Return To Competition Following Injury

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 Issues

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.

Conclusion

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.

References:

  1. Bianco, T., & Eklund, R. C. (2001). Conceptual considerations for social support research in sport and exercise settings: The instance of sport injury. Journal of Sport & Exercise Psychology, 2, 85–107.
  2. Creighton, D. W., Shrier, I., Shultz, R., Meeuwisse, W. H.,& Matheson, G. O. (2010). Return-to-play in sport: A decision-based model. Clinical Journal of Sport Medicine, 20, 379–385.
  3. Podlog, L., & Eklund, R. C. (2005). Return to sport following serious injury: A retrospective examination of motivation and outcomes. Journal of Sport Rehabilitation, 14, 20–34.
  4. Podlog, L., & Eklund, R.C. (2007). The psychosocial aspects of a return to sport following serious injury: A review of the literature. Psychology of Sport and Exercise, 8, 535–566.
  5. Podlog, L., & Eklund, R. C. (2010). Returning to competition following a serious injury: The role of self-determination. Journal of Sports Sciences, 28,819–831.
  6. Roderick, M. (2004). English professional soccer players and the uncertainties of injury. In K. Young (Ed.), Sporting bodies, damaged selves: Sociological studies of sports-related injury. Oxford, UK: Elsevier.

 

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