Research in Sports Medicine

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Re-injury worry, confidence and attention as

predictors of a sport re-injury during a competitive
season

Anna Christakou , Nektarios A. Stavrou , Maria Psychountaki & Yannis

Zervas

To cite this article: Anna Christakou , Nektarios A. Stavrou , Maria Psychountaki & Yannis
Zervas (2020): Re-injury worry, confidence and attention as predictors of a sport re-injury during a
competitive season, Research in Sports Medicine, DOI: 10.1080/15438627.2020.1853542

To link to this article: https://doi.org/10.1080/15438627.2020.1853542

Published online: 30 Nov 2020.

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RESEARCH IN SPORTS MEDICINE
https://doi.org/10.1080/15438627.2020.1853542

Re-injury worry, confidence and attention as predictors of a

sport re-injury during a competitive season
Anna Christakoua,b, Nektarios A. Stavrouc,d, Maria Psychountakic and Yannis Zervasc
a
Department of Physiotherapy, University of West Attica, Athens, Greece; bDepartment of Physiotherapy,
General Hospital of Evagelismos, Athens, Greece; cDepartment of Physical Education and Sports Science,
University of Athens, Athens, Greece; dSport Psychology Laboratory, Hellenic Sports Research Institute,
Olympic Athletic Center of Athens “Spyros Louis”, Maroussi, Greece

ABSTRACT ARTICLE HISTORY

Rehabilitation from sport injury involves not only physical, but also Received 4 April 2020
psychological considerations. Re-injury worry, confidence and Accepted 27 August 2020
attention are characteristics that may affect athletes’ returning to KEYWORDS
competition after a sport injury. The study aimed to describe the Worry; confidence; attention;
predictive ability of the re-injury worry, confidence, and attention to re-injury; sport
the total of re-injuries at the new competitive season. The sample
was 80 male athletes with at least three years of competitive
experience who had a sport musculoskeletal injury in the last
8 months and had followed properly their physiotherapy program.
They were ready for re-entry into competitive sport. They com­
pleted on returning to competition: (a) the Causes of the Re-Injury
Worry Questionnaire, (b) the Sport Confidence Questionnaire of
Rehabilitated Athletes Returning to Competition and (c) the
Attention Questionnaire of Rehabilitated Athletes Returning to
Competition. The three valid and reliable instruments predict the
total of re-injuries at the beginning and at the middle of the
competitive season. Future research should be conducted to exam­
ine the relationship between the physical and psychological char­
acteristics in re-injury’s prediction from different contact sports.

Introduction
Sport injury is an unfortunate physical event, which may cause loss of hours of training and
participation to competitions. Rehabilitation from sport injury involves not only physical, but
also psychological considerations. Williams and Andersen’s stress-injury model (Williams &
Andersen, 1998) provides a comprehensive, interactional model, explaining the relationship of
injuries/re-injuries and psychological risk factors which consists of three main factors: person­
ality traits, history of stressors, and coping resources. The history of stressors embraces one
variable which is called previous injuries. They reported that previous injuries might enlarge
vulnerability to athletic injuries caused by: (a) negative cognitive appraisals and anxiety and/or
(b) an increased risk of being re-injured, if not fully physically recovered. Injury may alter the
athlete’s efficacy to perform the task at the level required, or the athlete may be prone to
attentional disruption due to worry or concern over his/her injury (Williams, 2001).

CONTACT Anna Christakou [email protected] Department of Physiotherapy, University of West Attica,

Athens, Greece
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 A. CHRISTAKOU ET AL.

Only empirical research has investigated the direct relationship of previous injuries and
vulnerability to injury (Söderman et al., 2001). Maddison and Prapavessis (2005) showed
that previous injuries are positive related to injury frequency, although as a conjunctive
moderator. On the other hand, Hanson et al. (1992) found no relationship between
previous injuries and subsequent injury frequency or severity. Also, inadequate rehabilita­
tion and insufficient recovery are the most obvious explanations for the increase of the re-
injuries returning to competition (Devantier, 2011).
Re-injury worry is an important construct in competitive sport that may increase the
risk of re-injury. Johnson and Ivarsson (2011) indicate that players with a history of
previous injury demonstrated an increased level of worry compared to the players with­
out previous injuries. Incorrect performance of rehabilitation exercises could contribute to
athletes’ coordination decrease and muscle tension increase, which are linked to re-injury
occurrence (Taylor & Taylor, 1997). Therefore, when injured athletes return to sport field,
they worry about their physical condition and become pre-occupied with details of skills’
execution technique. Focusing on the technique could cause lack of movement flow,
which could lead to re-injury (Walker et al., 2004). The athletes may worry about re-injury
on returning to competition due to some uncertainties, such as opponents’ ability and
sport field’s condition. Competing against a strong and capable opponent could create
concerns about athletes’ performance at a high level of competency. If an opponent plays
tough, the previous injured athlete may worry about re-injury, especially if the athlete has
harmful experiences. As a result, the “uncontrollability” of opponents’ actions may be
underlying the worry about the unknown factor.
Confidence of the rehabilitated athlete is the belief of certainty that the athlete
possesses about his ability to be successful in the sport after an acute musculoskeletal
injury. During the recovery process, athletes should correctly follow and complete an
appropriate rehabilitation program to perform up to pre-injury level in the upcoming
competition (Nwachukwu et al., 2019). Short et al. (2005) reported that athletes with
previous injury had re-injury worry and low confidence for avoidance of re-injury.
Preliminary research suggests that psychological readiness encompasses three compo­
nents: confidence to return to sport, realistic expectations regarding one’s sporting
abilities and motives to regain previous performance standards (Ardern et al., 2014;
Podlog et al., 2015).
There has been limited research considering the role that attention plays in athletes’
return to sport following an injury. Taylor and Taylor (1997) reported specific focus styles
that are useful tools to facilitate the rehabilitation process. They mentioned that injured
athletes during the recovery should focus on facilitation cues and block out interfering
cues. Nideffer (1983) suggested that being injured reduces the ability to swift attention
from the injured area and a similar reaction occurs on athlete’s return to sport. Specifically
on returning to competition, rehabilitated athletes may trigger thoughts of the earlier
injury. This awareness results in a narrowing and internalizing of attention onto injured
area. Therefore, there is an increased risk of re-injury. Similarly, Williams and Andersen
(1998) mentioned that a previous injury may cause attention disruptions on athlete’s
return to sport, i.e. failure to detect or respond quickly to relevant cues in the central field
of vision. Moreover, Heil (2000) outlines how the decreased attention to performance-
related cues and the increased distractibility may undermine athletic performance and
increase the risk of sport re-injury. When the athletes focus on injured area’s sensations
 RESEARCH IN SPORTS MEDICINE 3

(i.e. internal relevant, such as pain or muscular fatigue), they may lead to ignore external
relevant cues.
No previous studies have investigated the predictive ability of the re-injury worry,
confidence, and attention to the total of re-injuries during a competitive season. There is
a lack of research confirming these psychological indices to a sport re-injury framework at
the beginning and at the middle of the new competitive season. What processes take
place in returning to sport following a re-injury is not only a question of theoretical
importance, but also one which has clinical relevance. Indeed, this knowledge might help
physiotherapists and coaches enhance athletes’ better preparation and performance after
an injury. Therefore, the purpose of the present study was to examine our predicted
model of re-injury by examining athletes’ re-injury worry, attention, and confidence
during the competitive season on contact sports.

Methods
Participants
The participants of the study were male athletes of basketball (n= 32), handball, (n= 28)
and water polo (n = 20), ranging in age from 18 to 40 years old (M = 27.35, SD = 4.43) with
at least three years of competitive experience (M= 10.88, SD = 4.29). All of them had an
acute sport musculoskeletal injury in the last eight months with a mean of 3.70 months
prior to data collection (SD = 1.69). The average duration of the injury was 41.40 days
(SD = 31.65). Participants completed a physiotherapy program 29.39 days (SD = 21.57) and
were ready for re-entry into competitive sport (Table 1).
All participants were informed about the procedures of the study and signed a written
informed consent form. They had the right to interrupt their participation from the study at
any time and they were informed that any publication of the results would be anonymous.
Ethical approval was obtained through the Ethics Committee of the University. In order for

Table 1. Descriptive statistics.

Previous injury N %
Ligament sprain 35 43.7
Muscle strain 33 41.3
Tendon strain 11 13.5
Fracture 1 1.3
Injury part
Ankle 23 28.8
Knee 14 17.5
Gastrocnemius 6 7.5
Achilles tendon 11 13.7
Shoulder 7 8.8
Humerus 8 10
Femur 11 13.7
Medical treatment
Conservative medical treatment 44 55
Surgical treatment 36 45
Number of physiotherapy sessions/week
3 13 16.3
4 7 8.8
5 59 73.6
6 1 1.3
4 A. CHRISTAKOU ET AL.

the participants be included in the study, they had to meet the following criteria: (i) male
athletes, (ii) from 18 to 40 years old, (iii) have been active in sports activities at least three
times weekly and to participate to competitions during the past three years, (iv) had
a musculoskeletal sport injury in the last eight months, (v) followed a surgical or conserva­
tive medical care in a public hospital or a private clinic on the day of injury, (vi) followed and
finished their physiotherapy program and (vi) were ready to re-entry into competitive sport.

Measures
Three valid and reliable questionnaires, which can be used both for clinical and research
purposes, were used: (a) the Causes of Re-Injury Worry (CR-IWQ) (12 questions) which
represents two factors, namely re-injury worry due to rehabilitation (R-IWReh) and re-
injury worry due to opponent’s ability (R-IWOab) (Christakou et al., 2011), (b) the Sport
Confidence Questionnaire of Rehabilitated Athletes Returning to Competition (SCQ-
RARC) (14 questions) consisting of two factors, that labelled confidence due to rehabilita­
tion (C-Reh) and general confidence (G-Con) (Christakou et al., 2019), and (c) the Attention
Questionnaire of Injured Athletes (AQ-IA) (10 questions) which represents two factors
namely functional attention (FA) and distraction attention (DA), respectively (Christakou
et al., 2012). The CR-IWQ and SSCQ-IA questionnaires were administered before the
competition and the AQ-IA after the competition at the beginning and at the middle of
the competitive season.
The reliability and validity process of the three questionnaires were conducted in three
independent research phases to investigate: (a) the content relevance, (b) the factor
structure and the factorial validity, (c) the concurrent validity, (d) the discriminant validity,
(e) the test–retest reliability (ICC) and the internal consistency. Thirty six judges assessed
the content validity of the initial versions of the questionnaires. Exploratory factor analysis
(EFA) was chosen to examine the factor structure of the instruments using 186 volunteer
athletes. Confirmatory factor analysis (CFA) was used to further examine further the
factorial validity of the instruments using a different sample of 186 participants.
A number of valid constructs were used to assess the concurrent and discriminant validity
of the questionnaires such as Competitive State Anxiety Inventory-2 (CSAI-2), Sport
Anxiety Scale (SAS), Competitive Worries Inventory (CWI), State Sport Confidence
Inventory (SSCI) and the Profile of Mood States (POMS). The reliability of the instruments
was examined using Pearson r (ICC) and Cronbach α.
Regarding the CR-IWQ instrument, EFA revealed a 12-item model, representing two
factors and CFA supported the two-factor model [χ2 (df 54) = 109.971, p< 0.001;
NNFI = 0.969; CFI = 0.975; RMSEA = 0.075 (90% CI of RMSEA = 0.055–0.095)]. Cronbach’s
α for the R-IWReh factor was 0.89 and for the R-IWOab was 0.96. The ICC for the CR-IWReh
factor was 0.94 (95% CI: 0.90 ≤ ICC ≤ 0.96) and for the CR-IWOab was 0.98 (95% C.I.: 0.98
≤ ICC ≤ 0.99) (Christakou et al., 2011).
Regarding the SCQ-RARC instrument, EFA revealed a 14-item model, representing two
factors and CFA supported the two-factor model [χ2 (df 76) = 122.54, p < 0.001;
NNFI = 0.971; CFI = 0.975; RMSEA = 0.058 (90% CI of RMSEA = 0.038–0.076)]. Cronbach’s
α for the SCO-R factor was 0.95 and for the G-SCO factor 0.89. The ICC for the C-Reh factor
was 0.81 (95% CI: 0.75 ≤ ICC ≤ 0.87) and for the G-Con factor was 0.70 (95% CI: 0.66 ≤ ICC ≤
0.75) (Christakou et al., 2019).
 RESEARCH IN SPORTS MEDICINE 5

Regarding the AQ-RARC instrument, EFA revealed a 10-item model, representing two
factors and CFA supported the two-factor model [χ2 (df 34) = 71.245, p< 0.001;
NNFI = 0.978; CFI = 0.983; RMSEA = 0.075 (90% CI of RMSEA = 0.050–0.100). Cronbach’s
α values for the FA and DA factors were 0.95 and 0.84, respectively. The ICC for the FA
factor ranged from 0.96 to 0.98 with an average value of 0.97, and the DA factor varied
from were 0.91 to 0.95 with an average value of 0.93. All questionnaires provided
acceptable convergent and discriminant validity (Christakou et al., 2012).

Procedures
The participants were found via personal and/or telephone contact with the athletes and/or
with their physicians and/or their physiotherapists and/or their trainers by the first author. The
three instruments were completed at the beginning and in the middle of the competition
season by all participants. The number of total possible re-injuries measured by the rehabilita­
tion personnel. The duration of the injury was assessed by the physician of the team using the
«Colorado Injury Reporting System» in which injuries classified as: (a) minor injury (requires
treatment, but without changing the sporting activities), (b) moderate injury (requires treat­
ment and change of sporting activity), (c) injury level I (no running sporting activity for 1one to
seven days), (d) injury level II (no running sporting activity for one to four weeks) and (e) injury
level III (any execution sporting activity for more than four weeks) (Hanson et al., 1992).
Also, in the present study was used: (a) a demographic questionnaire, (b) a form related
to athletes’ previous injury, and (c) a form related to the possible re-injuries during the
new competitive season completed from the rehabilitation personnel.

Statistical analyses
Hierarchical multiple regressions were performed to investigate the predictive ability of
the six factors of the three questionnaires to the total of re-injuries during the competitive
season. The sample size for all regression analyses was adequate according to the
recommendations of Tabachnick and Fidell (1996) with a statistical significance of
p <.05. The administration of the three questionnaires preceded the periods during
which re-injury was monitored, and more specifically in the beginning and in the middle
of the competition period. The re-injury was monitored at the end of the competitive
season for each athlete by the rehabilitation personnel.

Results
69, 41 and 17 athletes had one, two and three injuries, respectively, during the competitive
season. The hierarchical multiple regression analyses show that the three questionnaires
predicted the total of re-injuries at the beginning of the competitive season (Table 2). The
multivariate model suggested that all the variables (except general confidence) explained
a significant proportion of the variance in number of total of re-injuries (R2 = 0.80, R2
adj = 0.79). This indicated that the proposed model accounted for 80% of total of re-
injuries and the regression equation was significant (F-ratio = 49.22%, p< 0.001). The final
prediction formula for the total of re-injuries is as follows: Υ = −1.07 + 0.03ΧR-IWReh +
0.13ΧRIWOab – 0.01ΧGC – 0.04ΧC-Reh – 0.02ΧFA + 0.03ΧDA.
6 A. CHRISTAKOU ET AL.

Table 2. Hierarchical multiple regressions among CR-IWQ, SCQ-fI, AQ-RARC at the beginning of the
competitive season.
Variables b SE b β t
Model 1
Constant −1.91 .274 −6.97***
Re-injury worry 1st factora 0.03 0.008 0.29 4.00***
2nd factorb 0.13 0.014 0.65 9.03***
Model 2
Constant −0.73 0.398 −1.83
Re-injury worry 1st factora 0.03 0.008 0.23 3.28**
2nd factorb 0.14 0.014 0.72 9.77***
Sport confidence 1st factorc −0.02 0.007 −0.15 −2.17*
2nd factord −0.05 0.012 −0.26 −4.04***
Model 3
Constant −1.07 0.462 −2.31*
Re-injury worry 1st factora 0.03 0.008 0.28 3.94***
2nd factorb 0.13 0.014 0.67 9.31***
Sport confidence 1st factorc −0.01 0.007 −0.06 −0.89
2nd factord −0.04 0.012 −0.22 −3.54**
Attention 1st factore −0.02 0.009 −0.12 −2.09*
2nd factorf 0.03 0.011 0.15 2.68**
Note a Re-injury worry due to rehabilitation, b Re-injury worry due to opponent’s ability, c General confidence, d
Confidence due to rehabilitation, e Functional attention, f Disruption attention. * p < 0.05. ** p < 0.01. *** p < 0.000

Regarding the middle of the competitive season, the 6 variables partly predicted the
total of re-injuries (Table 3). The multivariate model suggested that all the variables
(except re-injury due to uncertainty and general confidence) explained a significant
proportion of the variance in number of total of re-injuries (R2 = 0.66, R2 adj = 0.64).
This indicated that the 3rd model accounted for approximately 66% of total of re-injuries
and the regression equation was significant (F-ratio = 23.95, p < 0.00). The final prediction
formula for the total of re-injuries is as follows: Υ = 1.84 + 0.03ΧR-IWReh −0.00ΧRIWOab –
0.01ΧGC – 0.03ΧC-Reh – 0.03ΧFA + 0.05ΧDA.

Table 3. Hierarchical multiple regressions among CR-IWQ, SCQ-fI, AQ-RARC at the middle of the
competitive season.
Variables b SE b β t
Model 1
Constant −0.34 0.25 −1.38
Re-injury worry 1st factora 0.05 0.01 0.50 5.32***
2nd factorb 0.04 0.02 0.28 3.00**
Model 2
Constant 2.13 0.58 3.71***
Re-injury worry 1st factora 0.03 0.01 0.28 2.83**
2nd factorb 0.04 0.01 0.27 3.14**
Sport confidence 1st factorc −0.03 0.01 −0.23 −2.28*
2nd factord −0.04 0.01 −0.24 −2.65*
Model 3
Constant 1.84 0.58 3.17**
Re-injury worry 1st factora 0.03 0.01 0.27 2.98**
2nd factorb −0.00 0.02 −0.01 −0.06
Sport confidence 1st factorc −0.01 0.02 −0.07 −0.66
2nd factord −0.03 0.01 −0.18 −2.00*
Attention 1st factore −0.03 0.01 −0.27 −2.50*
2nd factorf 0.05 0.02 0.26 2.21*
Note a Re-injury worry due to rehabilitation, b Re-injury worry due to opponent’s ability, cGeneral confidence, d
Confidence due to rehabilitation, e Functional attention, f Disruption attention. * p < 0.05. ** p < 0.01. *** p < 0.000
 RESEARCH IN SPORTS MEDICINE 7

Discussion
The results of the study showed that re-injury worry, confidence and attention predict
a re-injury at the beginning and at the middle of the competitive season. The proposed
theoretical model of Williams and Andersen (1998) has been confirmed in which the
previous injury may be an increasing factor of re-injury probability. The athlete may not be
prepared psychologically to return to sport, increasing the likelihood of negative cogni­
tive appraisals such as worry of re-injury, thus their confidence may be decreased when
he/she returns back to a competitive game. Previous injury may alter athlete’s efficacy to
perform the task at the level required and he/she may be prone to attentional disruption
due to worry over his/her previous injury (Williams, 2001). Also, Gkikopoulos et al. (2019)
showed athletes with the previous injury experienced average levels of re-injury worry
and distraction attention and high levels of confidence and functional attention on
returning to sport.
Less is known about the impact of re-injury worry, as a cognitive dimension of the
re-injury anxiety, on athlete’s returning to sport after an injury. Fear of re-injury or fear
of movement or kinesiophobia are more a biological mechanism associated with
definite danger (Walker et al., 2010) and are the most commonly used terms in
anterior cruciate ligament literature (Paterno et al., 2018; Ross et al., 2017). Whereas
Walker et al. (2010) suggested that “‘re-injury anxiety’” may be more appropriate to
describe the emotional response of the athlete as is associated with anticipation or
uncertainty on returning to sport after an injury. In terms of the consequences of re-
injury anxiety, studies have showed that it is the most commonly cited reason for
a reduction in or cessation of sport participation (Ardem et al., 2012). Wadey et al.
(2014) reported that re-injury anxiety has a negative relationship with the return
concern after an injury. For those athletes who return to competitive sport, re-injury
worry can also manifest by hesitation, holding back, giving less than maximal effort.
Caron et al. (2017) revealed that athletes with musculoskeletal injuries, who were
psychologically underprepared when returning to the sport, were afraid of being re-
injured. Paterno et al. (2018) found that athletes with greater self-reported fear move­
ment/re-injury had an increased risk of suffering a second ACL injury in the 24th
months after return to sport.
Confidence is another important factor to examine after a sport injury when athlete
returns to sport. Athletes reported the importance of confidence in the effectiveness of
the rehabilitation program, and confidence in their personal performance capabilities.
Conti et al. (2019) showed in their qualitative study, that participants felt confident upon
their initial return to competition because they believed in the abilities of their rehabilita­
tion practitioners and in the effectiveness of the work completed during their rehabilita­
tion programs. Athletes believed when they get back that their try to the rehabilitation
and training program was the key factor in achieving high physical performance capabil­
ities and increasing confidence in the injured body part. The same study described that
low confidence in personal abilities, decrements in skill execution and dysfunctional
physical sensations are predominance of factors that hindered athlete’s return to pre-
injury levels during first official game (Conti et al., 2019).
Attention may contribute significantly into the existence of a sport re-injury at the
beginning and at the middle of the competitive season. When an athlete is coming back
8 A. CHRISTAKOU ET AL.

from an injury, distraction of attention may cause re-injury. Evidence supports the con­
tention that sport injury can induce an internal focus on the injury site and shift the
athlete’s attention away from essential performance cues, the latter of which may lead to
decrements in performance (Christakou et al., 2012; Gray, 2015; Heil, 2000). Gray reported
that “a return to a high level of performance will require the re-adoption of an external
focus of attention” (p. 615). Athletes’ attention on the injured part may be detrimental
because they could not concentrate on what they planned to do to during the game,
while athletes remarked that focus [on the injury] during the match reduced my ability to
respond quickly to what was happening around me in the court (Conti et al., 2019). Our
findings propose that the rehabilitation team should evaluate the attention of returning
athletes after rehabilitation process and helping them to remain focused on crucial
performance elements during the new competitive season.
Our proposed model (Figure 1) explains re-injury’s prediction by re-injury worry,
confidence and attention, when athlete returns back to sport after an injury during the
competitive season. At the beginning of the competitive season, all of the six factors of
the psychological indices predict re-injury, whereas at the middle phase, re-injury was
predicted from the re-injury worry due to rehabilitation factor, the confidence due to
rehabilitation factor and from the attention factors.
The importance of the model is significant because it can enhance athletes’ better
preparation and performance after an injury. Study showed that re-injury worry, attention
and partly confidence predicts sport performance at the beginning of the competitive
season; thus may enhance performance (Christakou et al., 2014). The rehabilitation
personnel will be able to recognize from the beginning of the season the existence of
worries of re-injury, the level of confidence and attention of athletes with previous injury.
Therefore, the rehabilitation personnel may decide that the athletes with worries of re-
injury, reduced confidence and attention not to participate in difficult games to avoid re-
injuries. The athletes are required to follow psychological support program that includes
control of worries, increase confidence and attention. The possible prediction to avoid
further injury during the season will contribute to the reduction of the abstention because
of injury, thus increasing the participation of athletes in workouts and games, and there­
fore to maximize sport performance.

Previous injury

At the beginning
of the season

Re-injury worry
Confidence Attention
Re-injury

At the middle of
the season

Figure 1. Prediction model of sport re-injury at the beginning and at the middle of the competitive
season.
 RESEARCH IN SPORTS MEDICINE 9

The main strength of the study is that there has not been any previously published
research examining the probability of a re-injury assessing the variables of re-injury worry,
confidence and attention during a competitive season. Also, this study followed Brewer’s
(2010) recommendations for future research exploring the relationship between psycho­
logical factors and rehabilitation outcomes, i.e. a re-injury. Other strength was the objec­
tive evaluation of the causes of re-injury worry, confidence and attention using valid and
reliable instruments such as the CR-IWQ, the SCQ-RARC and the AQ-IA. Lastly, findings
from the study provide valuable insights into factors which can be influenced by
a successful return to competition following injury.
However, this study has also a few limitations. Heterogeneous sample is a limitation.
The most desirable samples are those that are homogenous with respect to injury type
and rehabilitation protocol. Some of the athletes of the present study have followed
a surgical and others a conservative therapy of their musculoskeletal injury. It is not
possible the generalizability of the present results to non-contact sports. Another limita­
tion is the use of self-report instruments and it is desirable to use additional objective
measures to validate athletes’ self-report of worry, confidence and attention (e.g. biolo­
gical indices).
Future research should be conducted to examine the relationship between the physi­
cal and psychological characteristics in re-injury prediction using a homogenous sample
of athletes. It is, however, difficult to recruit previous injured athletes which have the same
demographic characteristics (i.e. dominant limb, sport, sex, etc.) and type of injury. In
future investigations need to be carried out structural model equations for the considera­
tion of any proposed interpretative prediction model using a larger sample of athletes
with previous injury. In addition, other important characteristics necessary to be consid­
ered for the best examination forecasting predicted models of re-injuries (e.g. emotional
reactions, incentives). Lastly, it would be interesting to investigate the experiences of
rehabilitated athletes who failed to return to pre-injury levels or quit their sporting
activity.

Conclusion
Re-injury worry, confidence and attention predict a re-injury at the beginning and at the
middle of the competitive season. Future research should confirm the proposed model of
re-injury during the new competitive season, using a larger homogenous sample of
athletes with previous injury.

Acknowledgements
We would like to thank the participants and their rehabilitation staff for participating in the present
study. This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.

Disclosure statement
The authors declare that the research was conducted in the absence of any commercial or financial
relationships that could be construed as a potential conflict of interest.
10 A. CHRISTAKOU ET AL.

Funding
No funding to declare.

Data availability statement

The data used to support the findings of this study are available from the corresponding author
upon request.

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