International Ski and Snowboard Federation (FIS) consensus statement on return-to-performance in competitive alpine and freestyle skiers and snowboarders

Abstract

Returning to a high level of performance after injury is a significant challenge for athletes. However, current best practices for return-to-performance in competitive snow sports are not well understood due to a lack of research evidence and international harmonisation. The International Ski and Snowboard Federation commissioned this consensus statement to provide recommendations for the safe and successful return of competitive alpine and freestyle skiers and snowboarders to competitive performance. An international consensus panel was formed to contribute their knowledge and perspectives on return-to-performance. The panel included experts with extensive experience in return-to-performance. The panel consisted of 23 experts (7 women and 16 men) from various skiing and snowboarding disciplines and levels of competition. It included 16 researchers, 6 snow sports or International Olympic Committee officials, 9 physicians, 6 physical therapists, 2 sports psychologists, 2 coaches and 2 former athletes, some of whom had two backgrounds/functions. However, it was disproportionately European (78%) and North American (13%), with minimal representation from South America (4%) and Africa (4%) and no representation from Asia or Australasia. The RAND-UCLA Appropriateness Method was adopted for the underlying consensus process. First, the panel discussed which topics and questions should be included in the consensus statement before developing an overall structure. The consensus process then involved providing key content based on the literature or statements from experts/panel members. These were voted on three times by all the panel members, resulting in a list of 196 statements. The jointly developed overall structure and the final statement list then formed the basis for preparing the manuscript. This consensus statement aims to assist athletes, coaches and medical staff of international and national federations in planning and implementing safe and successful return-to-performance strategies for competitive alpine and freestyle skiers and snowboarders.

Introduction

Participation in competitive snow sports involves a substantial risk of injury.¹,¹⁴ Compared with other Olympic sports, snow sports such as alpine and freestyle skiing and snowboarding are associated with a particularly high risk of acute and overuse injuries.⁷,¹² These injuries commonly affect the head, knee and spine, whereas ruptures of the anterior cruciate ligament (ACL) are among the most common severe injuries.^{12 4},^{6 9 14} Injuries can significantly impair the future sporting careers of snow sports athletes,^{15 16} and return-to-performance (RTP) represents a major challenge.¹⁷,²⁰

In the last 15 years, interest in and recognition of the complexity of risk management and RTP in competitive alpine and freestyle skiers and snowboarders has increased, with a predominant focus on alpine skiing, ACL injuries and physical RTP.¹⁵,¹⁸²¹ However, there are still only a few sport-specific and holistic RTP protocols, including on-snow considerations and/or a more holistic biopsychosocial perspective.^{21 38 40} Moreover, there is a lack of sport-specific best practice guidelines, and some significant discrepancies between research and real-life practices exist. Such limited and/or discrepant information sources, along with a lack of guidelines, may result in uncertain outcomes and a premature return to high-risk activities, which could jeopardise long-term career success.

This consensus statement was commissioned by the Athlete Health Unit (AHU) of the International Ski and Snowboard Federation (FIS) and aims to provide consensus-based recommendations for safely and successfully planning and implementing RTP for competitive alpine and freestyle skiers and snowboarders. It particularly addresses the questions of WHY, WHAT, HOW, WHEN, WHERE and the WHO in relation to snow sport-specific RTP. Athletes, coaches, medical staff of international and national federations, and researchers may use it as a guiding document.

Methods

Panel selection

The lead author (JSp) was commissioned by FIS AHU to develop, together with an international expert group, evidence-based recommendations for best practices regarding the safe and successful RTP of competitive alpine and freestyle skiers and snowboarders. JSp acted as the panel chair, and he worked with EV, the senior author, to manage the consensus process. There was no further steering committee. 23 RTP experts were selected and invited by email to participate in an international consensus panel. The selection of potential experts with topic-relevant knowledge was based on personal contacts via the FIS AHU and International Olympic Committee (IOC) Health, Medicine and Science networks, as well as suggestions from National Skiing and Snowboarding Associations (NSSAs) or National Olympic Committees (NOCs) where such direct contacts existed. Even with the best of intentions, a certain selection bias of such a procedure cannot be ruled out, meaning that potential contributors may have been overlooked a priori. Researchers and NSSAs/NOCs/FIS/IOC team members (eg, officials, physicians, physical therapists and coaches), as well as former athletes with extensive experience in RTP, were eligible for inclusion. The panel members did not receive any incentives or financial compensation for participating in the process. All panel members, who are listed by name, along with their institutions and geographic locations in the author information, served as the authors of this consensus statement.

Equity, diversity and inclusion statement

A diverse international consensus panel was selected to represent the topic of RTP in competitive alpine and freestyle skiers and snowboarders. The panel was chosen to reflect differences in gender, nationality, professional background, competition level and snow sports discipline. However, we acknowledge that, despite our efforts to the contrary, certain perspectives, interests, groups and countries have limited representation. Notably, female representation on the panel was limited (7 women and 16 men), with disproportionate representation of European (78%) and North American (13%) experts and underrepresentation of those from South America (4%) and Africa (4%). Furthermore, experts from Asia and Australasia-Oceania were absent.

To ensure the maximum diversity of perspectives on snow sport-specific RTP, several factors had to be considered, such as snow sports disciplines, given roles and responsibilities within national and international snow sport federations, professional and national backgrounds, and sex. Despite our efforts to counteract this, unfortunately, women were underrepresented among the consensus panel members. At least, all panel members have experience of working with both male and female snow sports athletes who have recovered from injury. This means that the specific challenges that female athletes face when returning to performance can be considered adequately addressed. The lack of additional experts from Asia and Australasia-Oceania was primarily due to the absence of topic-relevant personal contacts within our accessible networks. In this context, international networking under the umbrella of FIS AHU should be further expanded and strengthened in the future.

To address the aforementioned limitations regarding equity, diversity and inclusion within our consensus panel, the proposals for the voting statements not only came from consensus panel members but were also derived from a systematic literature review on alpine skiing⁵² and based on a qualitative study on the perspectives and current practices of expert stakeholders of the corresponding competitive snow sports communities.¹⁸ This ensured that the voting statements also reflected the perspectives and experiences of individuals other than those of the consensus panel members.

Patient and public involvement

To foster active patient and public involvement, a former world-class alpine skier (TW) with substantial RTP experience was included in the consensus panel. Her task was to speak up for the athletes and ensure that any ideas generated in the meetings could be put into practice. Moreover, insights into freestyle disciplines were provided by another panel member (LB). LB’s perspective was that of a former world-class freestyle snowboarder, as well as a current team physiotherapist and researcher in freestyle skiing and snowboarding.

Evidence review

The panel chair conducted a PubMed search to identify topic-relevant literature prior to the consensus process on 20 August 2022 and before the manuscript was written (last updated on 6 May 2025).¹⁵,¹⁸²² Two additional articles not indexed in PubMed were added based on a key author search.^{21 43} This literature was made available to the panel members in the form of a digital data repository. The key search terms used were ‘alpine ski*’, ‘freeski’ or ‘freestyle ski*’ and ‘snowboard*’. All the considered studies related to the RTP of alpine and freestyle skiers originated from the field of competitive sports and were published in 2010 or later.

Owing to the relatively small number of studies that met these criteria,¹⁵,¹⁸²¹ we decided not to summarise the research findings systematically (ie, no data extraction or synthesis) but rather to make them accessible to the consensus panel members as full-text resources in a digital repository. It was considered manageable for the panel members to read the provided full-text articles individually to obtain an overview of the current state of knowledge as a basis for further panel discussions.

Consensus process

The process adopted the same approach as a previous study⁵³ and was based on the RAND-UCLA Appropriateness Method.⁵⁴ Three online consensus group meetings and three voting rounds were held until a final consensus was reached. Online supplemental file A summarises the detailed process for the development of this consensus statement. The strength of the chosen methodological approach lies in its ability to combine the limited published scientific literature on the topic of RTP in competitive alpine and freestyle skiers and snowboarders with the wide-ranging practical experience of experts in this field.

Owing to significant differences between snow sports governed by FIS https://www.fis-ski.com/inside-fis/organisation/about-fis/facts-figures and given that most members of the RTP expert panel have professional backgrounds in alpine skiing, freestyle skiing or snowboarding, the final version of our consensus statement covers only these sports. This differs from our original intention to cover all snow sports. Further initiatives are therefore needed to address RTP in other snow sports. However, some of the more general recommendations could be transferred to other disciplines with similar organisational frameworks, such as cross-country skiing, ski jumping, Nordic combined, biathlon and ski mountaineering.

Consensus results

Online supplemental file B presents the full list of the 196 statements that were derived, discussed and voted on during the consensus process. In the following, references are made to individual statements, numbered according to this list with #1 to #196.

Online supplemental file C summarises the voting results and choices of action made during the three rounds of voting.

Consensus definitions

To ensure consistent terminology relating to RTP for competitive alpine and freestyle skiers and snowboarders, the following definitions and explanations are proposed.

Key terms

Rehabilitation involves surgical intervention for the injury, if needed, followed by complete healing of the injured area and recovery of full physical, technical, tactical and mental capacities; it also involves regaining basic performance and returning to sport, as well as taking any preventive measures to reduce the risk of subsequent injury. (#28; #30; #31; #32; #37).⁵⁵ It begins when the injury occurs and ends when athletes reach the predefined multifactorial benchmarks (#127a).⁵⁵ Physical and psychological rehabilitation and training must go hand-in-hand (need for a biopsychosocial approach) (#29), and rehabilitation should address the athlete as a whole—sleep, nutrition, training schedules and psychosocial elements (#33).¹⁷,²⁰⁵⁵ In snow sports, rehabilitation additionally encompasses the reintegration of the athlete into the sport context and the resumption of sport-specific activities on snow (#38).

To distinguish it from the term rehabilitation, we recommend using the term training once athletes have fully returned to their regular teams. This may include unrestricted activities with an initial focus on physical, mental, technical and tactical improvement (early team training) and, later, with a competitive focus (regular team training).

RTP framework for competitive alpine and freestyle skiers and snowboarders

In accordance with the ‘2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern’,⁵⁵ our consensus panel considers RTP as a continuum with different phases and milestones, which should include biological, psychological and social aspects to inform best practices and shared decision-making. Moreover, we believe that a meaningful RTP framework must be simple and independent to be applicable and scalable (#111). With this in mind, we propose the following RTP framework for competitive alpine and freestyle skiers and snowboarders, as outlined in figure 1. The entire RTP process should ensure strong athlete commitment, interprofessional collaboration, clear communication and a high level of mastery (#90).¹⁷ Accordingly, responsibilities and information should be transferred smoothly and without strict boundaries between the RTP phases led by the medical team (surgeons, sport physicians, or any physician in charge of treatment), the physical therapy team (physiotherapists involved), the physical and mental performance team (interdisciplinary team consisting of strength and conditioning experts, sports scientists, and sports psychologists), and the coach responsible for the on-snow training.¹⁸ Both the rehabilitation and training phases should be evidence-based and informed, with ongoing clinical and functional monitoring and assessments.

Figure 1. Overall RTP framework for competitive alpine and freestyle skiers and snowboarders. RTP, return-to-performance.

Medical team-directed rehabilitation

Postinjury, presurgery, postsurgery

The medical team-directed rehabilitation phases include the postinjury, presurgery and postsurgery phases. During the postinjury phase, presurgery and postsurgery phase, immediate care in the acute phase is crucial; it should be provided in accordance with the type of injury and the available resources (#112).

The focus of the postinjury phase should be on wound healing, reducing swelling, normalising gait, restoring range of motion (ROM), assessing mental health and making a joint decision about treatment options.^{21 38 40} If surgery is needed, the ideal timing is dependent on the injury type, and earlier surgery is not always better; accordingly, decisions regarding surgeries should consider all relevant factors and be guided by a team of clinical experts (#113).

Prehabilitation activities during the presurgery phase, that is, preparing injured athletes for subsequent medical procedures by optimising their physical and mental health beforehand, should be considered and planned whenever indicated and feasible.

During the postsurgery phase, managing pain, reducing swelling, promoting early mobilisation and re-establishing neuromuscular function may be appropriate strategies (#114). In terms of pain management, it is important to keep in mind that pain is influenced not only by tissue damage but also by a range of emotions and contextual factors, which should be addressed by means of a comprehensive approach.⁵⁶

Physical therapy-directed rehabilitation

Physical therapy-directed rehabilitation consists of an early rehab phase with the aim of returning to activity and a mid-rehab phase with the aim of returning to snow.

Early rehab (return-to-activity)

Early rehab focuses on eliminating swelling, passive and active unloaded motion, maintaining general fitness (aerobic capacity, trunk strength and uninjured limb strength), regaining normal ROM, and promoting the progressive build-up of restricted off-snow activities with appropriate load control (#2; #5; #115).^{21 40} In this context, return-to-activity refers to the transition from early rehab to daily activities, basic functional movement tasks (#1). Following the back-to-activity decision, resuming modified sessions with the team on drylands may be considered (#3).

Mid-rehab (return-to-snow)

Mid-rehab aims to increase muscle strength (concentric and eccentric) up to the forces typical of snow sports; additionally, proprioceptive training, cognitive training and improvements in motor control, landing and dynamic movements may be possible training contents, depending on the type of injury (#116). Return-to-snow can be understood as a return to restricted on-snow skiing or snowboarding performed in a controlled, supervised, graduated and progressive manner (#8), including free skiing or snowboarding, starting with the absolute basics and progressively building up in terms of various parameters, such as sport-specific equipment, slope conditions, terrain, visibility and forms of exercise (#12).^{21 40} Following the back-to-snow decision, which should be based on predefined clinical/functional criteria and shared decision-making, performance team-directed on-snow sessions under the supervision of a coach, starting with easy and basic exercises, may be considered (#7).

Performance team-directed rehabilitation and training

Late rehab (return-to-sport)

Late rehab aims to maximise muscle strength and power, incorporating plyometrics, challenging obstacle courses, sport-specific movements, as well as technique-oriented on-snow training with increasing load, which could be targeted (#117). In the snow sports context, return-to-sport is the resumption of sport-specific training close to the typical training or competition form (eg, training in gates or snow parks) (#13); furthermore, it refers to a progression from supervised or modified training, both on-snow and off-snow, to unsupervised or unmodified activity (#14).⁴⁰ The back-to-sport decision encompasses the ability to engage in ‘normal’ skiing or snowboarding activities, such as free skiing or riding and training (#17).

Early team training (return-to-competition)

Early team training focuses on muscle strength and power maintenance, regular training with no flare-up of joint pain or effusion at the injury site, as well as no altered movement patterns or sporting postures, and on-snow training under different conditions (snow, visibility, terrain, temperature) could be attempted (#118). Return-to-competition can be considered the phase during which athletes prepare for exposure to stressors that may accompany competition participation after injury and performance-oriented execution of the sport; however, athletes’ performance level may be lower than their preinjury level (#18; #19; 20).²¹ Athletes should not return to competition at any level when they have significant physical or mental deficits that could impair their ability to compete safely (#21). In this context, it is essential to note that athletes may continue to exhibit functional performance deficits even after returning to sport^{22 57}; therefore, such deficits should be closely monitored and addressed even during early team training until they are fully resolved. The back-to-competition decision refers to the check point at which the athlete is entirely ready to resume participation in competitions.

Coach-directed training

Regular team training (RTP)

Regular team training means skiing or snowboarding without altered movement patterns (#120). There should be no flare-ups of pain or effusion following early snow training and no psychological concerns (#120). Moreover, there should be ongoing strength and plyometric work, and the athlete should have achieved 100% of the baseline measure or more (#120) or at least age, sex and level-appropriate reference values. The athlete may return to regular team training before being physically and mentally ready for a full, ordinary training load, provided that adequate modifications to the training can be made (#119). RTP refers to regaining the ability to perform at a high level with minimal or no physical or mental hesitation or impairment (#25). Reaching the back-to-performance endpoint means that the athlete has returned to an equivalent or higher performance level (eg, physically, mentally, technically and tactically) (#22,#26) and finally reflects stable competitive performance (#27). However, it is important to acknowledge that RTP may occur after an athlete has returned to competitions (#21).

Consensus recommendations

While there is a large body of evidence and consensus recommendations on injury type, injury severity and/or sport-specific considerations during rehabilitation up to the back-to-sport decision (which are also directly applicable to snow sports injuries),^{1755 58},⁶⁹ the following section focuses particularly on the later phases of RTP, for example, the performance team-directed and coach-directed off-snow and on-snow RTP activities, as well as the questions of ‘why’, ‘how’, ‘when’, ‘where’ and ‘who’ in the context of snow-sport-specific RTP, are important. Unfortunately, little is currently known about these later phases, for which sport-specific content is crucial. Accordingly, most of the statements in our consensus paper were not previously covered by any relevant guidelines. If they were, direct reference is made to the corresponding publications in the following sections.

Table 1 summarises the key content and recommendations presented in this FIS consensus statement on RTP for competitive alpine and freestyle skiers and snowboarders. Importantly, the number of scientific studies on RTP in competitive alpine and freestyle skiers and snowboarders remains limited to date, emphasising the urgent need for further research on RTP approaches in these sports. Accordingly, our recommendations provide current information on best practices, which are not entirely evidence-based.

Table 1. Overview of this consensus statement’s main contents and recommendations for the return-to-performance (RTP) of competitive alpine and freestyle skiers and snowboarders.

Topic	Contents/recommendations
RTP–WHY?	Structured RTP can enhance performance by addressing weaknesses and refining the quality of physical and mental skills. Adequate RTP may reduce the risk of subsequent injury, but an early return-to-sport can increase the risk. High-quality RTP before returning to sport can help prevent long-term health issues.
RTP–WHAT?	The RTP process should involve a phased approach. It begins with off-snow rehabilitation and psychological training, followed by a gradual progression of on-snow activities under the guidance of professional supervision. While there is a large body of evidence on what to consider during off-snow rehabilitation up to the back-to-sport decision, our consensus recommendations particularly focus on the later phases of RTP, for example, the performance team and coach-directed off-snow and on-snow RTP activities.
RTP–HOW?	The RTP process should be athlete-centred, with interprofessional collaboration ensuring clear communication and realistic expectations about recovery and potential setbacks. It should combine time-based and clinical/functional criteria-based rehabilitation to ensure safer and more effective progress. For athletes recovering from severe injuries, mental health screenings, such as the SMHAT-1, are essential to support their psychological well-being throughout the process.
RTP–WHEN and WHERE?	Generally, it is recommended that athletes avoid returning to sport prematurely; however, exceptions may be made for major events like the Olympics or World Championships, with the decision based on the athlete’s age, career timing and specific circumstances. Following any severe injury, the athlete should be informed about the risks associated with continuing their career. Whether or not to end a sports career due to injury may depend on the athlete’s opinion, career stage and injury history. The medical team should, however, advise termination when full recovery is deemed impossible, although no universal criteria exist. Rehabilitation can be home-based, offering comfort and cost savings, but it may lack expert care. Alternatively, it can be centralised, providing access to specialists and better monitoring, but possibly causing loneliness and added stress from comparisons with other athletes.
RTP–WHO?	For a successful RTP process that follows a biopsychosocial approach, clear communication, defined roles and an interprofessional team are needed. This interprofessional team should include physicians, physiotherapists, coaches and a mental health/performance expert. Each team member should have specific responsibilities and contribute to coordinated efforts and open communication throughout the RTP process.
Contextual adaptations	An effective RTP process requires a personalised approach, considering factors such as the individuality of the athletes, the specifics of their actual and previous injuries, their training age/biological maturation/performance level, the snow sport discipline in which they participate and their sex/gender. It must also consider contextual factors such as access to support and specialised equipment, as well as the athlete’s environment. This is particularly important for young athletes, as rehabilitation must be tailored to the available resources and the athlete’s specific needs.
Complementary measures	To support RTP activities, complementary measures include organisational steps like ensuring superior health insurance and access to relevant clinical and sports facilities. Additionally, efforts such as educating athletes on the recovery process, offering mentorship from former injured athletes and utilising data-driven metrics like strength tests and functional assessments are considered crucial to monitor and guide progress.

SMHAT-1, Sports Mental Health Assessment Tool 1.

RTP–WHY?

RTP activities may target performance recovery, prevention of subsequent injury and avoidance of long-term health impairments.

Performance recovery/enhancement

Athletes may recover their performance during the RTP process if the process is structured, disciplined, athlete sensitive, based on best practices and conducted with patience. (#67). For example, a long period of late rehab and return-to-sport activities, during which time and focus are placed on sporting elements that are not usually given attention during the normal season or persisting deficits, may even improve performance levels once full recovery has been achieved. (#34; #65). Moreover, supervised exercise may improve any technical ability that may not be optimal before injury (#66), and the time during the injury could be used for reflection, analysing their work, improving their system and working out new directions and goals (#68).

Prevention of subsequent injury

There is evidence of a high risk of subsequent injury, highlighting the importance of adequate rehabilitation time (#76). With respect to subsequent ACL injuries, for example, the risk of injury to the ipsilateral and contralateral knees is as high as 25% (#83),¹⁵ and evidence suggests that early return-to-sport after ACL reconstruction is associated with a higher rate of subsequent injury than in athletes who wait at least 9 months before returning to the snow (#78).⁷⁰ There is also evidence regarding increased ACL injury rates within the first 12 months following a concussion (#79).⁷¹ Accordingly, we consider it highly relevant that, before making back-to-sport and back-to-competition decisions, a comprehensive assessment of the injured athlete is performed (#69), and simple decision frameworks and rules are considered.^{70 72} For the prevention of subsequent injury, improving awareness, physical form and risk management (#71), as well as active mental training programmes to progressively rebuild confidence, achieve ideal physical intensity, ensure effective focus and manage emotions (#72), are considered helpful.

Avoidance of long-term health impairments

Returning too early may not only increase injury risk but also negatively impact long-term health (#73). Accordingly, to avoid long-term health effects, sufficient recovery before individuals return to sports is crucial (#74).

RTP–WHAT?

RTP may include a variety of off-snow RTP activities, restricted on-snow RTP activities and unrestricted on-snow RTP activities.

Off-snow RTP activities

Physical rehabilitation and training

Physical rehabilitation and training should be based on adequate increases, constant clinical/functional monitoring and appropriate measure adjustment (#86).^{1755 58},60 66 68 69 The key questions for planning the physical RTP process are as follows: What is the athlete’s training history and age? Which professionals are required at each stage? Who will lead each stage or the overall process? (#87). Tissue healing and functional physical recovery do not necessarily occur simultaneously; both need to be monitored and addressed during rehabilitation after an injury (#88). Injuries can potentially affect remote tissues, structures and neural control of movement, resulting in a detraining effect on the non-injured side or area (#89). Additionally, neurocognitive deficits following injuries may need to be addressed.^{27 46} For more specific recommendations regarding physical rehabilitation and subsequent training for different types and severities of injuries from a multisport perspective, we refer to previous consensus statements, which may also be applicable to competitive alpine and freestyle skiers and snowboarders.^{1755 58},⁶⁹ However, it is important to note that, to date, there are no snow sports-specific international standards; such standards should urgently be addressed in future research efforts.

Psychological rehabilitation and training

The entire RTP process should be accompanied by phase-specific mental training sessions and assessments (#118a),⁵⁵ particularly in patients with higher levels of kinesiophobia and lower psychological readiness for RTP.^{73 74} Accordingly, the physical medical care team should collaborate with mental healthcare experts.⁷⁵ For psychological rehabilitation and training, the focus should be on cultivating positive mindsets; setting goals; boosting motivation, confidence and focus; and promoting autonomy and stress management. All these factors may be supported by self-talk, mental imagery and discussions with and learning from peers who have been injured (#91, #92).¹⁷⁷⁵,⁷⁷ To sustain their connection with their athletic identity, athletes should adopt the right mindset, which is that ‘rehab is (physical and psychological) performance training’ (#35) and ‘rehab can make me better’ (#36).¹⁷ Moreover, it is important to keep athletes involved in their sport while avoiding premature return-to-sport.⁷⁷ For more detailed recommendations on psychological rehabilitation and training from a multisport perspective, please refer to an earlier consensus statement, which may also be relevant for competitive alpine and freestyle skiers and snowboarders.⁷⁵

Restricted on-snow RTP activities

In the late rehab phase, restricted RTP activities on snow may be reasonable. However, they must be carried out under well-controlled conditions and in a load-limited manner, progressing from basic tasks to more challenging tasks. More concrete examples of such on-snow activities can be found elsewhere.^{21 23 38 78}

Therapeutic on-snow sessions

Therapeutic on-snow sessions should begin with simple, highly controlled activities to help athletes regain their sense of moving on snow and their confidence (#93). These sessions should start at a basic level to ensure mastery (#94), gradually increasing in task difficulty, terrain difficulty, snow surface variation and session length (#95). Minimising external distractions may further enhance the effectiveness of these sessions (#96).

Technique-oriented on-snow sessions

Technique-oriented training sessions on snow should continue to gradually increase the difficulty of the slope or snow surface, the duration of the training session and the intensity of the exercise or session (#97). For effective technique-oriented on-snow sessions, on-snow coaches should be informed and involved as early as possible before returning to the snow (#98).

Unrestricted on-snow RTP activities

Once the medical, physical therapy and performance teams have collectively agreed on the back-to-sport decision, the injured athlete may return to team training, including unrestricted RTP on-snow activities with an increasing focus on performance.

Performance-oriented on-snow sessions

Regular performance-oriented on-snow training sessions should begin when the athlete can complete return-to-snow drills with no increase in pain or swelling and without compensatory movement patterns and should include a clear predefined progression plan (#99; #100).

RTP–HOW?

According to a previous study exploring the perspectives of high-performance snow sport stakeholders, RTP should be considered a continuous athlete-centred process supported by subject-specific experts and resources tailored to athletes’ needs.^{18 55} Additionally, a clear practical need was identified for more interprofessional collaboration and improved information flow between the different phases of RTP.¹⁸ Our panel considers the following aspects to be important in addressing the question of HOW to achieve successful and safe RTP for competitive alpine and freestyle skiers and snowboarders.

RTP as a back-and-forth process

Athletes need to be aware that rehabilitation (in the same way as the entire RTP journey) can progress in both forward and backwards directions (#168). In particular, interprofessional collaboration and systematic communication are crucial for addressing this back-and-forth during the RTP process (#101).^{18 38} The focus should not be on the RTP outcome but on what the athlete needs to do to fully return (#103).¹⁸

Realistic expectations about RTP

All persons involved need to be realistic regarding regression and progression along the continuum of RTP (#80).¹⁷ The majority of injuries allow athletes to return to sports after injury (#84), but factors that predict RTP are largely unknown, and caution should be taken when informing an athlete (#84a).⁷⁹

The most important thing regarding realistic expectations is to make the athlete understand that not all injuries are the same (#81). To successfully manage expectations, constantly providing perspective and emphasising patience are key (#192). When communicating expected times to return to sport, athletes should only be given the likely estimates of the upper-time and lower-time limits of RTP that are typical of their injury, not average times (#85).

Time-based versus criteria-based rehabilitation

According to stakeholders from the competitive snow sports community, RTP requires a clear structure and sport-specific orientation checkpoints.¹⁸ Typically, such orientation checkpoints during RTP can be time-based or criteria-based, ie, based on predefined clinical, functional or performance criteria to be assessed with specific protocols and test batteries.^{17 55}

Time-based RTP checkpoints are a minimum guide with respect to the biological healing time (#48). However, they are only rough estimates and may provide only a gross temporal orientation for planning RTP (#49). Moreover, they may promote realistic expectations (#50). The disadvantage of time-based RTP is that the timeline may deviate from the current rehabilitation state in individual cases in terms of the healing process and functional development (#51; #52). Injuries in snow sports are complex and multifactorial, so it is challenging to set strict time limits for common injuries (#60).

In contrast, criteria-based RTP checkpoints allow more individualised progression to better link relevant elements of recovery, especially for athletes without immediate support networks (#53; #54). Their focus on concrete rehabilitation content helps structure the process and guide decisions (#55; #56), increasing practical relevance (#61). A disadvantage of criteria-based RTP may be, however, that if not all (from a biopsychosocial perspective) relevant criteria are considered and monitored, a premature transition between the RTP phases may occur (#58).

In conclusion, a combination of both time-based and criteria-based RTP approaches may allow individual progress to be made in a safer environment than either approach alone (#62). However, it is nevertheless important to note that the specific constellations that may arise in individual cases may make it difficult to plan the time of rehabilitation when following a criteria-based approach (#57) and that snow sport-specific objective criteria are widely lacking for the later rehabilitation phases (eg, on-snow training) (#59).

Back to baseline values versus back to norm values versus striving for the optimum

Following longer training absences, back-to-sport tests are recommended (#105). In this context, baseline data may be helpful as a target, provided that pre-injury values are sufficient to meet sports demands (#40). Regarding the ultimately desired outcome of rehabilitation (eg, the criteria for the back-to-sport decision), different goals may be pursued: back to baseline values, back to norm values and striving for the optimum.

PROs and CONs for a ‘comparison with preinjury baseline values’

A target comparison to preinjury baseline values is reasonable, assuming that the athlete was at 100% before the injury (#39). However, the preinjury benchmark may be inadequate for athletes who were previously unfit or not well trained. Moreover, youth athletes may not have completed pre-season testing or have comparable physical baseline markers for back-to-sport testing (#43).

PROs and CONs for a ‘comparison with normative values’

In the absence of any individual preinjury-baseline values, a potential solution is to use age-level-specific, sex/gender-level-specific and performance-level-specific benchmarks from non-injured athletes as targets (#42). Moreover, if individual baseline values are poor, normative values originating from a comparable population are likely to be a better reference point (#44). However, if the normative values do not originate from a comparable population, they might be useless; the question then arises as to whether the target should be the norm or the ‘poor’ individual optimum (#45).

PROs and CONs for ‘striving for the optimum’

Baseline data (both individual preinjury-baseline values or normative values) should not act as ‘the’ only goal but should be used to supersede through rehabilitation (#41). In this context, top performers may use top performers as a target (#46). However, if the optimum is not matched to a specific population, such a reference may be useless (#47).

Differences between severe and non-severe injuries

Severe injuries and surgeries are considered major life events for elite athletes (#106). Accordingly, severe injury or surgery should trigger the use of the IOC Sports Mental Health Assessment Tool 1 (SMHAT-1) to screen for potential mental health symptoms and disorders (#107).⁸⁰ In such cases, we recommend performing SMHAT-1 (1) after the injury, (2) after the surgery and (3) at injury-specific follow-ups.⁸⁰

The SMHAT-1 consists of (1) triage with an athlete-specific screening tool, (2) six subsequent disorder-specific screening tools and (3) a clinical assessment (and related management) by a sports medicine physician or licenced/registered mental health professional (#109).⁸⁰ It was designed for licensed health professionals to evaluate elite athletes (≥16 years) at risk of or experiencing mental health issues (#108).⁸⁰

In contrast, the IOC Sports Mental Health Recognition Tool 1 was developed for athletes and their entourage (eg, friends, family and coaches) to help detect mental health concerns early, for example, during recovery from injury (#110).⁸⁰

RTP–WHEN and WHERE?

When should an athlete return to competition?

Athletes should principally be discouraged from returning to competition prematurely. However, under certain circumstances, depending on age and the timing of career, exceptions may be indicated (#130). Exemplary circumstances under which even an early return-to-competition is discussable include major events such as Olympic Games or World Championships, or potential impacts on overall cup standing; in such cases, the athlete may take conscious risk (#128). The minimum criteria under which an early return-to-competition may be considered are athlete-dependent and situation-dependent (#129).

When is it time to end a sports career due to injury?

Following an injury, depending on its severity, the athlete should be informed about the potential risks of continuing their career and, once all efforts have been exhausted and the sports medicine team reaches a consensus that full recovery is impossible, be made aware of this outcome (#132; #134).⁸¹ Whether the termination of a sports career should be considered depends on the athlete’s opinion, career stage, injury history and the significance of the ongoing risks associated with continued participation in the sport (#133). However, there is often a lack of single or universal criteria for advising athletes to stop participating in sports, which is why clinicians should provide athletes (and their families or guardians) with the scientific facts and uncertainties of the available evidence.⁸¹

Home-based versus centralised rehabilitation

Rehabilitation can be organised in either a more home-based setting or a more centralised setting.

Home-based rehabilitation enables athletes to remain within their familiar support network of family and friends, thereby reducing travel costs related to rehabilitation while enabling them to continue with their regular school, college or work activities; however, this may also result in suboptimal care if access to expert training facilities is limited (#136; #137).

Centralised rehabilitation provides athletes with access to specialised care, expert monitoring and testing opportunities, and efficient communication, as well as motivational incentives for other recovering athletes who are also on site; however, it may also lead to loneliness due to the absence of family and friends, and constant comparisons with peers can cause pressure, frustration or stress since each injury and recovery process is unique (#138; #139; #140; #141; #142; #176).

The key questions regarding the choice of home-based vs centralised rehabilitation are as follows: where is the athlete based? Are they able to see the rehab support staff? If not, are there recommended practitioners in that area? Can support be provided via video calls? Does the athlete have the necessary space and facilities for an effective video call or rehabilitation session? If physiotherapy is delivered by a local practitioner, who will take the lead—the local or team physiotherapist? (#166).

Regardless of whether rehabilitation takes place at home or a central location, if possible, we suggest that rehabilitation sessions be held from time to time at the same time and place as regular team training (motivational aspect for the injured athlete) (#143).

RTP–WHO?

Clear responsibilities, proper information flow and networking among those involved in RTP are key to working as an interprofessional team to ensure the safe and successful progression of RTP, particularly when moving from one specific phase to another.^{18 55} Ultimately, RTP should strive to be an athlete-centred process following the maxim of ‘one injury, one athlete, one process’.^{18 55} In this context, the following aspects should be considered when planning and implementing RTP activities.

A minimum team for a successful RTP process depends on the athletes’ needs; it may include the athlete, an orthopaedic and/or sports medicine physician, a physiotherapist and/or athletic coach, a mental coach and the coach responsible for on-snow training (#177).¹⁷ During the RTP process, it is critical to have a clear division of roles and tasks, with hierarchies kept as horizontal as possible and open communication among all team members (#149). Responsibilities, which depend on the composition of the interprofessional team, must be discussed and decided on early (#144).

Ideally, each expert is responsible for their specialty or phase. All efforts should be coordinated by a lead person for the RTP process; in many cases, a physical therapist is well-suited to take on this role (#145). Athletes should take an active part in the process and must have access to the knowledge they need to make decisions (#186). The team doctor should initiate any necessary medical or surgical referrals and investigations, communicate with medical or surgical teams as needed, and pass this information to the extended support team (#146). A strength and conditioning coach should be on board as soon as possible and work alongside the physiotherapist, psychologist and nutritionist if available (#147). The on-snow coach should be updated on the athlete’s rehabilitation progress and have access to medical support throughout the process since physical and mental recovery often remains incomplete when the coach overtakes the main responsibility (#148; #148a).

The athlete and the entire support network must work towards the same long-term goals at each rehabilitation phase (#151). They should stay informed of changes, coordinate their actions and involve the athlete in setting goals, conducting reviews and making decisions (#152; #153; #155).¹⁸ Open communication, possibly via a joint digital messaging group, a shared plan and a transparent presentation of monitoring and test results, especially during phase transitions, ensures a safe and efficient RTP process and guarantees that the athlete can understand all decisions and measures taken by the support network (#150; #154; #156).^{18 38}

Contextual adaptations of RTP activities

Athletes’ individuality and the specifics of their actual and previous injuries

An injury can jeopardise an athlete’s career. It may be a life-changing event with significant subjective meaning for the affected athlete, necessitating a highly individualised approach to returning to sport.^{55 82} Accordingly, a comprehensive individual athlete assessment at the start of the RTP process is recommended and may highlight specific areas to focus on (#158). For individually tailored RTP, the athletes’ experience, skills and fitness, as well as the type and severity of their injuries, should also be considered (#157). Regarding their history of previous injuries, the key questions that need to be considered are as follows: when did previous injuries occur? Why did previous injuries occur? Are there still ongoing rehabilitation needs following the previous injury? Are baseline measures lower than normative or ideal values due to the previous injury? (#161)

Training age/biological maturation/performance level

The specificity of the RTP content is dependent on the training age/performance level (#173) and should be aligned with athletes’ needs.⁵⁸

In youth-level athletes, training age and biological maturation should inform the RTP approach, not calendar age (#171). For youth-level athletes, developmental aspects such as restoring body function for lifelong activity, preventing further tissue damage and surgery, and minimising growth-related complications may be specific RTP priorities of particular importance.⁵⁸ Decisions on how to address injuries should be made jointly with athletes and all relevant stakeholders, taking into account the potential long-term consequences of the injury.⁵⁸ For example, youth-level athletes should be especially cautious not to return to sports prematurely after ACL reconstruction, as a rough estimate not before 12 months after surgery has been suggested.⁵⁸

Younger or less experienced athletes may require closer supervision during RTP, as they may progress more slowly, exhibit compensatory movements and require guided training to ensure that they use the correct technique (#160; #167; #170).⁵⁸ If athletes are under 18 years of age, their parents or legal guardians also play a significant role in supporting them during RTP (#178) in practical, emotional and financial ways. It is also recommended that the school or college environment becomes involved, as high expectations and pressures may originate there, taking up valuable time and affecting mental load and recovery (#169).

Barriers to RTP are often linked to access to support; as such, youth-level athletes in particular may not have access to professional support staff, specific equipment or specialised infrastructure, and their time, aside from school or college duties, and funding for a proper return-to-sport are limited (#164; #184). Another potential barrier may be that not all youth-level athletes have undergone a baseline testing protocol. In such cases, at least an in-depth physiotherapy assessment may help (#159).

Setting

RTP must be adapted to the availability of specialised resources (#162), as this availability can vary greatly depending on the country and continent. Accordingly, the current consensus statement, with a Europe-oriented panel, describes the ideal RTP scenario (when all necessary resources are available) rather than a scenario that can be applied to all situations in countries with fewer resources for competitive snow sports. In the latter case, RTP priorities must be set according to the specific situation. For example, indoor facilities such as ski halls and ski carpets could be options for RTP sessions, as they reduce travel time when long journeys are necessary for training on snow due to a lack of seasonal snow availability (#182). Moreover, conditions in ski halls or on the ski carpet are more predictable and stable, and there is often a local gym nearby, which facilitates ongoing late rehabilitation (#182).

Snow sports disciplines

In view of their wide-ranging similarities, the RTPs for competitive alpine and freestyle skiers and snowboarders do not differ significantly from one another, with the exception that freestyle disciplines require a return to acrobatic skills in a gym or on a trampoline before transitioning back to skiing/snowboarding skills on snow (#174).

Sex/gender

A gender-based approach should consider not only biological sex but also the sociocultural construct of gender (#175).¹⁷ Examples of gender-specific adaptations of RTP strategies from a gendered environmental perspective may include a female-specific perspective on injuries, sociocultural reservations of women against strength and conditioning, and gendered attitudes toward risk-taking or fear-coping strategies.⁸³

Complementary measures to support RTP activities

Organisational measures

Given the relatively high injury rates, competitive alpine and freestyle skiers and snowboarders, as well as their families, should be prepared for possible injuries. Accordingly, adequate insurance measures are recommended to be taken early in one’s career to have the possibility of professional care if needed (#183). Further organisational measures may include offering incentives for longer return-to-competition times (eg, by adjusting the FIS injury status to better protect pre-injury world ranking positions) and establishing FIS-labelled/supported RTP facilities to ensure a minimum level of RTP quality for athletes from smaller snow sports nations or those with less access to resources (#179;#185).

Educational measures

It is essential to educate athletes from the outset of the RTP process about the recovery journey, including its natural ups and downs, and strategies to cope with them (#191; #187). In particular, young athletes should receive structured guidance from national federations, and mentorship and peer support networks of formerly injured athletes can offer extra practical and emotional support (#180; #181; #188). Ensuring that all stakeholders understand the RTP process and the risks of premature return will further promote a safe, coordinated and effective return-to-sport process (#189).

Data/technology support

Objective metrics are essential for monitoring the RTP process and ensuring that all stakeholders have consistent information (#193).³⁸ These may include physical measures, such as isokinetic strength tests, jump and hop tests, and standardised functional performance assessments (#194)^{1721 30},^{33 36}; mental measures, such as the Athlete Fear Avoidance Questionnaire, the Tampa Scale of Kinesiophobia, or after ACL injuries, the 12-item Return-to Sport Scale (ACL-RSI).^{78 96 97} Daily monitoring of well-being, sleep, energy, injury, illness and training load should also be performed (#195).¹⁷ Knowledge of RTP test batteries and normative values can help athletes self-manage the process (#190). While data-driven decision-making supports RTP, it must be balanced with practical, implementable solutions (#196).

Conclusions

This consensus statement may serve as a guiding document for competitive alpine and freestyle skiers and snowboarders, as well as for coaches and medical staff from international and national federations and other entities, to help them plan and implement safe and successful RTP programmes after injury. It particularly focuses on the latest evidence- and expert opinion-based best practice recommendations for RTP regarding the WHY, WHAT, HOW, WHEN, WHERE and WHO questions. We hope that this will help address the lack of RTP guidelines specifically for the alpine and freestyle snow sport disciplines and the significant discrepancies between research, clinical practice and sporting practice by creating a framework that considers a biopsychosocial approach and the specific and complex nature of these sports. Moreover, this consensus statement is intended to stimulate further initiatives to fully address RTP in other snow sports disciplines, with specific recommendations and concrete RTP measures, tools and test protocols for different types of injuries.