Return-to-Sport/Activity Clearance Note (Non-Concussion Musculoskeletal)

Date: [Encounter date]

Patient: [Full name], [DOB]

Provider: [Provider name, credentials]

Referring Clinician/ATC: [Name and role] (Include only if applicable)

Reason for Visit: Evaluation for clearance to return to [specific activity] after [injury]

Injury Summary

[Primary diagnosis with body region and laterality; date and mechanism of injury; initial severity indicators (e.g., sprain grade, fracture type, instability episodes) when known; brief treatment course (immobilization, surgery, rehab, injections); relevant comorbidities affecting return] (Keep to one concise paragraph; omit exhaustive history unless it materially changes restrictions)

Activity Target

Sport/Activity: [Exact activity (e.g., soccer, CrossFit, warehouse work)]

Level/Context: [varsity / club / recreational / occupational]; [contact / limited contact / non-contact]

Position/Role and Key Demands: [Position or role and key physical demands such as cutting, pivoting, throwing, lifting, climbing] (If activity demands are unknown, state this explicitly and provide restrictions in functional terms)

Upcoming Events: [Events influencing timeline] (Include only if relevant)

Current Status

Subjective: [Current symptoms (pain location/severity, swelling, instability, weakness, numbness); functional tolerance with daily activities and sport-specific tasks; recent graded exposure in past 1–2 weeks; treatment adherence; patient-stated goals and perceived readiness] (Include brief direct quotes for critical statements about risk tolerance)

Objective Exam:

• Inspection: [Swelling, ecchymosis, deformity, incision/scar status, atrophy]
• Palpation: [Focal tenderness, warmth]
• Range of motion: [Active/passive with degrees; comparison to contralateral side]
• Strength: [MMT grades or dynamometry; note if pain-inhibited]
• Joint stability and special tests: [Named tests with results]
• Functional observation: [Gait, squat pattern, single-leg stance, sport-specific movement as relevant]
• Neurovascular status: [Sensation, reflexes, pulses, capillary refill]

(Document only what was examined; omit categories not assessed; avoid labeling items as "normal" unless directly assessed)

Functional Testing: [Test name, date performed, results with side-to-side comparison or limb symmetry index, pain during/after, movement quality observations, pass/fail against stated criteria] (Include only if formal functional testing was performed; if expected but not performed, state reason and note that clearance is based on exam findings and documented rehab progress; omit entirely if not relevant to the injury or decision)

Imaging Reviewed: [Modality, date, and clinically relevant impression; note whether images were reviewed directly versus report only] (Omit if no imaging was reviewed or indicated)

Assessment

[Current status of the injury (resolved / improving / persistent limitations); key objective findings supporting that status; residual impairments (ROM deficit, strength asymmetry, pain with specific activities); movement quality concerns, recurrent symptoms, or psychological readiness factors if present] (Do not introduce new patient-reported information here)

Clearance Determination

Clearance Status: [Not cleared for [activity] at this time / Cleared for modified participation (see restrictions below) / Cleared for full participation with conditions / Cleared for full participation without restrictions]

Effective Date: [Start date of clearance]

Valid Until: [Expiration or reassessment date] (Include if time-limited or contingent; otherwise omit)

Rationale:

• [Symptom status with activity and recent graded exposure]
• [Exam findings: ROM, strength, stability metrics supporting decision]
• [Functional test results or observed sport/work-specific tolerance]
• [Absence of adverse response to recent loading or criteria met per protocol]

Limitations of Today's Assessment: [Items not assessed that may affect certainty] (Omit if assessment was comprehensive for the decision)

Restrictions and Accommodations

Permitted: [Specific activities, practice types, and intensity levels allowed]

Not Permitted: [Movements, contact, or activities to avoid]

Limits: [Quantitative guardrails (e.g., load in lbs/kg, mileage, pitch count, work shift duration)]

Duration: [Start date through end date or until specified milestone]

Progression Criteria: [Who authorizes progression and objective criteria to advance]

(Include this section when patient is not fully unrestricted; if cleared without restrictions, state "No restrictions on participation")

Protective Equipment

[Device type and laterality; when required (all activity vs specific situations); duration of requirement] (Include only if equipment is required; omit if none prescribed)

Risk Counseling

[Primary risks discussed (re-injury, symptom flare, compensatory injury); risk mitigation strategies reviewed; warning signs requiring earlier reassessment (pain escalation, swelling, instability, neurological symptoms); confirmation that patient (and guardian if minor) verbalized understanding; participants in discussion]

Follow-up Plan

[Planned follow-up timeframe or PRN guidance; specific triggers for earlier reassessment; pending referrals or testing] (If clearance is conditional or time-limited, restate contingency here)