Abstract
DOI: https://doi.org/10.58984/smb2602085g
Return to sports (RTS) activities after injury represents a complex process in which psychological and psychosocial factors play a significant role. This paper provides a comprehensive evaluation of the characteristics of these predictors and their impact on the course of recovery and the final outcome of RTS after injury. The selection of relevant research literature was performed through electronic databases: PubMed, Scopus, Web of Science, and PsycINFO, while the screening and literature selection process itself followed the established protocols of the PRISMA 2020 declaration. Nineteen original research studies tracking three thousand five hundred seventy athletes were identified. Qualitative synthesis showed that higher levels of negative psychological constructs, primarily fear of reinjury, anxiety, depression, and kinesiophobia, were associated with a longer course and more unfavorable recovery outcomes. Psychological readiness, confidence, self-efficacy, and motivation were recognized as predictors of successful RTS, but also of an increased risk of occurrence of reinjuries. Social support and adaptive coping strategies showed a protective effect through the improvement of psychological readiness and the reduction of emotional distress. RTS represents a multidimensional process that requires an integrated assessment of physical, psychological, and psychosocial factors.
References
- Ardern, C. L., Bizzini, M., & Bahr, R. (2016). It is time for consensus on return to play after injury: five key questions. British Journal of Sports Medicine, 50(9), 506-508. https://doi.org/10.1136/bjsports-2015-095475
- Ardern, C. L., Taylor, N. F., Feller, J. A., & Webster, K. E. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: An updated systematic review and meta-analysis including 5755 patients. British Journal of Sports Medicine, 48(21), 1543–1552. https://doi.org/10.1136/bjsports-2013-093398
- Baltassat, A., Riffault, L., Villatte, G., Meyer, N., Antoni, M., & Clavert, P. (2024). History of mood and anxiety disorders affects return to work and return to sports after rotator cuff repair. Orthopaedics & Traumatology: Surgery & Research, 110(1), 103854. https://doi.org/10.1016/j.otsr.2024.103854
- Bouveau, V., Housset, V., Chasset, F., Bauer, T., & Hardy, A. (2022). Return to sports: Rate and time after arthroscopic surgery for chronic lateral ankle instability. Orthopaedics & Traumatology: Surgery & Research, 108(1), 103398. https://doi.org/10.1016/j.otsr.2022.103398
- Caumeil, B., Laboute, E., Verhaeghe, E., Pérez, S., & Décamps, G. (2024). Reinjury anxiety and return to sport after anterior cruciate ligament reconstruction: A cluster analysis and prospective study among 162 athletes. The American Journal of Sports Medicine, 52(7), 1645–1655. https://doi.org/10.1177/03635465241234887
- Ebert, J. R., Kneebone, L., Edwards, P., Radic, R., & D’Alessandro, P. (2025). Return to preinjury pivoting sports after anterior cruciate ligament reconstruction is different between males and females, as are the patient-reported reasons. Knee Surgery, Sports Traumatology, Arthroscopy, 33(7), 2405–2413. https://doi.org/10.1002/ksa.12588
- Faleide, A. G. H., Magnussen, L. H., Strand, T., Bogen, B. E., Moe-Nilssen, R., Mo, I. F., Vervaat, W., & Inderhaug, E. (2021). The role of psychological readiness in return to sport assessment after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 49(5), 1236–1243 https://doi.org/10.1177/0363546521991924
- Flanigan, D. C., Everhart, J. S., DiBartola, A. C., Blough, C., Schiele, S. E., Harris, K. M., & Emery, C. F. (2021). Positive reframing: An important but underutilized coping strategy in athletes undergoing sport-related knee surgery. Journal of Athletic Training, 56(12), 1334–1339. https://doi.org/10.4085/1062-6050-0618.20
- Forsdyke, D., Gledhill, A., & Madigan, D. (2022). Perceived social support, re-injury anxiety and psychological readiness to return to sport in soccer players. Journal of Sport Rehabilitation, 31(6), 750–758. https://doi.org/10.1123/jsr.2021-0181
- Glazer, D. D. (2009). Development and preliminary validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) scale. Journal of Athletic Training, 44(2), 185–189. https://doi.org/10.4085/1062-6050-44.2.185
- Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. A. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: The Delaware-Oslo ACL cohort study. British Journal of Sports Medicine, 50(13), 804–808. https://doi.org/10.1136/bjsports-2016-096031
- Grooms, D. R., Onate, J. A., & Myer, G. D. (2025). Neurocognitive and biomechanical paradoxes in return to sport clearance following ligamentous injuries. Journal of Athletic Training, 60(2), 142–151. https://doi.org/10.4085/1062-6050-0222.24
- Hilliard, R. C., Blom, L., Hankemeier, D., & Bolin, J. (2017). Exploring the Relationship Between Athletic Identity and Beliefs About Rehabilitation Overadherence in College Athletes. Journal of Sport Rehabilitation, 26(3), 208–220. https://doi.org/10.1123/jsr.2015-0134
- Kvist, J., Österberg, U., Gauffin, H., Tagesson, S., Webster, K., & Ardern, C. (2005). Fear of re-injury: A barrier for returning to sports after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 13(5), 393–397. https://doi.org/10.1007/s00167-004-0557-4
- Longo, U. G., De Salvatore, S., D’Orrico, F., Bella, M., Corradini, A., Rizzello, G., … & Denaro, V. (2023). The impact of psychological factors on return to sports after anterior cruciate ligament reconstruction: a systematic review. Osteology, 3(3), 78-93. https://doi.org/10.3390/osteology3030009
- McPherson, A. L., Feller, J. A., Hewett, T. E., & Webster, K. E. (2024). Psychological readiness and fear of reinjury as determinants of career termination versus return to sport after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine, 52(4), 985–993. https://doi.org/10.1177/03635465241229041
- Meier, M. K., Gross, C., & Shelton, J. L. (2020). Persistent fear-avoidance models and kinesiophobia trajectories in elite versus amateur athletes during rehabilitation. Journal of Sport Rehabilitation, 29(6), 754–762. https://doi.org/10.1123/jsr.2019-0201
- Meredith, S. J., Meyer, S. A., & Edwards, P. K. (2025). The role of motivation, self-efficacy, and cognitive restructuring in return to play timelines after musculoskeletal trauma. Sports Medicine, 55(3), 312–324. https://doi.org/10.1007/s40279-024-02114-x
- Nedder, V. J., Raju, A. G., Moyal, A. J., Calcei, J. G., & Voos, J. E. (2025). Impact of psychological factors on rehabilitation after anterior cruciate ligament reconstruction: a systematic review. Sports Health, 17(2), 291-298. https://doi.org/10.1177/19417381241256930
- Nwachukwu, B. U., Allen, A. A., & Williams, R. J. (2024). Psychosocial barriers, mental health comorbidities, and social support satisfaction during return to sport transition. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 40(5), 1520–1529. https://doi.org/10.1016/j.arthro.2023.11.012
- O’Connor, S., Moran, K., Sheridan, A., Brady, S., Bruce, C., Beidler, E., O’Hagan, A. D., & Whyte, E. (2021). Fear avoidance after injury and readiness to return to sport in collegiate male and female Gaelic games players. Sports Health, 13(6), 532–539. https://doi.org/10.1177/1941738121999047
- Ohji, S., Aizawa, J., Hirohata, K., Ohmi, T., Mitomo, S., Koga, H., & Yagishita, K. (2023). Kinesiophobia is negatively associated with psychological readiness to return to sport in patients awaiting anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 39(9), 2048–2055. https://doi.org/10.1016/j.arthro.2023.02.016
- Paterno, M. V., Schmitt, L. C., Thomas, S., Duke, N., Russo, R., & Quatman-Yates, C. C. (2019). Patient and parent perceptions of rehabilitation factors that influence outcomes after anterior cruciate ligament reconstruction and clearance to return to sport in adolescents and young adults. Journal of Orthopaedic & Sports Physical Therapy, 49(8), 576–583. https://doi.org/10.2519/jospt.2019.8580
- Paterno, M. V., Thomas, S., VanEtten, K. T., & Schmitt, L. C. (2022). Confidence, ability to meet return to sport criteria, and second ACL injury risk associations after ACL-reconstruction. Journal of Orthopaedic Research, 40(1), 182–190. https://doi.org/10.1002/jor.25071
- Podlog, L., Heil, J., & Schulte, S. (2015). Psychosocial factors in return to sport following injury: A meta-analytic review of protective and risk mechanisms. International Review of Sport and Exercise Psychology, 8(1), 110–135. https://doi.org/10.1080/1750984X.2015.1023340
- Senorski, E. H., Samuelsson, K., Thomeé, C., Beischer, S., Karlsson, J., & Thomeé, R. (2017). Return to knee-strenuous sport after anterior cruciate ligament reconstruction: A report from a rehabilitation outcome registry of patient characteristics. Knee Surgery, Sports Traumatology, Arthroscopy, 25(5), 1364–1374. https://doi.org/10.1007/s00167-016-4280-1
- Shaw, T. J., Giza, E., & Sullivan, M. (2025). Fear-avoidance mechanisms and athletic identity shifts following high-grade musculoskeletal and ankle injuries. Foot & Ankle International, 46(1), 78–89. https://doi.org/10.1177/10711007241285033
- Sun, J. N., Wang, R. S., Zheng, Q. Y., Ma, Y. R., & Chen, P. (2026). Cognitive-behavioural physical therapy improves psychological readiness for return to sport, knee function, and resilience in patients after anterior cruciate ligament reconstruction: A randomised controlled trial. Knee Surgery, Sports Traumatology, Arthroscopy, 34(2), 472–483. https://doi.org/10.1002/ksa.12687
- Thorolfsson, B., Piussi, R., Snaebjornsson, T., Karlsson, J., Samuelsson, K., Beischer, S., Thomeé, R., & Hamrin Senorski, E. (2023). Greater self-efficacy, psychological readiness and return to sport amongst paediatric patients compared with adolescents and young adults, 8 and 12 months after ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 31(12), 5629–5640. https://doi.org/10.1007/s00167-023-07623-5
- Triana, M., Font, J., & Soler, R. (2021). The overlap of depressive symptoms, anxiety, and kinesiophobia in orthopedic sports medicine: Impact on return to play success. Scandinavian Journal of Medicine & Science in Sports, 31(8), 1640–1649. https://doi.org/10.1111/sms.13982
- Ueda, Y., Matsushita, T., Shibata, Y., Takiguchi, K., Ono, K., Kida, A., Nishida, K., Nagai, K., Hoshino, Y., Matsumoto, T., Sakai, Y., & Kuroda, R. (2024). Association between psychological readiness to return to sports at 3 months postoperatively and risk of second ACL injury. Orthopaedic Journal of Sports Medicine, 12(4), 23259671241239325. https://doi.org/10.1177/23259671241239325
- Wadey, R., Podlog, L., Hall, M., Hamson-Utley, J., Hicks-Little, C., & Hammer, C. (2014). Reinjury anxiety, coping, and return-to-sport outcomes: A multiple mediation analysis. Rehabilitation Psychology, 59(3), 256–266. https://doi.org/10.1037/a0037032
- Webster, K. E., & Feller, J. A. (2019). A research update on the state of play for return to sport after anterior cruciate ligament reconstruction. Journal of Orthopaedics and Traumatology, 20(1), 1-7. https://doi.org/10.1186/s10195-018-0516-9
- Yang, J., Schaefer, J. T., Zhang, N., Covassin, T., Ding, K., & Heiden, E. (2014). Social support from the athletic trainer and symptoms of depression and anxiety at return to play. Journal of Athletic Training, 49(6), 773–779. https://doi.org/10.4085/1062-6050-49.3.65
- Zarzycki, R., Cummer, K., Arhos, E., Failla, M., Capin, J. J., Smith, A. H., & Snyder-Mackler, L. (2024). Female athletes with better psychological readiness are at higher risk for second ACL injury after primaryACL reconstruction. Sports Health, 16(1), 149–156. https://doi.org/10.1177/19417381231155120
