsequent outcomes.