Competitive athletes’ psychological and emotional experiences of injury rehabilitation: a scoping review

Abstract

Background

Sporting injuries have a psychological impact on competitive athletes, though most research focusses on the time of injury and returning to play. A greater understanding of the impact of injury rehabilitation programs on athletes is required. This scoping review synthesised the current peer-reviewed literature on the psychological and emotional experiences of competitive athletes undergoing injury rehabilitation.

Method

A systematic search of the PsycInfo, SportDiscus, MEDLINE, and Scopus electronic databases was conducted using keywords relating to psychology, rehabilitation, athletes, and injuries from January 1980 to April 2024. Studies that focussed on mental or psychological wellbeing during injury rehabilitation among competitive athletes aged ≥18 years who had suffered a musculoskeletal or soft-tissue injury were eligible for inclusion.

Results

In total, 64 studies were included, with 61% using a cross-sectional design. There was considerable variability in the definitions of injuries, competitive athletes, and injury severity in the included studies. The results highlighted the injury rehabilitation process is an emotional experience and while minimal psychological support was offered during rehabilitation, the level of social support received by athletes may positively and/or negatively impact their experience. Numerous coping strategies used during rehabilitation were identified, including goal setting.

Conclusion

The findings suggest that despite injury rehabilitation resulting in a range of emotions for athletes, minimal psychological support is offered, though positive social support can benefit experiences. Due to significant variation in definitions, including injury severity, it is difficult to draw consistent conclusions about athletes’ rehabilitation experiences. Future research should explore dynamic responses to injury throughout rehabilitation where possible. This information is critical for supporting competitive athletes’ mental or psychological wellbeing during injury rehabilitation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-025-02986-x.

Background

Sport participation can influence an individual’s physical and mental health [1]. In Australia, approximately 13.5 million people (~90%) aged 15 years or more participate in sport-related activities at least once each year [2]. However, participation carries a heightened risk of injury, especially among common contact sports such as football (soccer), Australian Rules football, and rugby, as well as in bat-and-ball sports like hockey and cricket [3, 4]. Competitive athletes also face a higher likelihood of injury due to their high training loads, which include many hours of high-intensity training across both sport-specific and conditioning programs [5, 6].

Athletes can be both physically and psychologically affected by injury, with injured athletes missing training and competition time. Following injury, athletes typically complete a rehabilitation program that often varies in length depending on the injury suffered and the biomechanical demands of successfully returning to their sport [7]. Research has shown that athletes can experience numerous negative emotions when injured, including depression, anxiety, anger, and feelings of isolation [8–11]. In contrast, others have reported more positive emotions and attitudes, such as joy, relief, and optimism [12–14]. A number of frameworks have been extensively used to understand factors that may influence an athlete’s psychological response to injury, including Kubler-Ross’ 5-stage Model of Grief [15], the Integrated Model of the Psychological Response to Sports Injury and Rehabilitation by Wiese-Bjornstal et al. [16], and the Biopsychosocial Model by Brewer and colleagues [17].

Research examining injury rehabilitation in both recreational and competitive athletes has often focussed on the psychological reaction immediately following injury [11] or before returning to play [9, 18]. For example, a review by Ardern et al. [19] on the psychological factors associated with returning to sport found that while negative emotions are often reduced as an athlete approaches a return to play, fear is still prominent when returning to sport and can cause athletes to not return at all. To our knowledge, however, no review has synthesised what is currently known about competitive athletes’ experiences during injury rehabilitation, which can account for a significant proportion of time from injury diagnosis to return to play. Scoping reviews are an appropriate method for exploring and identifying the extent, contexts, and characteristics of a research topic, examining methodologies, and identifying areas for further research [20]. A scoping review can also help determine whether there is the scope and need for a topical systematic review and allows for the identification of preliminary research gaps that could be investigated by future primary research [21]. Understanding athletes’ experiences during rehabilitation is crucial for informing sporting organisations on how athletes can be best supported to ensure that they are both physically and psychologically ready to return to training and competition.

The aim of this scoping review, therefore, was to summarise peer-reviewed literature on the psychological and emotional experiences during injury rehabilitation in competitive athletes and to identify key research gaps. A secondary aim of the scoping review was to explore the definitions, methodologies, and measures used to examine athlete injury rehabilitation within the literature.

Methods

Protocol and registration

This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses—Scoping Review extension (PRISMA-ScR, Tricco et al., 2018) (Additional file 1). The protocol for this review was prospectively registered with the Open Science Framework 10.17605/OSF.IO/J3Z59.

Eligibility criteria

Studies were included if they met the following criteria:

1. Population: Competitive athletes aged ≥18 years who suffered a musculoskeletal or soft-tissue injury. Competitive athletes were classified as any level above recreational due to varying differences between the classification of ‘competitive’ in different countries and sports. Studies that included recreational athletes or athletes below a level 7/8 on the Tegner Activity Scale [22] were excluded, unless the findings were presented separately for competitive and recreational athletes. Where data were presented separately, only competitive athletes’ data were included. Studies involving some athletes <18 years were included if the study-group-specific mean age was ≥18 years.

2. Injury classification: Musculoskeletal or soft-tissue injuries. Studies reporting on competitive athletes who had concussions, serious spinal-cord injuries, illnesses, or infectious diseases were excluded. Serious spinal-cord injuries were excluded due to the variations in injury rehabilitation protocols. Concussions were excluded due to the difficulty in separating the psychological consequences of the pathological injury and the athletes experience.

3. Outcome: Mental or psychological wellbeing focussing on the injury rehabilitation period from the athlete’s perspective, either prospectively or retrospectively. Studies were excluded if they solely focussed on athlete return to sport (either physically or psychologically) and did not explicitly examine the injury rehabilitation period.

4. Research design: Qualitative, quantitative, and mixed methods. Intervention studies were included if the control and intervention group results were reported separately, with data only extracted for the control groups, or before the intervention began, to ensure information reflected ‘usual’ rehabilitation protocols.

5. Publication status: Full-text refereed journal articles published in English. Articles published ahead of print were included if they had a digital online identifier (doi). Other publication types (e.g. conference abstracts/papers, systematic or narrative reviews, commentaries, editorials, dissertations/theses, study protocols, grey literature) were excluded as this review aimed to examine research methodologies, identify current research gaps, and was not examining the effects of interventions or individual sporting organisations injury rehabilitation processes.

Information sources and search strategy

An academic librarian assisted the literature search of four electronic databases (PsycInfo [via Ovid], SportDiscus [via EBSCOhost], MEDLINE [via Ovid], and Scopus [via Elsevier]), which was conducted to identify literature published from January 1, 1980, to April 2024. The search was limited to only English language studies. The search was limited to 1980 onwards because this is around when sport psychology became a more individualised area of research, with a specialised journal created for research, and the first papers including injury rehabilitation with a psychological response were published [23].

The search strategies comprised four keyword groups: psychological (‘mental health’, wellbeing, fear, coping, emotion*, psych*), rehabilitation (rehabilitation, ‘return to play’, ‘return to sport’), injury (‘sport injur*’, ‘athletic injur*’, sport medicine, injur*), and athlete (player*, elite, professional, competit*). Keywords within a group were combined using a Boolean OR and were searched with other keyword groups using the Boolean AND. Proximity operators (‘*’) were used to search for root keywords. A full search strategy for each database is provided in Additional file 2. The reference lists of included studies were also manually searched.

Selection of sources of evidence

Records were imported into EndNote (v20, Clarivate Analytics; Philadelphia, PA, USA) and duplicates identified and removed, with the remaining articles imported into Covidence (Veritas Health Innovation, Melbourne, VIC, Australia) for further de-duplication and record screening. Two reviewers (HRJ and CDB) independently screened all the titles and abstracts, with discrepancies resolved by discussion with a third reviewer (NDR). Full texts were independently screened by three reviewers, with one reviewer (HRJ) screening all articles and two reviewers (CDB and NDR) each screening half of the articles. Discrepancies were discussed among the reviewers until consensus, or a third reviewer’s evaluation was required.

Data charting process and data items

Data were extracted using a pre-designed standardised form by a single reviewer (HRJ), with 20% of included studies extracted in duplicate and cross-checked for accuracy by a second reviewer (NDR). The following data were extracted: participant characteristics (e.g. age, sex, country, sport, athlete status), injury (e.g. injury definition, type of injury, whether surgery was required), rehabilitation (e.g. length of rehabilitation), study design (including use of theoretical frameworks), measures used to assess mental or psychological wellbeing (e.g. questionnaires), and findings.

Synthesis of results

The first author developed the overarching themes for the results of all included studies, which were then presented to the remaining authors for cross-examination and discussion until consensus was achieved. The results are narratively described. Where necessary, tables were used to summarise important information. A quality assessment was not conducted as such assessments are typically not recommended for scoping reviews [24].

Results

Selection of sources of evidence

Figure 1 shows the PRISMA flowchart for each stage of the review. In brief, the titles and abstracts of 5474 articles were initially screened, with 474 full-text articles screened, and 64 studies included in this review.

Fig. 1.

PRISMA flowchart

Characteristics of sources of evidence

The study characteristics are summarised in Table 1. Data were available for 2248 athletes (60% male, 34% female, 6% not reported). Most studies (n = 39) collected data from both males and females and included athletes ranging in age from 18 to 44 years, while the most common group were collegiate athletes aged between 18 and 23 years (n = 28). Sample sizes ranged from 1 to 246 participants, with most studies (56%) including 10 or fewer participants. An underpinning theoretical framework was reported in 17% of studies.

Table 1.

Description of study characteristics (n=64)

Characteristics	n (%)
Mean age
18–30 years	50 (78%)
31–50 years	2 (3%)
18+ years	5 (8%)
Not reported	7 (11%)
Sex
Male	15 (23%)
Female	6 (9%)
Both	39 (61%)
Not reported	4 (6%)
Region
Europe	19 (30%)
Asia-Pacific	11 (17%)
North America	27 (42%)
South America	1 (2%)
Africa	1 (2%)
Multiple countries	3 (5%)
Not clearly reported	2 (3%)
Study design (used in analysis)
Cross-sectional	39 (61%)
Repeated measures	12 (19%)
Longitudinal	12 (19%)
Combination	1 (2%)
Sport
Individual	6 (9%)
Team	24 (38%)
Both	31 (48%)
Not reported	3 (5%)
Data collection
Interviews	27 (42%)
Self-report	17 (27%)
Focus group	1 (2%)
Combined	19 (30%)
Analysed sample size
1–10	36 (56%)
11–20	5 (8%)
21–50	8 (13%)
51–100	11 (17%)
100+	4 (6%)
Theoretical framework useda
Cognitive Appraisal Model	2 (3%)
Integrated Model of the Psychological Response to Sports Injury and Rehabilitation	6 (9%)
Ruff’s Model of Psychological Wellbeing	1 (2%)
Self-determination theory	2 (3%)
Social support theory	2 (3%)

Not all characteristics = 100% due to rounding. The table summarises information from the samples eligible for inclusion in the review

^aTwo studies used multiple frameworks; therefore, n indicates number of studies utilising each framework

Overall, 47% of the included studies collected qualitative data, while 25% collected both qualitative and quantitative data. Most studies (n = 39) utilised cross-sectional designs and either collected data from athletes while they were injured (n = 33) or asked athletes to recall previous injuries (n = 21) (Table 2). The definition of competitive athlete varied among studies, with athletes competing at the collegiate/university, semi-professional, professional, or international/Olympic levels (Additional file 3).

Table 2.

Summary of injury occurrence and time away in included studies (n=64)

	n (%)
Currently injured
Yes	33 (52%)
No	21 (33%)
Both	7 (11%)
Unclear	3 (5%)
Area of injurya
Head	3 (5%)
Arms	23 (21%)
Torso	13 (12%)
Lower body	42 (38%)
Other	12 (11%)
Not reported	17 (15%)
Surgery required
Yes	19 (30%)
No	2 (3%)
Both	8 (13%)
Unclear	35 (55%)
Time away from competition (mean)
0–12 weeksb	3 (5%)
12–24 weeks	9 (14%)
24–36 weeks	1 (2%)
36–48 weeks	5 (8%)
48+ weeks	1 (2%)
Range only reported	15 (23%)
Not clearly reported	30 (47%)

Not all data = 100% due to rounding

^aAs multiple areas of injury reported, n (%) based on total number

^bWeeks calculation based on 4.3 weeks per month

Overall, 65% of studies included athletes who had sustained a lower body injury, with 42% of studies including athletes who suffered an anterior cruciate ligament (ACL) injury, making it the most reported injury (Table 2). While 51 of the included studies did not explicitly report when the injury occurred (e.g. during the competitive season), 14 studies specified when injuries had occurred, including during pre-season training (n = 1), in-season training or competition (n = 10), or a combination of both (n = 3). Two studies included participants who had been injured not playing sport or at an external event. The length of time athletes spent away from competition varied widely between studies, ranging from 8 days to 6 years. Nearly half of the included studies (47%) did not clearly report how long the athletes were away from competition due to injury (Table 2).

In total, 48 studies reported how injury was defined, which included specific time periods (e.g. absence for at least 28 days [25]) to descriptions of the injury (e.g. ACL injury that required surgical intervention [26]) (Table 3). Four studies did not provide a definition of injury, though they included injury as an inclusion criterion. Only 22 studies specifically reported whether their participants suffered a minor, moderate, or severe (or similar) injury (Table 4), with just over half of these studies (n = 14) defining injury severity. Four studies used severity definitions provided by the National Athletic Training Association or the Colorado Injury Reporting System [85], with another five studies using definitions from other literature. Five studies provided their own definition of injury severity with no reference to previous literature.

Table 3.

Injury definition in included studies (n=64)

First author	Operational definition provided	Injury definition
Arvinen-Barrow [27]	✓	Recovered from severe sport-related injury
Arvinen-Barrow [28]	✓	Experienced career-ending injury
Bateman [29]	✕	No definition provided
Bejar [30]	✓	At least 4 weeks before return to play
Bejar [31]	✓	Unable to fully participate for at least 4 weeks
Bele [25]	✓	Absence for at least 28 days
Bon [32]	✕	No definition provided
Bone [33]	✓	Minimum of 1 week (5 consecutive days) time lost
Borman [34]	✓	First unilateral ACL rupture and underwent reconstruction surgery less than 12 weeks before
Buric [35]	✕	No definition provided
Carson [36]	✕	No definition provided
Carson [37]	✓	ACL injury requiring surgery and 6–12 months of rehabilitation
Carson [26]	✓	ACL injury that required surgical intervention
Carson [38]	✓	ACL injury that required surgical intervention
Clement [39]	✕	No definition provided
Clement [40]	✓	Restricted sport participation for a minimum of 6 weeks
Codonhato [41]	✕	No definition provided
Conti [42]	✓	Moderate-severe injury requiring a minimum of 2 months absence
Corbillon [43]	✓	Injury that limited participation for at least a week
Covassin [44]	✓	Unable to return to practice or game the same day or was absent from 1 or more days
Evans [45]	✓	Injury prevented participation for a minimum of 6 weeks
Gallagher [46]	✓	1 week or more of non-participation in practice or competition
Goldman [47]	✓	Injury preventing participation for a minimum of 8 weeks
Granito [48]	✕	No definition provided
Gray [49]	✓	Injury resulting in surgery and/or no participation for at least 6 weeks
Grindstaff [50]	✓	Severe enough to prevent participation in practice and competition for at least 30 days (and to require surgery)
Hillard [51]	✓	Musculoskeletal injury considered moderate in severity that resulted in at least 7 days of missed practice/competition
Johnson [52]	✓	Acute, long-term injuries. Unable to train/compete for minimum 5 weeks
Johnson [53]	✓	Unable to train or compete for a minimum of 5 weeks
Johnson [54]	✓	First-time total ACL tear
Johnson [55]	✕	No definition provided
Langford [56]	✓	Undergone uncomplicated primary ACL reconstruction
Lee [57]	✓	Lower-extremity musculoskeletal condition that required surgery
Madrigal [12]	✓	Sport injury expected to prevent/limit sport participation for at least 4 days
Mahoney [58]	✕	All underwent reconstructive knee surgerya
Mainwaring [13]	✓	Sprain/torsion injuries to the knee severe enough to require at least diagnostic arthroscopic surgery
Mankad [59]	✓	Long-term injury
Mankad [60]	✓	Seriously injured athletes
Masten [61]	✕	All underwent arthroscopy or other more demanding surgical proceduresa
McDonald [62]	✓	High severity injury—expected to limit participation for at least 3 weeks
Mehta [63]	✓	Primary, unilateral UCL reconstruction
Morgan [64]	✓	Required orthopaedic surgery during collegiate career
Newman [65]	✓	Suffered an injury in the past year that resulted in at least 1 week of missed participation
Paraskevopoulos [66]	✕	Sport injury within the last 2 yearsa
Piussi [67]	✓	ACL injury
Qin [68]	✓	Injury that occurs suddenly in a sports situation, resulting in a lack of special training for at least 1 month
Quinn [69]	✓	Out of competition and/or training for a minimum of 4 weeks
Quinn [70]	✓	Unable to participate for a minimum of 4 weeks and up to several months
Reel [71]	✓	Severe injury—required no participation for at least 1 month
Robbins [72]	✓	Forced to sit out of practice or competition for at least 3 days
Rock [73]	✓	ACL-reconstruction surgery required
Roderick [74]	✕	Not reported
Roy [75]	✕	Not reported
Ruddock-Hudson [76]	✓	Injury: ‘any physical damage sustained by sports participation which required medical attention, resulting in the absence from training or a game’ (AFL and AFLPA 2004) (53 p. 378)
Ruddock-Hudson [10]	✓	Out of practice and games for at least 8 weeks
Thatcher [77]	✓	Severe injury preventing participation in practice/competition for more than 21 days
Torres [78]	✓	Acute musculoskeletal sports injury that required inability to engage in full sport participation for at least 4 weeks
Tracey [79]	✓	Moderate to severe injuries and out of practice and/or competition for at least 7 consecutive days
Trainor [14]	✓	Serious injury: time loss of 21 days or more from participating
Wadey [80]	✓	Lower limb injuries during training or competition
Wadey [81]	✕	Sport-related injurya
Wadey [82]	✓	Injury requiring minimum 4-week absence
Yang [83]	✕	Not reported

^aNo specific definition provided but participants required to meet injury inclusion criterion to be eligible for the study

Table 4.

Injury severity in included studies (n=64)

First author	Injury severity reported					Injury severity definition provided	Previous injury experienced? (% of participants)
	Minor	Moderate	Severe/major	Other	Not reported
Abgarov [84]					✓		✓ (83.3%)
Arvinen-Barrow [27]			✓			⤫	✓
Arvinen-Barrow [28]					✓		?
Bateman [29]	✓	✓	✓			⤫	?
Bejar [30]					✓		?
Bejar [31]					✓		✓
Bele [25]			✓			✓	✓ (100%)
Bon [32]					✓		✓
Bone [33]	✓	✓	✓			⤫	?
Borman [34]					✓		?
Buric [35]					✓		?
Carson [36]					✓		✓ (100%)
Carson [37]					✓		✓ (50%)
Carson [26]					✓		✓ (60%)
Carson [38]					✓		✓ (60%)
Clement [39]	✓	✓	✓			⤫	?
Clement [40]					✓		?
Codonhato [41]	✓	✓	✓			⤫	?
Conti [42]		✓	✓			⤫	?
Corbillon [43]					✓		✓ (99%)
Covassin [44]					✓		?
Evans [45]					✓		?
Gallagher [46]					✓		?
Goldman [47]					✓		?
Granito [48]		✓	✓			✓	✓ (57.1%)
Gray [49]					✓		?
Grindstaff [50]					✓		?
Hillard [51]					✓		?
Johnson [52]			✓			✓	✓ (31%)
Johnson [53]			✓			✓	?
Johnson [54]					✓		✓
Johnson [55]				✓		⤫	?
Langford [56]					✓		?
Lee [57]					✓		✓ (50%)
Madrigal [12]					✓		✓(50%)
Mahoney [58]					✓		✓ (100%)
Mainwaring [13]			✓			✓	?
Mankad [59]					✓		?
Mankad [60]			✓			✓	?
Masten [61]					✓		✓
McDonald [62]			✓			✓	✓ (75%)
Mehta [63]					✓		?
Morgan [64]					✓		✓
Newman [65]					✓		?
Paraskevopoulos [66]					✓		?
Piussi [67]					✓		?
Qin [68]		✓				✓	?
Quinn [69]			✓			⤫	?
Quinn [70]			✓			⤫	✓ (61%)
Reel [71]			✓			✓	?
Robbins [72]	✓	✓	✓			✓	?
Rock [73]					✓		⤫
Roderick [74]					✓		✓
Roy [75]					✓		?
Ruddock-Hudson [76]					✓		?
Ruddock-Hudson [10]					✓		?
Thatcher [77]			✓			✓	?
Torres [78]					✓		?
Tracey [79]		✓	✓			✓	✓ (90%)
Trainor [14]			✓			✓	?
Wadey [80]					✓		?
Wadey [81]					✓		?
Wadey [82]			✓			✓	?
Yang [83]					✓		✓ (67.4%)

Only five studies explicitly stated that their focus was on long-term injuries, with one study defining a long-term injury as longer than 5 weeks, three studies classifying it as a minimum of 8 weeks, and one study failing to provide a definition. These long-term injury classifications were based on previous research or industry definitions. However, the rehabilitation period for these long-term injuries varied between and within studies from 2 to 18 months. Additionally, 11 other studies only included ACL-injured athletes, who had a minimum 6-month long rehabilitation. While this injury is typically classified as a long-term injury, with even accelerated ACL rehabilitation protocols lasting 6 months [86], these 11 studies did not make mention of the terminology long-term.

Synthesis of results

Various self-report measures were used among quantitative studies (Additional file 4). The most frequently used measures were the Social Support Survey (SSS) (n = 7), the Profile of Mood States (POMS) (n = 4), the Sports Injury Rehabilitation Beliefs Survey (SIRBS) (n = 5), and the COPE inventory (n = 4), which aligned with four main outcomes: social support, emotions, rehabilitation, and coping.

These four themes were also prominent in the qualitative studies. As such, the results are presented under these sub-headings. The findings from all studies are detailed in Additional file 5.

Social support

Social support was measured in nine quantitative studies and 10 mixed method studies, while themes related to social support emerged in 26 qualitative studies. Social support played a major role in the experiences athletes endured during injury rehabilitation. Family and friends were often regarded as the largest providers of social support, and this was of high importance to athletes [10, 12, 25, 32, 41, 42, 44, 63, 71, 83, 84]. Specifically, domestic support for those who were immobilised by injury was considered vital in assisting the rehabilitation process [34, 66, 73, 80]. Positive interactions and support from rehabilitation staff (e.g. athletic trainers and physiotherapists) were also important, especially when providing positive encouragement and informational, emotional, and motivational support [10, 13, 25, 31–35, 39, 40, 42, 44, 49, 63, 66, 72, 73, 83]. Conversely, support from teammates and coaches varied among studies. Some reported teammates being crucial support providers [10, 38, 40, 44, 63, 79], especially when received from other injured or previously injured teammates [42, 54]. However, other studies reported that teammate support was lacking [39, 84] or had a negative impact when they believed teammates were ‘watching on’ [38]. Athletes reported that coaches were lacking in their provision of support throughout rehabilitation [10, 13, 32, 34, 38, 39, 48–50, 68, 72, 76, 84].

Emotions

Emotions were measured by a variety of self-report measures in 11 quantitative studies and 10 mixed method studies, with 25 qualitative studies reporting themes broadly related to the emotional experiences during injury rehabilitation. Athletes reported experiencing several emotions throughout the injury rehabilitation process, with rehabilitation often referred to as a ‘rollercoaster’ of emotions ([10] p. 384, 49 p. 283), a ‘mental battle’ ([10] p. 384), or a ‘massive game psychologically’ ([55] p. 72). Negative emotions were mostly reported during the initial injury phase (e.g. immediately post-injury) and included shock, depression, frustration, anger, loneliness, and anxiety [10, 13, 14, 26–28, 30, 31, 35, 36, 40, 41, 46–48, 50, 53, 56, 58–60, 62, 69, 71, 74–77, 79–81]. The process of injury diagnosis was also an emotional period for athletes, especially when the initial diagnosis underestimated the extent of an injury or there was a delay in receiving a diagnosis [13, 45]. Athletes reported feeling like their world had fallen apart during this period [59].

Reports on emotional changes throughout injury rehabilitation were mixed. For many athletes, emotions became more positive as rehabilitation progressed and a return to sport was imminent [10, 12, 26, 56, 76, 77]. However, some studies reported that athletes experienced mood swings or fluctuations in emotions throughout rehabilitation, especially when setbacks occurred, with negative emotions such as loneliness and isolation increasing as rehabilitation progressed [10, 45, 57, 73, 79]. This was further demonstrated through reports of re-injury fear and anxiety during the rehabilitation program or when returning to sport, which helps highlight the rollercoaster of emotions experienced [10, 13, 14, 40, 58, 63, 77, 81, 82].

Rehabilitation experience

Experiences during rehabilitation were mentioned in 25 qualitative studies, 12 mixed methods studies, and measured in four quantitative studies. Boring, repetitive, and frustrating were common descriptions of rehabilitation programs [10, 31, 34, 38, 40, 60, 68, 75, 76, 81]. This resulted in athletes lacking motivation and frequently missing scheduled rehabilitation sessions [75, 76, 81]. Additionally, fixed rehabilitation protocols (e.g. for ACL injuries) meant that athletes perceived less autonomy and control over their rehabilitation program, which negatively influenced motivation [31, 36]. Feeling isolated and alone was common for athletes throughout rehabilitation, especially among those who had suffered long-term injuries [10, 14, 25, 45, 74, 76, 81]. Extended periods of individual (isolated) training were considered challenging, while training with injured teammates was more enjoyable and motivating [10, 54, 71, 76]. Despite 21 studies in this review collecting at least one timepoint of data during injury rehabilitation, very few studies provided information as to how the rehabilitation process was administered. This includes a lack of information on who was specifically involved in the prescription and delivery of rehabilitation, where sessions were run, and how often the athlete engaged in rehabilitation.

Coping

Coping was measured in several quantitative (n = 5) and mixed methods studies (n = 14), and an additional 14 qualitative studies. Sport psychology techniques such as visualisation and goal setting were mentioned as positive coping strategies to help regulate emotions [10, 26, 31, 36, 50]. The availability of a professional psychologist or counselling support was documented in four studies; but even when available, athletes sometimes declined the support or did not believe it was beneficial [28, 32, 60, 68]. However, Johnson et al. [52] found that less than 50% of athletes believed they were ‘psychologically restored’ ([75] p. 300), while Mankad et al. [60] reported less than 10% of athletes were physically and psychologically rehabilitated when returning to sport. Reel et al. [71] suggested individual counselling may help athletes deal with the emotional challenges of injury rehabilitation [71].

Discussion

Summary of evidence

This scoping review summarised peer-reviewed literature examining the psychological and emotional experiences of competitive athletes during injury rehabilitation and explored the definitions, methodologies, and measures used. Overall, the findings suggest that injury rehabilitation is an emotional experience for athletes and that the level of social support received may positively and/or negatively impact the athlete experience. Included studies varied by research design, data collection methods, and how competitive athlete and injury severity were defined. Few studies used an underpinning theoretical framework to inform the study design and the analysis of findings. Gaps in reporting included when the injury occurred (e.g. time in competitive season, during pre-season), whether surgery was required, and whether athletes had previously experienced an injury, all of which may influence their experiences of injury rehabilitation.

The current review identified that athletes experience a range of emotions immediately post-injury and during their rehabilitation, including frustration, anxiety, and depression [13, 14, 36, 81]. Negative emotions were typically reported immediately post-injury [28, 30, 60, 76], which were often exacerbated while waiting for a formal diagnosis [13, 45]. This is consistent with previous reviews that have reported the psychological impact of injury on athletes [18, 87]. Despite the psychological impact of an injury, minimal psychological support, such as the presence or availability of sport psychologists, was offered to athletes, with such support not always perceived as beneficial [28, 32, 60, 68]. It is difficult, however, to understand why such support may have been viewed in this way, as little information concerning access and availability of psychological support was reported in the included studies. Overall, these findings align with the integrated model of the psychological response to sports injury and rehabilitation [16], which describes emotional responses to injury as dynamic and can be influenced (positively or negatively) by personal (e.g. injury and individual differences) and situational factors (sport, social, and environment). However, because most of the included studies were cross-sectional and included data collected across rehabilitation periods ranging from 3 to 99 weeks, it was challenging to identify how emotional responses changed over time and whether they differed by the length of rehabilitation. As cross-sectional designs only capture data from a single time point, which may be at any point during or post-injury rehabilitation, longitudinal and repeated measure study designs are needed. While longitudinal studies may be more challenging to conduct, they are better suited for identifying the dynamic responses that may occur throughout injury rehabilitation.

One factor found to play an important role in the injury experience was social support, with athletes reporting they relied heavily on social support from a range of people, including allied health professionals (specifically athletic trainers and physiotherapists), teammates, and family members. This aligns with previous research which has found that social support can increase athlete performance, self-confidence, and motivation as well as act as a buffer against stress and burnout [88]. The social support that was provided in the identified studies included positive encouragement, emotional support in the form of talking or venting, and domestic support [43, 72, 73, 80–82]. Of note, athletic trainers (formal health care professionals who serve or treat athletes under the direction of, or in collaboration with, a physician) were unique to US athletes and were commonly referenced in studies examining collegiate athletes, which was the most investigated population among included studies. It is important to understand the role that athletic trainers play for injured athletes to determine whether this type of support should be replicated in other geographical regions and competitive standards.

It should also be noted that in some studies, however, that a lack of social support had a negative influence on competitive athletes’ rehabilitation experiences. This ranged from altered relationships with teammates because of the injury, which resulted from scepticism about the injury, to rehabilitation protocols that separated injured athletes from their teammates, and a mismatch between the social support the athletes needed and what was provided [40, 72, 86]. Overall, these results highlight that while social support is critical to athletes’ injury rehabilitation, such support must be tailored to the athletes’ needs to ensure that it is positively perceived and facilitates, rather than restricts, access to this source of support.

Interestingly, this scoping review found coaches often provided limited support to injured athletes, which may be due to the training and performance of competing athletes being their key role, with medical teams in place to help assist injured athletes [89]. This finding aligns with King et al.’s [90] review on the coach’s role during an athlete’s injury rehabilitation, where athletes looked to coaches for support and guidance, however, teammates and physiotherapists more commonly provided this social support. However, it is unclear whether social support, especially from coaches, for individual (solo) and team sport athletes differed, as most included studies focussed on team sport athletes and pooled the rehabilitation experiences across all athletes, where individual and team sport athletes were recruited. More research on individual sport athletes is needed to determine how social support varies due to the one-on-one relationship with coaches and the lack of teammate support, who were identified as key social support providers among team sport athletes [10, 38, 40, 42, 44, 54, 63, 79]. Such social support may influence their psychological and emotional experiences during injury rehabilitation.

Rehabilitation was found to be a boring, frustrating, and isolating process for athletes, which could negatively impact adherence to prescribed rehabilitation protocols [10, 30, 31, 38, 40, 60, 75, 76, 81]. It is difficult to understand the reasons behind the negative appraisal of rehabilitation due to minimal contextual information provided by studies regarding who was involved, where (e.g. onsite/offsite), when and how frequently the rehabilitation sessions occurred, the timing of the injury (e.g. differences between in-season, off-season, and pre-season injuries), as well as if surgery was required, which are all factors that could influence rehabilitation experiences. Future research should systematically collect such contextual data, including rehabilitation protocol information, to provide further insights into the complexity of injury and rehabilitation experiences. Interestingly, a previous review on rehabilitation adherence by Goddard et al. [91] noted that an athlete’s history of injuries and previous successful or unsuccessful rehabilitation experiences could factor into rehabilitation adherence. This is supported by two studies by Tracey [79] and Johnson et al. [54], included in this review, who found that a previous injury can positively influence rehabilitation due to previous successful outcomes. However, few included studies reported on whether athletes had suffered a previous injury. To help understand the rehabilitation experiences of athletes, research investigating and reporting the contextual factors of the injury and rehabilitation setting is required to help inform future recommendations. The development of a standardised framework that records contextual factors of a rehabilitation setting would enable this data to be documented consistently across future studies.

Though this scoping review included studies of competitive athletes only, the definition of ‘competitive’ varied among studies and ranged from athletes competing at a national or international level [28] to local (district) or club level [73] athletes. The difference in the level of competition may have impacted the resources available to athletes and consequently the injury rehabilitation experiences reported. Additionally, within some studies, rehabilitation experiences may have differed between amateur and professional athletes who competed at the same level within the same sport. For example, Buric et al. [35] noted that professional male athletes were in constant contact with doctors and physiotherapists during injury rehabilitation, while amateur female athletes felt there was a lack of health care resources available within their club, despite both teams playing in the first Croatian Football League. Therefore, it is challenging to detail the differences in the injury rehabilitation experiences among athletes competing at various levels due to the differences in data collection methods, the within-study pooling of results, as well as team and individual sport differences. Using classification frameworks such as McKay et al.’s participant classification framework [92] would characterise athletes based on their level of competition and could allow for comparison within and between studies.

This review also identified differences in the definitions used for injury, severity, and length of injury. The definition of injury, often used as a study inclusion criterion, ranged from injuries that limited participation for 1 day [44] to injuries that limited participation for a minimum of 4 weeks [31, 69], or required surgery and a minimum of 6 months of rehabilitation [26]. Similarly, injury severity definitions varied greatly. However, it must be acknowledged that over half of the studies did not explicitly describe participant injury severity. Previous reviews [18, 19] have found that injury severity can impact the psychological experience of athletes, with more severe injuries resulting in ‘prolonged and severe negative psychological responses’ ([18] p. 8). A similar finding was made by Ruddock-Hudson and colleagues [76], who reported that long-term injuries often elicit a more negative rehabilitation experience compared to short-term or minor injuries. However, included studies in this review often combined the experiences of athletes rehabilitating from short and long-term injuries, as well as different injury severities. For example, Bon and Doupona [32] pooled the experiences of participants who had suffered a 3-week injury with those who had suffered a 10-month injury, despite the potential impact of injury length on their experience. This limits the ability to draw confident conclusions regarding differences in rehabilitation experiences due to the heterogeneity of injury definitions and the aggregated reporting. Therefore, there is a need to harmonise the definitions of injury severity and injury length (e.g. short- and long-term), as well as the need to clearly report injury definitions used to assist with understanding the rehabilitation context and the consequent experience. While injury definitions vary [93], the development of a standardised framework to guide the classification and reporting of injury severity would enable comparisons in future research studies.

Of note, the findings of this review align with a recent consensus statement that highlighted that individual factors and an athlete’s access to social support, for example, are key to their navigation of the rehabilitation period and subsequent return to play [94]. It was also recommended that further research is needed to examine and understand the environments in which athletes rehabilitate their injuries [94], for example, which is further supported by this scoping review where few studies specifically examined environmental influences or documented the rehabilitation processes. Interestingly, the consensus statement noted that a range of research methods are required to examine rehabilitation experiences [94], though this current scoping review did identify that 25% of studies adopted mixed methods approaches. Overall, while it is important to develop insights into athletes’ rehabilitation experiences from a holistic perspective [94], this scoping review has highlighted that clear definitions of injury, injury severity, and competitive athlete status are required as these are central to understanding the injury experienced by the athlete.

Strengths and limitations

A strength of this scoping review included examining the experiences of injury rehabilitation among competitive athletes across studies varying in research designs, methodologies, and measures used. In lieu of an accepted and consistent definition for competitive athlete, we included studies on athletes who competed at various standards, although it is acknowledged that the findings from these studies may not be directly comparable.

Limitations of this review included most studies being conducted in athletes from high-income countries, particularly US collegiate athletes, and a lack of studies on individual sport athletes, resulting in findings that may not be generalisable to low/middle-income countries or individual sport athletes due to differences in available support. Future research is needed to explore the rehabilitation experiences of athletes in low- and middle-income countries. Additionally, cross-sectional studies, both those that collected data during a single point in the injury rehabilitation process or reflected on previous injury, were unable to capture the dynamic rehabilitation experience and may have been affected by recall bias, particularly if there was a significant time difference between the injury or rehabilitation period and the data collection. Future research should focus on capturing how rehabilitation experiences may change over time. Furthermore, studies focussing on only the return to play phase of rehabilitation were excluded as this may not accurately reflect the overall rehabilitation experience. As such, relevant information may have been omitted from this review. The inclusion of athletes aged 18 years and above is also a potential limitation. The psychological and emotional experiences of adult athletes may differ from younger athletes, which may be due to available resources and prior experiences of injury rehabilitation. This scoping review only included papers published in English. While the inclusion of only English language studies has been shown to minimally impact review findings [95], it is possible that this review excluded relevant research which may have impacted the observed findings. Future reviews could expand the number of databases searched (e.g. LILACS) and include non-English language studies. Lastly, due to resource constraints, data from only 20% of the included studies were extracted in duplicate. While few discrepancies in extracted data were noted between reviewers, it is possible that some errors may have occurred.

Conclusion

This scoping review has highlighted that the injury rehabilitation process is an emotional experience for competitive athletes, with the process reported as being boring, frustrating, and isolating. While minimal psychological support was reported to be offered to athletes during their injury rehabilitation, social support often had a large impact on the athletes’ personal experience. Of note, there was significant variability in the reporting of definitions surrounding competitive athletes, injuries, and severity. Additionally, studies typically did not distinguish between different levels of athletes, sex, types of sports, and injuries, making it difficult to draw conclusions regarding injury rehabilitation experiences in different settings and circumstances. Future research should consider reporting stratified results as well as developing and using standardised definitions. Moreover, there is a need for longitudinal studies as well as a focus on contextual factors such as the timing of injury and the impact of previous injuries.

Authors’ contributions

HRJ and NDR conceived the idea for the review. HRJ, CADB, and NDR contributed to the search, study selection, and data extraction. All authors contributed to data synthesis. HRJ wrote the first draft of the manuscript. All authors provided critical revision of the manuscript and approved the final submission.

Funding

No funding was received from any agency in the public, commercial, or not-for-profit sectors for this research.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

None declared.