Examining the Relationship between Psychological and Functional Status after a Sports Musculoskeletal Injury

Abstract

The purpose of the present study was to investigate the relationship between re-injury worry, confidence, and attention and athletes’ functional status upon returning to sport after an injury. The sample consisted of 28 amateur-level male football players, aged 18 to 35 years, with a previous lower-limb injury. The athletes followed a physiotherapy rehabilitation program and completed three valid questionnaires examining re-injury worry, sport confidence, and attention returning to sport. The sample also performed three functional tests: (a) single-leg hop for distance, (b) side hop, and (c) the vertical jump. The results showed high correlations between the psychological factors between the functional tests. Physiotherapy duration was positively highly correlated with the time of absence from sport and severity of injury. The severity of the injury was also positively highly correlated with the time of absence from sport. The factors “Functional Attention” and “Distraction Attention” showed a positive and negative correlation with the single-leg hop for distance and the vertical jump, respectively. Athletes with a grade II severity injury showed greater attention compared to grade III severity injury. The increased level of re-injury worry was positively related to “Distraction Attention” and negatively related to the functional ability of the injured limb. The psychological readiness was partially related to the athletes’ functional status. The present study reports the importance of psychological readiness and its relationship with athletes’ functional status of returning to sport following a musculoskeletal sport injury.

1. Introduction

The number of people involved in sports has increased significantly; the Sports and Fitness Industry Association provides detailed data on sports participation trends in the United States [1]. It is reported that nearly 230 million Americans participated in some form of sports, fitness, or physical activity in 2021, reflecting an upward trend compared to previous years and resulting in an increase in musculoskeletal injuries [1]. Injuries lead in the absence of the competition season. At the same time, sports injuries, in addition to limited functional mobility, often cause psychological disturbances, which can affect the duration and effectiveness of the rehabilitation program [2].

Psychological factors play an important role in the rehabilitation process of the injured athletes and explain why only some athletes manage to return to precompetitive levels [3]. According to systematic reviews by Nwachukwu et al. [4] and Piussi et al. [5], approximately 65% of patients with musculoskeletal injuries—particularly those with ACL tears and rotator cuff injuries—reported psychological barriers, such as fear of re-injury, as the primary reason for not returning to sport, especially within the first six weeks after surgery.

Re-injury worry, the cognitive component of anxiety, contributes to athletes not returning to sport following an injury. It can also increase the risk of re-injury [6]. Players who were injured in the past showed an increased level of worry compared to the players without previous injuries [7]. When athletes perform the rehabilitation exercises incorrectly, the probability of re-injury is higher, which leads to the decrease of athletes’ coordination and the increase in tension [8]. When injured athletes return to the sports field, they worry about their physical condition and overthink details of skills’ execution techniques. It is crucial for athletes to have both an adequate psychological and functional condition to perform at their prior physical level; therefore, it is essential to assess both conditions when returning to sporting competitions after a musculoskeletal injury. Also, re-injury worry is associated with athletes’ reduced self-confidence and attention after musculoskeletal injury in the return-to-competition phase [2,6].

The confidence of a rehabilitated athlete refers to the certainty they have in their ability to succeed in sport following an acute musculoskeletal injury. During the recovery process, athletes should properly adhere to and complete an appropriate rehabilitation program to perform at their preinjury level in upcoming competitions, thereby increasing their confidence [4,6]. Athletes with a history of injury often have low confidence in avoiding re-injury [9]. Previous studies suggest that psychological readiness includes three components: (a) confidence in returning to sport, (b) realistic expectations regarding sporting abilities, and (c) motivation to regain previous performance standards [10,11].

Only a few studies, such as those by Lentz et al. [12], Kvist et al. [13], and Ross et al. [14], have investigated the role that attention plays in athletes. Specific focus styles facilitate the rehabilitation process, and injured athletes should focus on cues that facilitate their attention and block out cues that lead to distraction [8]. The decreased attention to performance-related cues and the increased distraction can undermine sport performance and increase the risk of re-injury [15]. Christakou et al. [6] showed that attention is a significant predictive factor in returning to competition. They emphasized that the rehabilitation team should assess athletes’ attention and help them stay focused on essential performance elements during the new competitive season.

Little research has been performed investigating the relationship between psychological readiness and functional performance. Ueda et al. [16] reported that athletes can return to their previous physical performance if they have higher psychological readiness. Hurley et al. [17] suggested that athletes after shoulder surgery did not return to the sport due to reduced psychological readiness. Greater frontal-plane knee range of motion has been associated with greater psychological readiness [18]. Greater psychological readiness and higher limb symmetry indices for quadricep strength were associated with more symmetrical multi-planar knee kinematics [19]. An athlete’s psychological readiness to return to sport has also been associated with hop test scores and muscle strength [20]. However, the correlation was weak, indicating that athletes’ psychological readiness to return to sport is influenced not only by objective physical recovery of the knee but also by their psychological state. Psychological readiness 9 months after surgery was found to be a predictor of return to sport 2 years after anterior cruciate ligament reconstruction, while functional tests had no predictive value [21]. Athletes who showed superior self-reported knee function at 6 months and greater psychological readiness to return to sport at 12 months returned to the preinjury sport 1 year after ACL injury treated without reconstruction [22]. Those athletes who had higher knee function and greater psychological readiness to return to sport returned better and more quickly to their preinjury sport level after an injury compared with those who did not have good function and psychological readiness [16]. Additionally, knee flexion strength and hamstring-to-quadriceps ratios were significantly higher in the group with better psychological readiness [23].

No previous studies have specifically investigated the relationship between the following psychological characteristics, such as re-injury anxiety, confidence, and attention, and the functional status of previously injured athletes before their return to sporting competitions. The existing literature does not assess the relationship between these psychological factors and the functional status of rehabilitated athletes who were ready to enter the competition. Consequently, the impact of these psychological factors on functional recovery remains unclear. Thus, this is the first study that examines the relationship of the specific psychological factors with the functional status in the previously injured athlete population. This study aims to fill that gap by examining how these factors influence musculoskeletal recovery and readiness for competition.

This examination plays an important role in sport musculoskeletal recovery. This knowledge might assist physiotherapists and coaches in identifying negative psychological characteristics in injured athletes returning to sport. By doing so, they can help these athletes improve their functional performance and reduce the risk of re-injury. Thus, the aim of the present study was to examine the relationship between re-injury worry, confidence, and attention and the functional status of athletes in the phase of re-entry to competitive activity after a recent musculoskeletal injury. The hypothesis of the study was that athletes’ psychological readiness would have a relationship with their functional status.

2. Materials and Methods

This was a cross-sectional research design.

2.1. Sample

Participants’ inclusion criteria were (a) active male amateur athletes with a frequency of 3 times/week for 2 h each time and who participated in competitions during the last three years, (b) aged from 18 to 35 years old, (c) participating in contact sports, (d) with no previous surgery on limbs, (e) acute musculoskeletal sport injury in the last 6 months, (f) followed conservative medical care in a public hospital or a private clinic on the day of injury, (g) followed and finished their rehabilitation program for their injury, and (h) were ready for re-entry into competitive sport. The exclusion criteria were (a) injury also on the other side and (b) incomplete participant data.

The injury severity was assessed using the Colorado Injury Reporting System. According to this system, injuries are classified as (a) mild (requires treatment, but without change of sports activity), (b) moderate (requires treatment and change of sports activity), (c) grade I severity (no performance of sports activity for one to seven days), (d) grade II severity (no sports activity performed for one to four weeks), and (e) severity grade III (no sports activity performed for more than four weeks) [24].

We estimated a priori minimum sample size using G*Power version 3.1.9.7. Based on 80% power for detecting a large effect and a significance criterion of α = 0.05, (two-tailed), we aimed to recruit at least 23 athletes. Twenty-eight adult male football players volunteered for this study aged 26.18 ± 5.48 years old. All of the athletes had experienced an acute musculoskeletal injury before completing the questionnaire, with a mean duration of 26.21 days (SD = 8.32), including 10 ankle and 5 knee ligament sprains, 11 thigh muscle strains, and 1 tibia bone fracture. All of the injuries occurred at the lower extremity, particularly in the area of the thigh (39,2%), the ankle (35,7%), the knee (17.0%), and the hip (7.2%) (Figure 1). The mean physiotherapy treatment lasted 19.64 ± 8.51 days, and the athletes were absent from sport activities for 24.61 ± 9.06 days (

Table 1. Descriptive statistics of the demographic data of the sample (n = 28).

Variables	Min/Max	M	SD
Age	18/35	26.18	5.48
Competitive experience (years)	3/23	12.64	7.05
Duration of injury (days)	14/48	26.21	8.32
Duration of absence from sport (days)	14/45	24.61	9.01
Duration of physiotherapy treatment (days)	7/45	19.64	8.51
Physiotherapy treatment sessions (per week)	2/5	3.21	1.10
		Frequency	Percentage
Sex	Man	28	100
Sport	Football	28	100
Competing level	Amateur	28	100
Type of injury	Ligament sprain	15	53.6
	Muscle strain	11	39.3
	Bone fracture	1	3.6
	Plantar fasciitis	1	3.6
Area of injury	Ankle	10	35.7
	Knee	5	17.9
	Thigh	11	39.2
	Hip	2	7.2
Medical treatment	Yes	19	67.8
	No	9	32.2
Injury deterioration	Yes	2	7.1
	No	26	92.9

). All of the athletes had completed their rehabilitation program and were ready to return to competition.

2.2. Measures

Three validated questionnaires and three functional tests were employed in the present study.

• The Causes of Re-Injury Worry Questionnaire [25] (CR-IWQ; Cronbach’s α = 0.93).

This questionnaire consists of 12 questions across two factors:

▪

Re-injury worry due to rehabilitation (Cronbach’s α = 0.95, score range 8–56): A higher score reflects greater concern about re-injury as a result of an ineffective rehabilitation program.

▪

Re-injury worry due to opponent’s ability (Cronbach’s α = 0.93, score range 4–28): A higher score indicates heightened worry about re-injury due to the opponent’s skill level.

2.

The Sport Confidence Questionnaire of Rehabilitated Athletes Returning to Competition [26] (SCQ-RARC; Cronbach’s α = 0.92).

This questionnaire comprises 14 questions divided into two factors:

▪

Confidence due to rehabilitation (Cronbach’s α = 0.93, score range 8–56): A higher score suggests that the athlete feels more confident because of an effective rehabilitation program.

▪

General confidence (Cronbach’s α = 0.97, score range 6–42): A higher score indicates the athlete’s overall confidence in their own abilities.

3.

The Attention Questionnaire of Rehabilitated Athletes Returning to Competition [27] (AQ-RARC; Cronbach’s α = 0.95).

This questionnaire includes 10 questions, organized into two factors:

▪

Functional Attention (Cronbach’s α = 0.97, score range 7–49): A higher score denotes greater focus and attention from the athlete.

▪

Distraction Attention (Cronbach’s α = 0.94, score range 3–21): A higher score points to a greater level of distraction experienced by the athlete.

Three functional tests were used to evaluate hop performance on the injured side: (a) the side hop test, (b) the hop-for-distance test, and (c) the vertical jump test [28]. The Intraclass Correlation Coefficient (ICC) values for all three tests ranged from 0.85 to 0.97, indicating high test–retest reliability. These tests have been predominantly used with patients who have undergone ACL injury and reconstruction [28]. Fältström et al. [29] investigated the validity, reliability, and quality of the side hop test (SHT) in soccer players following ACL reconstruction. They found that the side hop test demonstrated excellent validity and reliability (ICC 0.92–1.0). However, the quality of the test varied by sex and age, with male players generally showing fewer flaws, particularly in double hops and foot turns with the hopping limb. Kurz et al. [30] highlighted the excellent validity and reliability of the modified forward hop test. Furthermore, Swearingen et al. [31] suggested that the single-leg vertical jump can be used in conjunction with the single-leg hop for distance or the modified single-leg hop for time (SHT) as outcome measures for assessing lower-extremity function. In another study, subjects performed the single-leg hop test, vertical jump, and side hop test on both legs across three different test sessions. This test–retest design study demonstrated excellent reliability [28].

For measuring vertical jump performance, the MyJump2 application (version number 6.1.7) was utilized as a valid tool to assess jump height, force, velocity, and power [28]. Montalvo et al. [32] conducted a single-session experimental design in which vertical jumps were assessed using four field test devices, including MyJump2, alongside motion capture and force platforms as criterion reference measures. They concluded that MyJump2 effectively replaces motion capture and force platforms for evaluating vertical jump tests, particularly for measuring jump height. The MyJump2 app demonstrated excellent validity, with an Intraclass Correlation Coefficient (ICC) of 0.99 across all jump modalities.

2.3. Procedure

The participants were found via personal and/or telephone contact with them and/or their physicians and/or their physiotherapists and/or their coaches and trainers from football, basketball, and handball by the authors from the cities of Athens and Sparta. Participants who met the inclusion criteria were informed during the first meeting, which took place one week before the team’s first sport competition game, about (a) the purpose of the study, (b) the voluntary nature of participation, and (c) the confidentiality of their responses. Also, they were informed that any publication of the results would be anonymous. They were asked to sign an informed consent document for participation in the present study. The duration of the meeting was approximately 15 min. The study was approved by the University’s Institutional Research Ethics Committee prior to data collection (663/11 January 2023).

In the second meeting, which took place the day before the team’s first competition, the CR-IWQ and the SCQ-RARC were completed. Functional tests were also performed on the same day. After the official competition, the AQ-RARC was completed.

The first functional test was the single lateral jumps in time/side hop (Figure 2a). The athletes stood on the leg being tested with their hands behind their back. They jumped from side to side between two parallel strips of tape placed 40 cm apart on the floor. They were told to jump as many times as possible within a 30 s period. The number of successful jumps, where the athlete did not touch the tape, was recorded. Touching the tape was recorded as an error. If more than 25% of the jumps had errors, a second trial of 30 s was performed after a 3 min rest period. The test was performed with both lower limbs [28].

In the second functional test, which is the single-leg hop-for-distance test, a controlled, balanced landing were performed by the athletes, and they were instructed to keep the landing foot in place (Figure 2b). Thus, they stood on the leg that was tested and then hopped as far as possible. The participants landed on the same leg with a free leg swing, and their hands were behind their backs. No extra hops were allowed until the examiner registered the landing position; failure to maintain the landing without additional hops resulted in a disqualified hop. The distance was measured in centimeters from the toe at push-off to the heel at landing [28].

The vertical jump test is performed as a countermovement jump (Figure 2c). The athletes were in a standing position with their hands behind their backs. They were instructed to quickly bend their knees as much as desired and then immediately jump upwards, aiming to maximize the height of their jump. The emphasis was on achieving maximum vertical displacement. The application recorded the height, force, velocity, and power performance. The test was performed with both lower limbs [28]. The height of the vertical jump was measured by applying a valid tool, the MyJump2 app.

2.4. Statistical Analysis

Descriptive statistics, including the mean (M), standard deviation (SD), skewness, and kurtosis, were utilized for analyzing the demographic data, questionnaire factors, and functional tests. Shapiro–Wilk normality tests were also performed to assess the normality of the data. If the test is non-significant, the distribution of the sample is not significantly different from a normal distribution, i.e., it is probably normal, which means we used Pearson r correlations. Otherwise, for non-parametric data, we utilized Spearman r correlations.

Regarding the assessment of the relationship between the measured variables, based on the results of these normality tests, (a) the six questionnaire factors were correlated using Spearman r correlations, (b) the functional tests were correlated using Pearson r correlations, (c) the questionnaire and functional factors were correlated with the duration of injury, the physiotherapy treatment, and the time of absence from sport using Spearman r correlations, and (d) the six questionnaire factors were correlated to the functional factors using Spearman r correlations.

Also, we performed independent t-tests to evaluate comparisons of the questionnaire factors and the functional tests between grade II and III severity groups of the study. Furthermore, paired-sample t-tests were performed to examine comparisons between the injured and the healthy limb in the 3 functional tests. We calculated the effect size via r = t/√N (r: effect 204 size; t: t value; N: observation number), and we verified our findings by using the formula r =Mean/SD, which is valid only for paired-sample t-tests. We divided the t value to the square root of the observation number to obtain the effect size. An effect size r that is less than 0.3 indicates a small effect. An effect size r between 0.3 and 0.5 indicates a medium effect, and a value greater than 0.5 indicates a large effect [33,34]. A significance level of p < 0.05 was considered statistically significant. All statistical analyses were conducted using IBM SPSS Statistics Version 23.0 (IBM Corp., Armonk, NY, USA).

3. Results

In

Table 2. Descriptive statistics of the questionnaire factors.

Questionnaire Factors	Score Range	M	SD	Minimum	Maximum	Skewness	Kurtosis	Percentage *
Re-injury worry due to rehabilitation	8–56	17.80	10.10	8	56	1.23	0.50	31.80
Re-injury worry due to opponent’s ability	4–28	10.00	5.90	4	28	1.30	1.75	35.80
Confidence due to rehabilitation	8–56	40.90	9.20	15	56	−0.80	0.50	73.00
General confidence	6–42	32.30	7.50	10	42	1.23	1.20	76.90
Functional Attention	7–49	35.70	9.20	15	49	−0.06	−0.50	72.90
Distraction Attention	3–21	7.30	4.00	3	21	0.81	−0.30	34.80

* Percentage of the mean score and the highest value of each factor.

, we present the descriptive statistics of the questionnaire factors. In particular, mean scores above 61% of the highest score for each factor were considered high, scores between 31% and 60% were considered average, and scores below 30% were considered low. Athletes exhibited average levels of “Re-injury worry due to rehabilitation” (M = 17.86 ± 10.11, 31.89% of the highest score), “Re-injury worry due to opponent’s ability” (M = 10.04 ± 5.96, 35.85% of the highest score), and “Distraction attention” (M = 7.32 ± 4.07, 34.85% of the highest score) (Table 2). Conversely, athletes demonstrated high levels of “Confidence due to rehabilitation” (M = 40.93 ± 9.24, 73.08% of the highest score), “General confidence” (M = 32.32 ± 7.52, 76.95% of the highest score), and “Functional attention” (M = 35.75 ± 9.20, 72.95% of the highest score) (Table 2).

The correlations between the three questionnaires and between the three functional tests are shown in

Table 3. Spearman r correlations among the questionnaire factors.

Questionnaire Factors	Total Score CR-WQ a	Factors CR-WQ		Total Score SCQ-RARC b	Factors SCQ-RARC		Total Score AQ-RARC c	Factors AQ-RARC
		Re-Injury Worry Due to Rehabilitation	Re-Injury Worry Due to Opponent’s Ability		Confidence Due to Rehabilitation	General Confidence		Functional Attention	Distraction Attention
Total Score for Causes of Re-injury Worry Questionnaire	1	0.84 **	0.53 **	−0.09	−0.02	−0.10	0.03	−0.04	0.26
Re-injury worry due to rehabilitation	0.84 *	1	0.16	−0.07	−0.07	0.06	0.16	0.04	0.32
Re-injury worry due to opponent’s ability	0.53 **	1.65	1	0.15	0.19	−0.03	−0.27	−0.31	0.11
Total Score for Sport Confidence Questionnaire of Rehabilitated Athletes Returning to Competition	−0.09	−0.07	0.15	1	0.95 **	0.73 **	0.31	0.32	−0.32
Confidence due to rehabilitation	−0.02	−0.07	0.19	0.95 **	1	0.56 **	0.29	0.34	−0.33
General confidence	−0.10	0.06	−0.03	0.73 **	0.56 **	1	0.28	0.28	−0.24
Total Score of Attention Questionnaire of Rehabilitated Athletes Returning to Competition	−0.31	0.29	0.28	0.03	0.16	−0.27	1	0.88 **	−0.15
Functional Attention	0.32	0.34	0.28	−0.04	0.04	−0.31	0.88 **	1	−0.55 **
Distraction Attention	−0.32	−0.33	−0.24	0.26	0.32	0.11	−0.15	−0.55 **	1

^a Causes of Re-injury Worry Questionnaire, ^b Sport Confidence Questionnaire of Rehabilitated Athletes Returning to Competition, ^c Attention Questionnaire of Rehabilitated Athletes Returning to Competition, * p < 0.05, ** p < 0.01.

and

Table 4. Pearson r correlations among the functional tests.

Functional Tests	Side Leg Hop Distance	Side Hop	Vertical Jump Height	Vertical Jump Feet	Vertical Jump Force	Vertical Jump Velocity	Vertical Jump Power
Side leg hop distance	1	0.38 *	0.36	0.44 *	0.30	0.47 *	0.39 *
Side hop	0.38 *	1	0.21	0.25	0.15	0.26	0.22
Vertical jump height	0.36	0.21	1	0.79 **	0.12	0.89 **	0.43 *
Vertical jump feet	0.44 *	0.25	0.79 **	1	0.19	0.89 **	0.48 **
Vertical jump force	0.30	0.15	0.12	0.19	1	0.16	0.75 **
Vertical jump velocity	0.47 *	0.26	0.89 **	0.89 **	0.16	1	0.46 *
Vertical jump power	0.39 *	0.22	0.43 *	0.48 **	0.75 **	0.46 *	1

* p < 0.05. ** p < 0.01.

, respectively. In particular, Distraction Attention was negatively correlated with “Functional attention” (r = −0.55, p < 0.01), and “Confidence due to rehabilitation” was positively correlated with “General confidence” (r = 0.56, p < 0.01) (Table 3). Many average and highly statistically significant correlations were found between the three functional tests (Table 4).

Also, the present results showed a positive medium correlation between the total score of the Questionnaire Attention and the single-leg hop for distance (r = 0.40, p < 0.05) and a negative medium correlation between the Distraction Attention and the vertical jump height (r = −0.37, p < 0.05)

Regarding the correlations between the questionnaire and functional factors with the duration of injury, the physiotherapy treatment, and the time of absence from sport, the results showed that the physiotherapy duration was positively highly correlated with the time of absence from sport (r = 0.79, p < 0.01) and severity of injury (r = 0.65, p < 0.01). The severity of injury was also highly positively correlated with the time of absence from sport (r = 0.83, p < 0.01).

Regarding the comparisons between grade II and III severity groups of the study regarding the questionnaire factors and the functional tests, the results showed that athletes with a grade II severity injury appeared to have a higher total score of attention compared to those with grade III severity injury (t = 1.71, p < 0.05).

Lastly,

Table 5. Mean and standard deviation (SD) of the functional tests between injured and healthy limbs.

Functional Tests		Mean (SD)	Lower/Upper Borders	t	Effect Size
Side leg hop distance	Injured limb	108.60 (33.59)	−22.95/−10.34	−5.41 ***	1.02
	Healthy limb	125.25 (27.75)
Side hop	Injured limb	29.9 (10.97)	−5.03/−1.76	−4.25 ***	0.8
	Healthy limb	32.68 (10.22)
Vertical jump height	Injured limb	17.60 (4.78)	−2.81/−0.40	−2.73 **	0.5
	Healthy limb	19.21 (5.24)
Vertical jump feet	Injured limb	356.61 (75.47)	−38.1/−11.36	−3.79 ***	0.72
	Healthy limb	381.34 (64.01)
Vertical jump force	Injured limb	1324.91 (324.26)	−156.68/70.4	−2.77 **	0.15
	Healthy limb	1398.02 (433.29)
Vertical jump velocity	Injured limb	0.89 (0.15)	−0.097/−0.032	−4.14 ***	0.75
	Healthy limb	0.96 (0.12)
Vertical jump power	Injured limb	1175.53 (438.33)	−320.8/−109.79	−4.18 ***	0.79
	Healthy limb	1390.84 (377.11)

** p < 0.01. *** p < 0.001.

shows that the performance of all of the functional tests was statistically different between the injured and the healthy limb. All of the effect sizes showed large effects, except for the variable “Vertical jump height”, which showed a medium effect, and the variable “Vertical jump force”, which showed a small effect [33,34].

4. Discussion

The aim of the present study was to examine the relationship between re-injury worry, confidence, and attention in athletes and their functional status and demographic data related to the rehabilitation process.

Firstly, athletes exhibited average levels of both re-injury worry and Distraction Attention along with high levels of confidence and Functional Attention. According to the theoretical model proposed by Williams and Andersen [35], athletes may not be fully psychologically prepared to return to sport, which increases the likelihood of negative cognitive appraisals, such as re-injury worry. This, in turn, may lead to decreased confidence and attention when they re-enter competitive play. Similarly, Gkikopoulos et al. [2] found that athletes with previous injuries experienced average levels of re-injury worry and Distraction Attention but displayed high levels of confidence and Functional Attention upon returning to sport. Christakou et al. [6], in their proposed model, reported that the psychological factors of re-injury worry, confidence, and attention may impact athletes returning to sport competition after a musculoskeletal injury, and they may cause a re-injury. Similar results were reported recently by Christakou et al. [36] for both sexes. Competing against opponents might generate negative thoughts in previously injured athletes due to the frequent physical contact during competition [25]. The quality of the rehabilitation program also significantly impacts the athlete’s re-injury worry [25]. Given that all athletes successfully completed their rehabilitation process, it is likely that their injuries were fully healed. Athletes tend to have higher levels of confidence when they return to sport fully recovered. When returning to competition with a fully healed injury, athletes may neglect internal cues from the previously injured area and focus more on relevant cues during competition [26].

The present results demonstrated a positive correlation between the two factors of confidence and between Functional and Distraction Attention. When athletes successfully complete their rehabilitation program, it is likely that their injury has fully healed. This successful recovery may lead to higher levels of confidence when returning to sport [37]. Additionally, athletes who exhibit high levels of Functional Attention and maintain focus on their target during the game are less likely to be distracted by irrelevant cues. This heightened focus can lead to better performance and a reduced risk of re-injury [27].

No other study has reported a connection between attention and specific functional tests, such as the single-leg hop for distance, side hop, or vertical jump. Our findings suggest a relationship between functional status and attention. This study’s hypothesis was only partially confirmed, as no relationship was found between re-injury worry, confidence, and functional status. It is crucial for athletes returning to sport after an injury to focus on essential performance cues. Distraction theories from social psychology highlight how attention can be diverted by task-irrelevant or threatening cues [38]. A previous injury is one such factor that can increase distractibility [31]. When athletes return to competition, they may become preoccupied with concerns about their physical conditioning, leading to negative thoughts about their performance. This preoccupation might cause them to focus less on task-relevant cues, potentially decreasing their performance and increasing the risk of re-injury [39]. Also, the difference in functional status between the two legs may be based on attention levels, but this needs to be studied further. To solidify these findings, further research should be conducted to confirm the relationship between attention and functional performance in athletes.

The severity of the injury was also highly positively correlated with the time of absence from sport. More severe injuries were associated with longer periods away from sport, as similarly reported by Gkikopoulos et al. [2]. This finding can be explained by the fact that injuries requiring longer rehabilitation periods are typically more severe. Athletes with serious injuries need extended time to heal and must undergo prolonged rehabilitation programs, which can last for days, weeks, or even months. As a result, these athletes are absent from sports activities for an extended period, focusing on recovery and rehabilitation.

Additionally, athletes with grade II injuries showed higher overall attention scores compared to those with grade III injuries. Conversely, athletes with grade III injuries exhibited lower Functional Attention and higher Distraction Attention [6]. This may be because athletes who sustained more severe injuries, and therefore experienced a longer absence from competition, may be more concerned about potential injury or re-injury to the same or another part of the body. These concerns may lead to reduced concentration during matches. Short et al. [9] found no statistically significant differences between different levels of injury severity, which could be because athletes, after completing their rehabilitation programs, are eager to return to competition and may feel confident they will not be re-injured. However, these concerns might contribute to a decrease in Functional Attention during competition. The reason for the increase in Distraction Attention and the decrease in Functional Attention between the two severity groups remains unclear [6]. It is possible that the mechanisms of Functional Attention during competition differ from those of Distraction, highlighting the need for further research on the impact of injury severity on attention levels in rehabilitated athletes returning to competition. Future studies should aim to confirm these findings.

It is crucial for athletes to possess both psychological readiness and functional ability when returning to sport competition to minimize the risk of re-injury. Assessing certain factors, such as re-injury worry, confidence, and attention, in previously injured athletes and identifying significant correlations with functional tests can aid the rehabilitation team in enhancing performance and reducing re-injury risks upon return to sport. The clinical significance of these findings lies in improving athletes’ preparation and performance after an injury. Rehabilitation teams can utilize reliable psychometric instruments, like the questionnaires employed in this study, to evaluate these psychological characteristics before athletes resume competition. Early identification of re-injury worries, as well as levels of confidence and attention at the start of the season, allows for targeted interventions. Athletes exhibiting high levels of re-injury worry or reduced confidence and attention may benefit from tailored psychological support programs and might be advised to gradually reintegrate into competition while avoiding particularly challenging games initially. Proactively addressing these factors can help prevent further injuries throughout the season, leading to decreased absence from training and competitions and ultimately maximizing athletic performance.

This study has several limitations that warrant consideration. As a cross-sectional study, it provides a snapshot of the relationships between variables at a single point in time. Consequently, the generalizability and causality of the results should be further explored through additional multicenter and longitudinal studies. Other limitations include the heterogeneity in injury duration and the variability in both the duration of rehabilitation programs and the length of absence from sport. Additionally, the study did not investigate whether athletes who received medical treatment exhibited better psychological readiness. Future research should focus on examining differences in re-injury worry, confidence, and attention across various demographic characteristics, such as gender, athlete categories, and among those who have returned to their preinjury level. Further studies could also explore the relationship between re-injury worry, confidence, and attention in athletes recovering from acute versus chronic injuries. Additionally, comparing these psychological factors in athletes who have received medication or undergone surgical treatment for musculoskeletal injuries would provide valuable insights.

5. Conclusions

The present findings suggest that athletes who have undergone rehabilitation for their injury might experience average levels of re-injury worry and Distraction Attention and higher levels of confidence and Functional Attention upon returning to competition. A high relationship between the three functional scales and between the confidence and attention variables was apparent in the present study. The attention variable was correlated with the single-leg hop for distance and the vertical jump height. Future studies with more homogenous samples of previously injured athletes may confirm the present results. Further examination should be conducted regarding the relationship between psychological and physical characteristics of rehabilitated athletes with different demographical data. It is important to assess how these differences relate to sport performance upon athletes’ return to competition.