Evidence suggests the challenges of injury recovery may not cease at the completion of athletes’ physical rehabilitation. Over the past decade, researchers have uncovered a range of psychosocial issues, challenges, and demands associated with the return to competition following injury. In this entry, athlete experiences returning to competition, the motivational issues surrounding return, and options for evaluating athletes’ mental readiness to resume competitive activities are examined. Throughout this entry, the phrase return to competition refers to injured athletes’ transition from injury rehabilitation to sport-specific training and competition.
Athlete Experiences of the Return
In an attempt to examine athlete experiences in returning to competition following injury, researchers have solicited the perspectives of athletes, coaches, and sport medicine practitioners. Issues of competence, autonomy, and relational concerns prominently appear throughout published literature. Competence refers to a sense of being capable or proficient in one’s pursuits. Competence concerns comprise the most commonly reported sources of athlete apprehension during the return to competition transition.
Competence issues are salient in athlete expressions of anxiousness over re-injury, concerns about the impact of injury on skill execution or loss of overall physical fitness. Athletes also typically report uncertainties about performing at pre-injury levels. Concerns over re-injury and competing at pre-injury levels are not surprising, given elite athletes’ interest in athletic attainment and the inability to pursue goals over a potentially prolonged absence during injury recovery.
Research has also highlighted the salience of autonomy issues among returning athletes. Autonomy pertains to an individual’s sense of choice or control over one’s actions and behaviors. During the return to competition transition, athletes may experience varying degrees of choice and control over the timing and circumstances of their return. Whereas some athletes may be free to return at a time and manner of their own choosing, evidence suggests that many athletes face external pressures to return from coaches, teammates, or even sport medicine practitioners. Such pressures appear to be largely a function of the temporal proximity of upcoming competitions and the importance of the athlete in attaining desired team outcomes. Further complicating the situation are the internal pressures athletes place upon themselves to return to competition. Internal pressures may stem from intraindividual concerns regarding an inability to perform sport skills, self-generated worry that one is losing considerable fitness, or self-induced distress over “falling behind” fellow competitors during one’s sport absence. Unfortunately, indicators of functional capacity (e.g., proprioception, joint range of motion) or consideration of the athlete’s long-term health and well-being can sometimes be a secondary concern.
Finally, relational issues pertaining to the lost sense of connection to others and one’s sport have been reported in the psychology of sport injury literature. Athlete perceptions of inadequate social support have also been highlighted. In particular, feelings of detachment and isolation, occurring during rehabilitation, may persist until such time as athletes are able to fully resume competitive play and contribute to valued team outcomes. Inadequate levels of social support may also contribute to relational concerns. For example, athletes report some coaches to be distant and insensitive to injury, uninterested in providing desired rehabilitation guidance, or as lacking a belief in their ability to return. Such distancing by a coach may contribute to the perception that one is not a valued member of the team and that only those who are competing are deserving or worthy of the coach’s attention. Confronted with this reality, it is not surprising that athletes all too commonly feel a sense of estrangement from their sport.
A lack of social support may also come in the form of insufficient information about recovery progressions and the requirements for attaining return to competition readiness. Specifically, some athletes have reported a lack of guidance and information from coaches and physiotherapists regarding adequate rehabilitative training to facilitate re-entry to the competitive arena. Such instances are unfortunate, given substantial evidence supporting the benefit of social support for injured athletes. Social support from coaches, family members, and athletic trainers may be essential in enabling the athlete to overcome the demands and uncertainties inherent in the return to competition.
Given the apparent relevance of competence, autonomy, and relational issues, Leslie Podlog and colleagues examined the impact of rehabilitation environments that satisfy athletes’ need to feel competent, volitional, and connected to relevant others. Findings reveal that support for athletes in these three areas promotes enhanced well-being and effective return-to-competition outcomes. In particular, athletes who experienced a sense of competence and autonomy during rehabilitation had more positive emotions, which likely fostered a “renewed perspective on sport” following the return to competition (e.g., greater sport appreciation, heightened motivation for success, enhanced mental toughness). Moreover, those who felt a sense of connection to relevant others indicated less negative affect and greater self-esteem—both of which decreased the likelihood of athletes’ experiencing “return concerns” (e.g., increased competitive anxiety, re-injury concerns). These findings highlight that the satisfaction of injured athletes’ needs may facilitate perceptions of well-being and positive return to competition outcomes. Given these findings, it seems reasonable to suggest that interventions targeting competence, autonomy, and relatedness needs may help mitigate the challenges inherent in the return to competition. Further applied research aimed at minimizing athletes’ return to competition concerns is needed, however, to explore the merits of this contention.
Motivational researchers Edward Deci and Richard Ryan suggest that the reasons why people engage in a behavior (i.e., their motives for action or involvement) may have important implications for the sustainment of such behaviors and the extent to which individuals experience optimal functioning or well-being. A wealth of evidence across various life domains including education, work, and relationships supports this line of reasoning. Operating from a similar assumption, Leslie Podlog and Robert Eklund recently examined the implications of athlete motives to return to competition on perceptions of post-injury performance. In an investigation with high-level athletes from Canada, Australia, and England, the researchers found that intrinsic motives to return to competition such as a love of the game or the excitement of participation were positively associated with a “renewed perspective on sport.” On the other hand, athletes who were extrinsically motivated—that is, those who returned to competition because they wanted to attain external rewards or to avoid punishments, such as exclusion from participation—experienced greater “return concerns.” Return concerns included, but were not limited to, diminished confidence, unsatisfying performances, and heightened competitive anxiety. Similarly, in an experimental investigation with professional Australian football league players, Podlog and Eklund found that greater intrinsic (versus extrinsic) motivations resulted in more positive thoughts and emotions regarding a return to competition. Interestingly, athletes who returned for intrinsic reasons such as a love of the game reported diminished perceptions of threat, unfairness, and potential damage to one’s ego than their extrinsic counterparts. These findings suggest that the motivations underlining athletes’ return to competition may have important consequences for the quality and nature of their return. In particular, the aforementioned studies by Podlog and Eklund indicate that intrinsic reasons for returning to competition may be associated with positive perceptions of a return to competition and enhanced post-injury performances.
Assessing Psychological Readiness to Return to Competition
Taking into account the abundant challenges and motivational demands placed upon returning athletes, the need for psychological evaluation is critically important. Several options presently exist for assessing athletes’ psychological status upon return to competition. One option is D. W. Creighton and colleagues’ three-step return to competition decision-making model. In Step 1 of the model, the health status of the athlete is assessed through the evaluation of medical factors (e.g., medical history of the patient, lab tests such as X-rays or MRIs, severity of the injury, functional ability, psychological state). Step 2 involves consideration of the risks associated with participation by assessing variables such as the type of sport played (e.g., collision, noncontact), the position played (e.g., goalie, forward), the competitive level (e.g., recreational, professional), the ability to protect (e.g., bracing, taping, padding), and the limb dominance of the patient. Step 3 in the decision-making process includes consideration of nonmedical factors that can influence return to competition decisions. Relevant considerations here include the timing in the season (e.g., playoffs), pressure from the athlete or others (e.g., coach, athlete’s family), ability to mask the injury (e.g., pain medications), conflict of interest (e.g., potential financial gain or loss to the patient or clinician), and fear of litigation (e.g., if participation is restricted or permitted). The model provides a framework outlining the complex interaction of factors ultimately contributing to return to-competition decisions. Utilizing the three-step process can help guide clinician decisions regarding athletes’ return to competition.
In an effort to assess athletes’ psychological state mentioned in stage 1 of Creighton and colleagues’ model, researchers and practitioners are encouraged to use Douglas Glazer’s Injury–Psychological Readiness to Return to Sport scale. The inventory is a valid and reliable scale consisting of six questions designed to assess athlete confidence regarding various aspects of their return to competition. For example, athletes are asked to rate their overall confidence to return to competition, their confidence to play without pain, and their confidence to give 100% effort. Given its concise nature, the readiness to return questionnaire can be easily administered by sport psychologists and health practitioners in the rehabilitation setting.
Another possibility in assessing psychological readiness to return to competition is Natalie Walker and colleagues’ Re-Injury Anxiety Inventory. The questionnaire contains 28 statements aimed at uncovering the extent to which athletes experience uncertainty regarding re-injury. Fifteen of the questions pertain to re-injury anxieties during rehabilitation. These 15 questions require athletes to reflect upon the extent to which they are worried or feel nervous about becoming re-injured during rehabilitation. Another 13 questions assess re-injury worries upon return to competition. These 13 questions ask athletes to indicate how “worried” or “nervous” they are about becoming re-injured during re-entry into competition. Walker and her collaborators made efforts to distinguish fear (a flight-or fight response to danger) from anxiety (uncertainty, worry, or concern) indicating the latter is a more accurate description of the athlete’s state of mind.
Both the readiness to return and re-injury anxiety questionnaires may facilitate assessment of athletes’ psychological state as they approach a return to competition. Low scores on either scale may alert health practitioners to the fact that athletes may not be psychologically prepared to resume competitive activities. Initial evidence suggests that athletes who experience heightened re-injury anxiety may have an elevated risk for poorer return-to-competition outcomes such as heightened competitive anxiety and diminished confidence in performing sport skills. It is also possible that re-injury anxieties or a lack of confidence in return-to-competition abilities increase athletes’ actual risk of re-injury. This suggestion, however, requires further research.
Returning to competition following injury may entail a range of psychosocial challenges and demands. Issues pertaining to athletes’ sense of proficiency, perceptions of autonomy, and feelings of connection to relevant others appear to predominate during the re-entry period. Evidence also reveals that athlete motivations to return to competition following injury may have important consequences for post-injury performances. Given the plethora of demands and motivational challenges associated with a return to competition, ensuring a holistic assessment of athletes’ physical and psychological readiness is imperative. Creighton and colleagues’ three-step decision making model can be a useful tool in determining an athlete’s ability to safely and successfully compete after injury. Finally, two questionnaires, the Injury–Psychological Readiness to Return to Sport scale and the Re-Injury Anxiety Inventory, show promise in facilitating evaluation of athletes’ mental preparedness to return to competition.
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