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The Sport Psychologist, 2015, 29, 1 -14 http://dx.doi.org/10.1123/tsp.2014-0063 © 2015 Human Kinetics, Inc.

Psychological Readiness to Return to Competitive Sport Following Injury: A Qualitative Study

Leslie Podlog University of Utah

Sophie M. Banham and Ross Wadey University of Roehampton

James C. Hannon University of Utah

The purpose of this study was to examine athlete experiences and understandings of psychological readiness to return to sport following a serious injury. A focus group and follow-up semistructured interviews were conducted with seven English athletes representing a variety of sports. Three key attributes of readiness were identified including: (a) confi- dence in returning to sport; (b) realistic expectations of one’s sporting capabilities; and (c) motivation to regain previous performance standards. Numerous precursors such as trust in rehabilitation providers, accepting postinjury limitations, and feeling wanted by significant others were articulated. Results indicate that psychological readiness is a dynamic, psychosocial process comprised of three dimensions that increase athletes’ perceived likelihood of a successful return to sport following injury. Findings are discussed in relation to previous research and practical implications are offered.

Keywords: psychological readiness, sport injury, rehabilitation, return-to-sport

Podlog is with the Dept. of Exercise and Sport Science, Univer- sity of Utah, Salt Lake City, UT. Banham is with the Dept. of Life Sciences, University of Roehampton, London, UK. Wadey was with the Dept. of Life Sciences, University of Roehampton at the time of this research and is now with the School of Sport, Health and Applied Science, St. Mary’s University, Twicken- ham, UK. Hannon was with the Dept. of Exercise and Sport Science, University of Utah at the time of this research and is now with the College of Physical Activity and Sport Sciences, West Virginia University, Morgantown, WV. Address author correspondence to Leslie Podlog at [email protected].

Traditionally, the decision to return a formerly injured athlete to the competitive arena has been based on an athlete’s ability to demonstrate sufficient clinical/ functional ability and to pass sport specific physical tests (Clover & Wall, 2010). Recent evidence suggests, however, that physical and psychological readiness to return to sport may not coincide (Podlog & Eklund, 2006; Wadey & Evans, 2011). The recent case of Der- rick Rose, the Chicago Bulls all-star point guard is a fine example. During the 2012–2013 season, Rose suffered a torn anterior cruciate ligament in his left knee and underwent reconstructive surgery to repair the ligament. Despite medical clearance and significant public pressure

to return, Rose self-professed that he was not psychologi- cally ready to resume his on-court duties. While Rose may have received more media attention than many of his contemporaries, increasing evidence suggests that Rose is by no means alone (Kvist, Ek, Sporrstedt, & Good, 2005; Podlog & Eklund, 2006; Ristolainen, Kettunen, Kujala, & Heinonen, 2012). It is apparent that many athletes may be reentering competitive sport before feeling mentally prepared to do so or in spite of the fact that they lack sufficient psychological skills necessary for coping with the challenges inherent in the return transition (Podlog & Eklund, 2006).

One model examining the influence of psychosocial factors on recovery outcomes is Wiese-Bjornstal, Smith, Shaffer, and Morrey’s (1998) integrated model of psy- chological response to the sport injury and rehabilitation process. Wiese-Bjornstal et al. posit that cognitive and affective factors influence behavioral responses (e.g., adherence, behavioral coping, social support seeking behaviors), which in turn impact physical and psycho- social recovery outcomes. Empirical support for these contentions has been found with links between cognitive appraisals (e.g., perceptions of rehabilitation progress), affective responses (e.g., happiness, excitement), and rehabilitation behaviors (e.g., adherence; Brewer, 2004; Podlog & Eklund, 2009; Tracey, 2003). Far less attention

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however, has been devoted to an examination of the physical (e.g., joint laxity, instability, muscular strength, and endurance) and psychosocial recovery outcomes (e.g., treatment satisfaction, quality of life, readiness to return to sport) mentioned in the integrated model. An important psychological recovery outcome is psychologi- cal readiness to return to sport. Psychological readiness has been suggested to have a range of implications for athletes’ return-to-sport including the level of postinjury performance, competitive anxiety, and reinjury occur- rence (Heil, 1993). As Brewer (2004) asserted, however, little is known about what constitutes psychological readiness to return (i.e., what psychological readiness is), the factors that precipitate its development and what rehabilitation practitioners can do to increase the readi- ness of their athletes. Unfortunately, few researchers have heeded Brewer’s suggestion since his statement was first published.

One exception to Brewer’s suggestion is Glazer’s (2009) 6-item Injury-Psychological Readiness to Return to Sport Scale (I-PRRS; e.g., “My overall confidence to play is…”, “My confidence to play without pain is…”, “My confidence to give 100% effort is…”). Although Glazer (2009) reported initial reliability as well as, content, concurrent, and external validity, the items comprising the I-PRRS focus exclusively on confidence, thereby failing to take into account other factors (e.g., emotions or mood states) that may be relevant to athlete perceptions of psychological readiness to resume sport participation following injury (Morrey, Stuart, Smith, & Wiese-Bjornstal, 1999). Moreover, the I-PRRS was not theoretically or conceptually grounded, and no attempt was made to take athletes’ perspectives into account when developing the scale items.

Although no other measures directly address the construct of psychological readiness to return sport after injury, researchers have developed measures assessing constructs related to—but conceptually distinct from— psychological readiness. In particular, four measures of potential relevance to athletes’ psychological readiness have been developed. These include the Tampa Scale of Kinesiophobia (TSK; Miller, Kori & Todd, 1991), the Re-Injury Anxiety Inventory (RIAI; Walker, Thatcher, & Lavallee, 2010), the Knee Self-Efficacy Scale (K-SES; Thomeé, Wahrborg, Borjesson, Thomee, Eriksson, & Karlsson, 2006), and the ACL-Return to Sport After Injury Scale (ACL-RSI; Webster, Feller, & Lambros, 2008).

Miller et al. (1991) developed the 17-item TSK to assess fear of movement/reinjury among chronic low back pain sufferers (e.g., “I’m afraid that I might injure myself if I exercise,” “my pain would probably be relieved if I were to exercise”). Similarly, Walker, Thatcher, and Lavallee (2010) developed the RIAI to assess athletes’ anxiety regarding reinjury during the rehabilitation phase (15 items; e.g., “I am worried about becoming re-injured

during rehabilitation”) and upon reentry into competitive sport (13 items; e.g., “I am worried about becoming re- injured during re-entry into competition”). The K-SES (Thomeé, et al. 2006) asks athletes about their perceived present physical performance/function and about how confident they are in the future physical performance/ prognosis of their knee. Initial psychometric testing of the K-SES demonstrated good reliability, and good face, content, construct and convergent validity. Finally, Web- ster et al. (2008) developed the ACL-RSI to assess the psychological impact of returning to sport following an anterior cruciate ligament reconstruction. They found that three types of psychological responses were associated with the resumption of sport activity including emotions, confidence in performance, and risk appraisal. Items reflecting these three subscales were incorporated into a 12-item ACL-Return to Sport after Injury (ACL-RSI) scale. While the above inventories represent important progress with regard to the measurement of phenomena associated with psychological readiness, such measures either lacked a clear conceptual grounding (e.g., I-PRRS), did not aim to examine psychological “readiness” per se (e.g., ACL-RSI), or focused exclusively on one injury type, namely a knee injury (e.g., K-SES).

In addition to the above inventories, investigators have examined a variety of phenomena related to the return to sport phase following injury. For instance, researchers have assessed the influence of motiva- tions to return on return-to-sport outcomes (Podlog & Eklund, 2005), adult and adolescent athlete experiences in returning to sport (Podlog & Eklund, 2006; Podlog et al. 2013), and the influence of psychological need satisfaction (competence, autonomy, and relatedness) on athlete well-being and return-to-sport outcomes (Podlog, Lochbaum, & Stevens, 2010). In further research on the return to sport following injury, Langford, Webster and Feller (2009) found that participants who had returned to competitive sport at 12 months, scored significantly higher on the ACL-RSI scale (reflecting a more positive psychological response about sport participation) at both 6 and 12 months than participants who had not returned to competitive sport. Interestingly, Langford et al. (2009) did not find significant differences on emotional response (as measured by the ERAIQ) among athletes who returned to competitive sport (51%) and those who did not (49%) at 12-months post-ACL reconstructive surgery. Their findings suggest that there are significant psychological differences regarding sport resumption between athletes who do, and do not, resume competitive sport 12-months following ACL reconstruction.

In reviewing the findings regarding the return to sport phase following injury, Ardern, Taylor, Feller, and Webster (2013) supported previous findings by Podlog and Eklund (2007) that autonomy, competence, and relatedness were salient issues among returning athletes. Ardern et al. (2013) also found that positive psychological

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responses including motivation, confidence, and low fear were associated with a greater likelihood of returning to preinjury levels of participation and in expediting resump- tion of competitive activities. Finally, the researchers concluded that fear was a salient emotional response upon athletes’ return to sport, despite a trend of increasing posi- tive emotions as recovery and rehabilitation progressed.

Summarizing the above work, it is evident that researchers have generally taken a quantitative approach to assessing constructs of potential relevance to athletes’ psychological readiness to return to sport following injury and/or factors associated with the return to sport transi- tion. Despite the merits of a quantitative approach, there remains a lack of conceptual clarity on what it means to be psychologically ready to return to competitive sport following injury. Without a clear conceptual understand- ing of what psychological readiness is, a quantitative approach cannot assist in developing knowledge and understanding of this phenomenon. In line with proposi- tions highlighted in the integrated model, and consistent with Brewer’s (2004) suggestion, further research is needed to (a) more fully explore and operationalize the nature of psychological readiness to return (i.e., to under- stand what “readiness” is), and (b) to understand how athletes can develop a state of readiness. One effective approach toward this end would be to examine athletes’ experiences and understandings of being psychologically ready to return to sport.

Understanding the elements of psychological readi- ness to return after injury as well as its precursors is sig- nificant for several reasons. First, a better understanding of what psychological readiness is will help coaches as well as sport psychology and sport medicine practitioners ensure that returning athletes experience high levels of the characteristics constituting readiness to return. Second, a better understanding of readiness may help practitio- ners identify athletes who may not be ready to return to sport and more susceptible to detrimental return-to-sport outcomes (e.g., performance anxiety, reinjury anxiety, and actual reinjury occurrence). Third, a more precise knowledge of what constitutes psychological readiness is important for further research aiming to examine the consequences of psychological readiness for postinjury performance and athlete well-being. Fourth, a clearer understanding of readiness precursors will provide rehabilitation practitioners with a better idea of how to increase the psychological preparedness of their ath- letes. Fifth and finally, ascertaining athlete perspectives of psychological readiness is essential for further scale development and psychometric testing of a readiness measure. As such, a clearer understanding of psycho- logical readiness to return to sport after injury has clear theoretical and practical implications. Given the above, the purpose of the current study was twofold. Our first purpose was to explore injured athletes’ experiences and understandings of ‘psychological readiness’ to return to

sport after injury. In doing so, we aimed to identify the key attributes of psychological readiness. Our second aim was to better apprehend the factors (i.e., precursors) influencing the development of this psychological state.

Method

Participants

In the current study, seven participants (n = 3 females, 4 males; mean age of 21.9 years, SD = 3.8 years) from the United Kingdom representing two team sports (soccer, rugby union) and two individual sports (gymnastics, martial arts) participated in the investigation. Competitors ranging from a club to a professional level were solicited for study involvement to ascertain a broad range of per- spectives on the meaning of psychological readiness to return. Participants experienced a minimum of two-month absence from sports participation due to injury and had returned to competitive sport within the last 12 months or were in the process of returning after injury. Participant demographics are provided in Table 1.

Procedure

Following University Ethical approval, participants were selected on the basis that they were able and willing to offer insights into psychological readiness to return to competitive sport following injury. Potential participants were contacted via referrals from coaches and physio- therapists, opportunities as a result of the second and third authors’ contacts, and snowballing (i.e., referral from participants). All participants who were contacted agreed to participate in the study. Rather than obtaining a sample from one rehabilitation clinic or competitive team (or group of athletes), athletes were sought from different settings. The rationale for this criterion was based on a desire to obtain a constructed group rather than a pre- existing one. Leask, Hawe, and Chapman (2001) found constructed group discussions to be more animated and enthusiastic, and participants expressed more divergent views and articulated greater complexities of a chosen topic. Discussions with preexisting groups were generally flatter and less enthusiastic, displaying a higher level of apparent conformity to conventional wisdom. Athletes from various clinics, teams or competitive levels were contacted, and if they expressed an interest in partici- pating in the study, the second author emailed them a participant information sheet. The information sheet contained information concerning the study purposes and procedures, the reason for recording the interviews, and confidentiality information. All potential participants who received the participant information sheet accepted their invitation to participate and provided written informed consent.

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We selected a qualitative approach to address our two questions of interest. As Creswell (2007) suggests, qualitative methodologies are particularly useful when the researcher is hoping to gain insights into a topic that has received limited attention in previous research, where there is an interest in uncovering the experiential aspects of the topic under investigation, or where the goal is to gain detailed insights, opinions and perspectives from those with first-hand knowledge of a particular phenom- enon. Given the dearth of research on the components of readiness to return, the factors that precipitate its development, and the lack of research examining athlete perspectives, experiences and insights regarding the characteristics of readiness, a qualitative approach was deemed appropriate for the current study.

It was decided that to best understand participants’ perspectives, we should collect data across two stages. First, a focus group was conducted with our sample. The rationale for using a focus group was to explore the participants’ shared understanding and experiences and to further enable them to develop and refine their ideas. Flowers et al. (2001) and Palmer, Larkin, Visser, and Fadden (2010) found that new insights into phenomena can arise due to shared experiences, which would not have arisen in one-to-one interviews. Wilkinson (2003) reported that focus groups can also facilitate personal dis- closure more than individual interviews. The focus group for this study was set up to explore how an injured athlete would recognize when he or she is psychologically ready to return to competitive sport and how readiness could be cultivated or developed. Probes were used throughout to explore the meaning of psychological readiness and its precursors. The focus group was conducted by the second author who fulfilled a number of roles: (a) facilitating the discussion (e.g., asking questions and introducing scenarios), (b) monitoring the discussion (e.g., listening,

prompting for more information, bringing in quieter par- ticipants), and (c) maintaining a reasonable and ethical environment (i.e., making sure all participants expressed their opinions, preventing them from being silenced by other groups members or pressured to conform to a con- sensus position). These roles were practiced and refined during a pilot focus group. The focus group took place on a University campus and lasted for 1 hr 45 min.

Considering that one potential limitation of focus groups is that they might dilute accounts of personal experience (cf. Flowers et al., 2001), the second stage of data collection involved follow-up one-to-one interviews with each participant. The aim of the follow-up interview was to permit the participants to elaborate on the specific details of their own stories. The data gleaned from the individual interviews would serve as a complement to the focus group data by enabling the participants to further develop their understanding and contextualize their expe- riences (cf. Lambert & Loiselle, 2007). The questions focused on the dimensions of psychological readiness (e.g., “What does psychological readiness to return to sport mean to you?”, “What qualities and attributes do you associate with someone who is psychologically ready to return to their sport?, “How do you think the following attributes or qualities relate/do not relate to an athlete’s psychological readiness? [Attributes arising from the focus group were used as the basis for discussion here]) and its precursors (“What factors positively influence psychological readiness?”, “What factors assists in the development of psychological readiness?”). Interviews were conducted by the second author in private, either in person at the same University campus or when prag- matic issues necessitated (e.g., training commitments) via the telephone. During the interviews the aim was to listen attentively to what participants had to say and probe spontaneously at certain points, only using the

Table 1 Participant Characteristics

Participant Age

(years) Gender Sport Competitive Level Injury Sustained Stage of Return

Severity (Time Loss)

Oliver 21 male rugby union regional fractured metatarsal full return to competition

6 months

Tanya 18 female rugby union national ruptured posterior cruciate ligament

conditioning phase

9 months (estimate)a

Ellen 20 female gymnastics national fractured metatarsal, ligament damage (ankle)

conditioning phase

6–8 months (estimate)a

Daniel 20 male football club fractured ankle, ligament damage (ankle)

full return to competition

6 months

Allison 22 female martial arts club bruised bone (foot) full return to competition

4 months

Doug 30 male football professional Achilles tendon damage full return to competition

8 months

Jack 22 male rugby union regional grade 2 hamstring tear conditioning phase

36 months (estimate)a

aEstimates are provided for athletes that are still in the conditioning phase of their recovery. Estimates have been provided by the athletes.

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schedule in a flexible manner. Indeed, Smith, Flowers, and Larkin (2009) reported, “Good interviewing requires us to accept, and indeed relish, the fact that the course and content of an interview cannot be laid down in advance” (p. 65). The duration of the interviews ranged from 45–120 min.

Data Analysis

Interview data were analyzed using the constant com- parative method of analysis outlined by Maykut and Morehouse (1994). We chose this type of analysis as it was consistent with well-established qualitative analysis procedures. Such procedures had been used successfully in previous sport psychology studies (e.g., Tracey, 2008; Wadey, Clark, Podlog, & McCullough, 2013), and we were interested in focusing on what is said rather than, for example, other types of analysis that focus on the hows of people’s lives (Smith & Sparkes, 2005). The analysis was a joint product of the participant and the analysts (authors) and involved two general steps: the focus group transcript was inductively analyzed, whereas the indi- vidual transcripts were deductively and inductively ana- lyzed (Patton, 2002). Specifically, analysis of the focus group transcript proceeded using the following four-stage inductive process: (a) active engagement with the data by reading and rereading the transcripts and listening to the audio-recordings to ensure the participant was the focus of analysis; (b) line-by-line analysis of the participants’ experiential understandings and experiences to identify specific ways by which they understood and experienced psychological readiness. This step involved writing notes on a hard-copy of each of the transcripts to produce a comprehensive and detailed set of initial, exploratory comments; (c) emergent themes were found from reduc- ing the volume of detail (the transcript and initial notes) by mapping the interrelationships, connections, and patterns between exploratory notes (e.g., effective goal setting and motivation to regain previous performance standards). The themes reflected the participants’ original words and thoughts but also the analyst’s interpretation; and (d) connections across emergent themes were found using abstraction to identify lower and higher-order themes as well as general dimensions (e.g., confidence in one’s rehabilitation, formerly injured body part, and performance capabilities). Given our interest in obtain- ing athletes from a wide range of rehabilitation clinics, teams and competitive levels, our criteria to determine the presence of a theme was if one athlete reported it (Wadey et al., 2013).

Following inductive analysis of the focus group, individual transcripts were analyzed deductively and inductively using procedures outlined by Patton (2002). Specifically, each transcript was analyzed line-by-line, ultimately resulting in a within-case profile of readiness precursors and dimensions that captured the pattern for that particular participant. Once all the within-case profiles had been developed, the final stage of analysis involved the creation of cross-case profiles for each

precursor and attribute of psychological readiness to return, by integrating each individual’s personal profile and the emergent themes generated from the initial focus group analysis.

Two trustworthiness procedures were used in this study to bolster the rigor of the findings by ensuring that interpretations were plausible and reflected the experiences of participants: peer-debriefing and member- checking (Creswell, 2007; Rees, Smith & Sparkes, 2003). Throughout the analysis process, interpretations and initial themes were reflected to the first, third, and fourth authors who acted as critical friends. The role of these individuals was to question, prompt discus- sions, and explore alternative explanations. In addition, when themes were developed, participants were invited to reflect on the interpretations that had been made. This opened dialogue on the overall themes as well as individual experiences of these themes, providing the researchers with additional insight into the plausibility of interpretations.

Results In addressing our first research aim, we found that three general dimensions or attributes of psychological readi- ness emerged. These included: (a) confidence in returning to sport, (b) realistic expectations of one’s sporting capa- bilities, and (c) motivation to regain previous performance standards. General dimensions, higher-order themes, and lower order themes are presented in Figure 1. In line with our second research purpose, participants also articu- lated various factors (i.e., precursors) that they believed facilitated the development of psychological readiness to return to sport after injury. Figure 2 presents the readiness precursors and dimensions. Presentation of the findings is organized into two general sections. The three com- ponents of psychological readiness are presented first followed by the precursors of psychological readiness.

Confidence in Returning to Sport

The key element of psychological readiness to return fol- lowing injury described by participants was confidence in returning to sport. Confidence was multidimensional in that it consisted of three higher-order themes, namely: (a) a belief in the efficacy of one’s rehabilitation program, (b) a belief that one’s formerly injured body part was fully healed, and (c) efficacy in one’s performance capabili- ties. In terms of efficacy in one’s rehabilitation program, athletes highlighted the importance of feeling that they had made positive progress in their rehabilitation and that they had access to appropriate rehabilitation facilities and programs (i.e., exercises and rehabilitation techniques) set out by trained sport medicine professionals.

Oliver commented:

I think the quality of rehab that you’ve had is very important [for psychological readiness]. So if you’ve gone to, you know, “Mr Rehab” who’s been working

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Figure 1 — Model depicting the lower order themes, higher-order themes and general dimensions

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Figure 2 — Precursors facilitating psychological readiness to return to sport after injury

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with rugby players for 60 years and he knows exactly what he’s talking about and goes to all the courses, like he’s up to date and stuff like that, or you go to some sort of back alley doctor who’s gone, “yeah just do heavy weights until you feel better” like you’re going to feel a lot better with the quality of rehab that you get and a lot more psychologically ready. . .

In regard to his belief in the efficacy of his reha- bilitation program, Daniel also suggested that “…good facilities while you’re rehabilitating, surely can only be a positive thing” for one’s confidence in returning to sport.

Closely related to a belief in the efficacy of the rehabilitation program itself, was the perception that one’s formerly injured body part was fully healed and that reinjury preoccupations were minimal or nonexistent. As Daniel stated:

Um, well, kind of carrying on from the discussion before [on psychological readiness], I put down that the thought of injury or re-injury is no longer in one’s thought process when making decisions during performance. So that’s kind of something we discussed earlier, being able to put that [re-injury concerns] in the past and realise that the strength of the muscle or limb is actually stronger than before the injury. So you may have actually rehabilitated that injury so that the muscle or whatever is stronger than it was before.

During the focus group and individual interviews, a number of athletes made statements that reflected the multidimensional nature of confidence. For instance, Jack commented, that readiness was about being “...confident in your own ability [to execute skills], confident in the injured body part…and being confident that you’re not going to get re-injured and that you’re ready to perform at the highest standard possible”. He went on to suggest that:

If I was confident, I’d know that it [the injury] was going to be ok, ‘I’ve done a lot of work on it [my hamstring] and I’ve gradually got it to the point where I can say, ‘yeah, you can sprint and you’ll be fine’. Knowing that [that I can sprint] in the back of my head, I’ll feel ready. I’m probably still not at that stage yet.

Similarly, Doug indicated that in terms of psycholog- ical readiness “confidence is the biggest thing… You have to have confidence in your rehab program, confidence in actually believing you’re physically able to compete at a certain level without any fear of re-injury.”

Realistic Expectations of One’s Sporting Capabilities

A second essential component (i.e., general dimension) of psychological readiness to return was having realistic

expectations of one’s ability to attain specific perfor- mance levels. Epitomizing the comments of others was the suggestion by Doug that, “you can’t hide from the fact that you’ve been injured” and that it was important to “be realistic that you can’t always do it straight away and maybe at the beginning it’s just putting in the building blocks”. Along these lines, Allison commented:

…Sometimes you need to take a step back and remember that actually you’ve been out for several months, you’re not going to go back at the same level as when you left and if you can’t understand that, if you can’t get your head around that then maybe you’re not quite ready to return.

During the focus group discussion, Tanya stated that readiness was about “being realistic, but not expecting too much or too little and then commitment [is impor- tant]…” while Doug stated that realistic expectations were about having:

the perception that you can’t just go back to where you left off… there’s a gradual build up, there’s a gradual progression that leads you into that develop- ment from rehab into ultimately performing and then eventually back to where you were, if not beyond where you were before.

Motivation to Regain Previous Standards of Performance

The third and final component of readiness to return described by participants was motivation to regain previ- ous standards of performance. Given participants’ aware- ness of the fact that returning to previous performance levels would likely take time, the corollary was that one required a sufficient level of motivation to regain previous performance standards. It was suggested that possessing such motivation went “hand in hand with being psycho- logically ready”. Allison illustrated the role of motivation as an attribute of psychological readiness to return:

That’s when you know you’re definitely ready to go back, when your first session you fight for more, you’re motivated to come back to the next training session, you’re motivated to train harder, that’s when you’re definitely ready to go back. If you come out of your training session thinking, ‘I don’t know if I can do this’ then don’t go back.

The comments of Oliver also captured the impor- tance of motivation to return to preinjury levels as a component of readiness to return. He noted, “… yeah motivation as well, like if you’ve been motivated all the way through rehab, and you feel like you’re ready to play, people have told you you’re ready to play, you’re going to feel a lot more motivated to play and therefore a lot more psychologically ready.”

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Precursors of Psychological Readiness to Return to Sport

Precursors of Confidence in Returning to Sport. Three key precursors of confidence in returning to sport were described including: (a) having trust in the knowledge and expertise of rehabilitation providers, (b) social support that satisfied one’s recovery needs, and (c) the achievement of physical standards/clinical outcomes. With regard to the development of trust in rehabilitation practitioners’ knowledge and expertise, the importance of cultivating a relationship with medical practitioners was emphasized. As Daniel stated, “After I developed a relationship with physios and doctors and I completely trusted them, as soon as they told me that [that I was ready to return to sport] then for me that was like a green light and suddenly all other concerns seemed to slip away.” Daniel, like others, suggested that the trust he had in the knowledge and expertise of his physio- therapist, provided him with confidence in the efficacy of his rehabilitation program, the fact that his injury was completely healed, and that he was ready to resume a high level of competitive play.

Trust in the physiotherapist was also enhanced when athletes were given a rehabilitation program by a physio- therapist who had designed and implemented numerous physical recovery programs for athletes who had previ- ously overcome injury and successfully competed at a high level of postinjury performance. Oliver commented that “getting a genuine program to follow, set out by a trained professional” who had had countless successes in helping injured teammates make a successful return to sport, fostered trust in his team physiotherapist. “I’ve seen everyone [teammates] come back from injury and play well and that’s going to install quite a lot of trust in the physio…” Such trust reinforced Oliver’s belief in the value of his rehabilitation program and imbued him with confidence in his injured limb and his ability to compete at a high level. Epitomizing the sentiment of others, Oliver stated: “I think the quality of my physio really, really helped instil confidence in my injured foot and my ability to compete.”

An additional precursor in the development of confidence was social support received from relevant others, in particular, physiotherapists and coaches. Sup- port in the form of positive feedback from significant others (i.e., esteem support) as well as reassurance and informational support following injury related setbacks were seen as integral in the development of confidence to return. Daniel commented:

I was lucky that I had a doctor and a physio helping me out so I was [mentally] positive. I was surrounded by positive reinforcement with people telling me that I was making big steps. So that for me is one thing that if you have that support would cause you to be confident in your rehabilitation program.

Similarly, the anecdote by Jack highlighted the ben- efits of receiving informational support:

I was playing some touch rugby…I slid on my knees, because of when I had the operation on my left knee, my left knee has never been able to fully flex to 100% and it was pushed into that when I skidded… it was really swollen on the Thursday morning. I absolutely panicked that it was back, it was really tight. I couldn’t really walk. I got on the phone to the physio and she said “look, don’t worry it’s just swollen, it’s never been used to going into that posi- tion”. So that for me [the physio’s comments] gave me another big confidence boost. . . .”

Jack went on to comment that the physiotherapist’s “reassurance over the last twelve months has really done wonders for my head… So yeah, I think the sup- port from someone you trust plays a big role in building confidence.” Having one’s reinjury concerns allayed, trust in the knowledge of rehabilitation providers, and receiv- ing feedback that one was making positive steps in the rehabilitation process all helped to cultivate an internal perception of confidence.

Another important confidence precursor was the achievement of physical standards/clinical outcomes (e.g., muscular strength or endurance). Tanya commented, “I had strength testing on my legs um, and that came up all positive so yeah I’m not worried about being weak or anything. They’re [my legs are] back stronger than what they were before…” She suggested that achieving certain strength levels enhanced her confidence in her performance capabilities. Overall, athletes indicated that the attainment of small, progressive goals (e.g., balanc- ing on one ankle for 10 s and later 20 s) signaled steady improvement that facilitated confidence perceptions. Jack stated:

I think what’s important is to set small [rehabilita- tion] goals and in the game related aspects of the sport. I’m not there yet, but I assume once you are almost ‘good to go’ you can kind of slowly, do aspects of your sport and set small goals, so you don’t rush into it. And then you build your confidence, and because you’re happy with how it’s going [your rehabilitation], you’re more psychologically ready to return; you’re not just returning, but you slowly move into it.

Precursors of Realistic Expectations of One’s Sporting Capabilities. Three precursors in relation to realistic expectations regarding the ability to attain specific performance levels were mentioned. These included: patience, accepting one’s postinjury limitations, and effective goal setting. Athletes suggested that the culti- vation of a patient mind-set was important in ensuring that expectations regarding when one could return to competition and performance levels upon the return

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were reasonable. According to Doug, “just being patient, wanting to do it [return to sport] but being realistic and saying you can’t do it…” was important in helping him to ensure that he was psychologically prepared to return to competition. Accepting that one’s time away from sport may impact skill execution and performance capabilities was also deemed essential in the creation of realistic performance expectations. As Ellen indicated, “acceptance of knowing what you’re going to be able to do [after returning to competition] and accepting the fact that you’re not going to be able to do as much will help in setting realistic goals for what you think you’ll be ready to do.” Similarly, Allison suggested the impor- tance of accepting one’s injury recovery status and being honest with oneself about one’s level of psychological readiness. She indicated “…you know you’re going to have a loss of fitness [upon returning to competition]. If you’re not ready to accept that you’ve lost it [fitness] and willing to fight for it back then you’re probably not ready to go back.”

Last, the act of setting effective goals was seen as an important precursor of realistic performance expecta- tions. Goal setting was perceived as helpful in outlining the intermediary steps required to attain certain levels of athletic proficiency. Along these lines, Allison com- mented, “I think when you return, or just before your return you need to be very, very, very aware that you’re not going to be as good as you were when you left and you need to be very aware that you need to set very small, clear goals about how you’re going to get your fitness and technique back.” Athletes also suggested that coaches and physiotherapists were influential in setting effective goals that in turn facilitated realistic expectations. Oliver commented “goal setting’s very important, but realistic goals set by professionals will usually be more helpful with feeling psychologically ready.” Oliver also stated, “I got the proper help that I needed, that was available to me at the club and they [physiotherapists] gave me realistic expectations…”

Precursors of Motivation to Regain Previous Per- formance Standards. The perceived precursors of motivation to regain previous performance standards included: (a) effective goal-setting, (b) the boredom of injury, (c) feeling wanted by significant others, and (d) social support. The process of setting and attaining realistic goals positively influenced athletes’ motivation to achieve previous performance standards. According to Daniel:

Once I was able to set the right and realistic goals for myself I gained more motivation. Improving weekly on certain tasks is a massive thing and you know if those are your goals and you’re achieving your goals then you’re motivated to set more goals and keep with it.

Interestingly, the boredom of the injury recovery process was also seen as motivationally beneficial. For some athletes the tedium of repetitious rehabilitation

exercises provided greater impetus to resume competitive activities. According to Daniel, “I did start to become a little bit bored of my injury, mainly when I had my cast on and that gave me more motivation to get out of the cast as soon as possible.”

Feeling wanted by the coach and teammates also contributed to enhanced motivation levels. Teammates and coaches who verbalized their desire to have the injured athlete return and who recognized the missed contributions of the injured athlete helped energize par- ticipants in their quest to achieve and surpass preinjury levels. The comments of Daniel nicely captured the importance of “feeling wanted”. “Personally I was really lucky to have a lot of friends helping me out, and yeah that definitely motivated me because... you know there’s people out there that really want you to recover from the injury and you want to show them that you can recover and that all the help that they’re giving you isn’t in vein.”

As the above comment suggests, feeling wanted by teammates and coaches was closely tied to the importance of receiving social support. An important source of social support which aided the development of motivation to return to preperformance standards was having an “injury buddy.” Athletes suggested that having a fellow athlete with a similar injury who was experiencing the same challenges and demands as they were was motivationally beneficial. Tanya described the impact that her “injury buddy” had on her motivation:

We always train together and make sure we do the rehab together, we sort of set each

other little goals as well…if you have little worries or setbacks you’ve got more trust and comfort in your injury buddy because you’re going through the same thing so there’s more understanding. So if you have worries then you can speak to them and they’ll understand it and somehow manage to motivate you.

Discussion

As far as the researchers are aware, this was the first investigation to identify the key attributes and precur- sors of psychological readiness to return after injury. Our findings suggest that psychological readiness can be considered a dynamic, psychosocial process comprised of three dimensions that increase athletes’ perceived likelihood of a successful return to sport following injury. Findings from this study suggest confidence was a key component of psychological readiness and that confi- dence was multidimensional in nature, a finding echoed in previous research (e.g., Carson & Polman, 2012; Chase, Magyar, & Drake, 2005; Glazer, 2009; Podlog & Eklund, 2006). For example, Carson and Polman (2012) found that the main aim of professional rugby union players before a return to competition was to build confidence in the injured limb, while Chase et al. (2005) found that the cultivation of self-efficacy and the utilization of psychological skills (e.g., imagery, relaxation) were

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important in helping gymnasts overcome their fear of injury. Specifically, athletes suggested that they required a strong conviction that their program of rehabilitation was effective in enabling them to fully recover, that their injury was fully healed, and the perception of readiness to compete at a high level and meet competitive demands. The multidimensional nature of confidence also sup- ports previous scale development by Glazer (2009) who addressed various confidence components in his inventory (e.g., confidence to give 100% effort, to not concentrate on the injury, to handle the demands of the situation, in one’s skill level/ability). Collectively, these findings indicate that confidence in relation to different areas may be essential in ensuring that athletes are psy- chologically prepared to resume competitive activities. From a practical standpoint, it seems important for sport medicine and sport psychology practitioners to minimize reinjury apprehensions, promote efficacy in the value of rehabilitation and one’s healing, and facilitate the belief that one is ready to compete at a high level. Strategies for enhancing confidence are described below.

A novel contribution of this study was the identifica- tion of factors believed to be directly linked to the develop- ment of confidence to return after injury. Consistent with Wiese-Bjornstal et al.’s (1998) integrated model, a key personal factor—the achievement of physical standards/ clinical outcomes—was seen as pivotal in developing confidence. Although previous research has not specifi- cally focused on the nature of psychological readiness, it has been found that successful completion of strength and sport specific tests is influential in the development of confidence among athletes returning to sport follow- ing injury (Carson & Polman, 2012; Podlog & Eklund, 2006). Moreover, consistent with Wiese-Bjornstal et al.’s (1998) conceptual tenets and past research, situational factors, including trust in the knowledge and expertise of rehabilitation providers (Roderick, 2004) and social support (Yang, Corinne, Lowe, Heiden, & Foster, 2010), appeared instrumental in the development of confidence in returning to sport.

The issue of trust in rehabilitation providers has received limited attention in the literature (Clement & Shannon, 2011; Russell & Tracey, 2011; Tracey, 2008). Athletes in this study highlighted the importance of trust in significant others in alleviating injury concerns and increasing confidence in the ability to perform at a high level. Roderick (2004) found that trust in the knowledge of physiotherapists was imperative for professional Eng- lish soccer players, some of whom expressed ambivalence about the knowledge and expertise of particular medical practitioners. Further research is required however, to address the impact of trust in support on the development of psychological readiness to return and return outcomes.

With regard to social support, athletes placed a strong emphasis on the need for support, in particular from sport medicine practitioners and coaches in increas- ing confidence in the injured body part and in relieving injury concerns. Recently, Clement and Shannon (2011) emphasized the key role that physiotherapists play in

providing social support during the return to sport phase. Clement and Shannon also found that athletes reported a lack of coach support. Collectively, these findings point to an apparent contradiction whereby athletes seek coach support in building confidence to return to sport but also indicate that such support may not be forthcoming. Pre- vious research by Podlog and Dionigi (2010) suggests that coaches are aware of the value of coach support and assistance in rehabilitation. Whether such support is provided may differ depending upon the specific sport culture or coach in question. Quantitative inquiry would be beneficial in addressing the extent to which coaches are involved in providing social support and building athlete confidence upon the return to sport. Social support from an “injury buddy” was also perceived to influence the development of confidence. The notion of an “injury buddy” is akin to the idea of injury role-models, the latter of whom have been found to help facilitate recovery by providing injured athletes with information and hope that a successful return is possible or by pairing injured athletes at a similar stage of recovery (Podlog & Eklund, 2006).

Of the confidence precursors identified, it is apparent that all are subject to improvement through systematic training. For example, the achievement of physical standards/clinical outcomes can be enhanced through goal-setting techniques (Evans & Hardy 2002). Similarly, trust in rehabilitation providers and social support may be addressed through education, effective communica- tion strategies, and rapport building (Tracey, 2003). In addition, the use of demonstrated psychological interven- tions such as imagery and relaxation may be valuable in enhancing various confidence facets before the resump- tion of competitive activities (Chase et al., 2005; Wadey & Evans, 2011). Further, research testing the value of these interventions in ensuring the psychological readiness of returning athletes is warranted.

A second key attribute of psychological readiness to return was realistic expectations regarding one’s perfor- mance capabilities. Podlog and Eklund (2009) also found that realistic expectations were important in determining the extent to which high-level athletes perceived their return to sport to be a success. These parallel findings suggest that realistic expectations are not only integral in ensuring readiness but in enabling athletes to appraise their return after injury as successful. Establishing real- istic expectations however, may be challenging for many elite athletes, given that performance expectations and an intense desire to demonstrate high levels of compe- tency may cloud perceptions of readiness. Some of the athletes in Podlog and Eklund’s (2009) study indicated that they had difficulties setting realistic expectations. The realization of an inability to meet high expectations was a valuable reminder of the importance of creating realistic ones. Coaches and rehabilitation specialists may be pivotal in helping athletes with the difficult task of establishing realistic expectations. Doing so appears to be imperative in enabling athletes to feel psychologically ready and successful upon their return to competition.

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Several precursors including patience, accepting postinjury limitations, and goal setting, were also seen as important in the development of realistic performance expectations. Gould, Udry, Bridges and Beck (1997) also found that patience and taking it slowly was cited more by athletes they characterized as successful recoverers from injury than unsuccessful ones. From a practical standpoint, instilling a sense of patience, helping athletes to set challenging but flexible goals, and encouraging acceptance of one’s recovery status may be influential in the creation of realistic expectations regarding the upcom- ing return to competition. Once again, sport medicine professionals may be vital in educating athletes about the importance of remaining patient and not engaging in rehabilitation regimens that extend beyond practitioner recommended guidelines.

A final attribute of psychological readiness to return was motivation to regain previous performance standards. Given athletes’ recognition of the need to maintain realistic expectations, it was not entirely surprising that they also believed that a requisite level of motivation was required to regain previous performance levels. An important applied implication of this finding is the need to assess athletes’ motivation levels as well as the types of motives energizing their return to competition after injury. Podlog and Eklund (2005) found that the types of motivation driving athletes’ return to sport may have relevant implications for the outcomes of that return. Specifically, competitive athletes who were primarily motivated by intrinsic factors appeared to have a greater likelihood of experiencing a renewed sport perspective, while those extrinsically motivated were more likely to experience return concerns (e.g., competitive anxiety, fear of reinjury, perceptions of diminished performance). From an applied standpoint, it is important to note that motivation levels can be shaped by environmental factors. Contemporary social psychological theories of motiva- tion such as self-determination theory recognize that the extent to which individuals’ psychological needs are satis- fied may have important implications for intraindividual motivation levels. As such, practitioners are encouraged to ensure that returning athletes are liberally endowed with high motivation levels if they are likely to overcome the multitude of challenges that lay ahead.

Findings regarding the precursors of motivation to regain previous performance standards, suggest vari- ables that should be targeted in attempting to positively influence this readiness attribute. While two of the precursors emerged for other readiness facets (i.e., goal setting and social support), two novel ones - the boredom of injury and feeling wanted - were also highlighted. The boredom of injury and feeling wanted by team- mates and coaches have yet to be discussed in previous research as precursors of motivation to regain previous performance standards. Paradoxically, several athletes felt that the boredom of injury enhanced their motiva- tion by providing greater impetus to extricate oneself from the monotony of the rehabilitation process and to

return to the sport they enjoyed. This finding indicates that practitioners should encourage athletes to “use” the potential tedium of rehabilitation exercises as a source of motivation to resume the sport that brings enjoyment and personal fulfillment. This is not to suggest that rehabilitation specialists should encourage athletes to prematurely expedite the rehabilitation process, but rather to use boredom as a positive motivational tool. Similarly, recognition that returning athletes felt a need to be wanted by their teammates and coaches suggests that feeling valued, wanted, and needed by relevant others served as a positive motivational force. This finding suggests the relevance of being cared for by significant others. Further research examining the importance of feeling wanted or perceptions of being cared for by others is warranted with regard to its value in enhancing athletes’ psychological readiness to return.

Limitations and Future Research Directions

As with any study there are a number of limitations to this research. First, given the relatively small sample size, findings from this study should be considered preliminary. Further research examining the generalizability of the findings from the current study is warranted. Second, as three of the athletes had yet to return to competition, they were unable to comment on possible return-to-sport outcomes associated with psychological readiness. In addition to examining readiness precursors, it would be theoretically informative and practically useful to examine the consequences of readiness to return to sport. To this end, research tracking readiness precursors and outcomes using prospective repeated measure designs would contribute to the extant literature. Alternatively, a sample of athletes who had already returned to sport fol- lowing injury would be able to retrospectively comment on outcomes of psychological readiness. Regardless of whether researchers choose to employ a prospective or retrospective design, it is apparent that further research examining readiness outcomes is needed. In addition, further investigation is needed to develop a measure of psychological readiness that incorporates the three readi- ness components revealed in this study and to examine its reliability and validity. As indicated previously, limitations associated with previous readiness measures (e.g., Glazer, 2009) suggest the value of further readiness measures that are multidimensional in nature and that take into account athlete perspectives. Finally, it is possible that our sample was biased insofar as only athletes who felt ready to return felt able and/or willing to share their insights. That said, a number of participants, in particu- lar those in the conditioning phase, relayed instances in which they felt they were not entirely psychologically ready to resume competitive play. Further research using a diverse sample of athletes who may or may not be psychologically ready to return is needed to shed further light on this construct of interest.

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Conclusion Overall, it is clear from this study that psychological readiness is a dynamic, psychosocial process which athletes may experience before, during, or after their transition from rehabilitation to returning to competitive sport. It appears to be comprised of three dimensions that increase athletes’ perceived likelihood of a suc- cessful return to sport following injury: (a) confidence in returning to sport; (b) realistic expectations of one’s sporting capabilities; and (c) motivation to regain previ- ous performance standards. Novel findings also emerged through athlete description of readiness precursors. In particular, the importance of trust in rehabilitation pro- viders, social support, goal-setting, and the achievement of physical standards/clinical outcomes were all salient factors that helped cultivate psychological readiness to return to sport. It may be that ensuring athletes possess high levels of all three attributes is essential for ensur- ing readiness, a question for further empirical scrutiny. Moreover, by addressing the precursors outlined in this study, practitioners are well-positioned to help athletes experience this valuable psychological state.

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