Summary:
Introduction:
Return-to-sport (RTS) criteria are widely utilized in the sports field to assist specialists in the decision-making process. In addition to biomechanical recovery, psychological readiness may play a critical role in successful RTS and reducing re-injury risk.The importance of psychosocial factors in RTS decisions has been highlighted in the international Consensus statement for hamstring injury management in London. For the first time, the working group emphasized the role of psychosocial processes, with 98.3% of experts agreeing on the inclusion of emotional and psychological well-being in RTS screening (Paton et al., 2023). Despite this acknowledgment, there is limited clarity regarding the extent of research addressing psychosocial factors in RTS following hamstring injuries.
Purpose and objectives:
This scoping review aimed to examine the evidence regarding psychological, social, and contextual factors influencing RTS following hamstring injuries. Specific objectives include:
- Identifying the outcomes currently used to evaluate psychological readiness and social-contextual factors in RTS following hamstring injury.
- Refining the conceptualization of "psychological readiness" for RTS in the context of hamstring injuries.
- Mapping variations across sports, countries, sex, and environmental contexts in the consideration of psychological, social, and contextual factors during RTS decision-making.
Methods:
This review followed the scoping review guidelines outlined in the JBI Manual for Evidence Synthesis The protocol of this study was registered in Open Science Framework repository (OSF) in March 2024 (https://doi.org/10.17605/OSF.IO/8RK7E). The literature search was conducted between March and December 2024 in seven major electronic databases: Medline, Embase, PsycINFO, CINAHL, SPORTDiscus, Scopus and ProQuest. Publications in five languages (English, French, German, Spanish and Italian) were included. The search strategy was designed to systematically identify studies addressing three main concepts: athletes with hamstring injuries, psychosocial management and return-to-sports processes. All study designs were eligible for inclusion, including thesis and dissertations for grey literature.
Data extraction focused on demographic variables (e.g., age, gender, and sport type), study methods, psychological, social, and contextual outcomes, and reported measures of RTS readiness. The use of the MMAT ensured a robust assessment of methodological quality across mixed study designs, allowing for a comprehensive synthesis of quantitative and qualitative findings.
Results:
From 1882 studies, 12 met the inclusion criteria and were retained for final analysis. These studies used four different methodologies, including 2 RCT, 5 observational studies, 4 Delphi studies and 1 letter to the editor. 799 athletes and 546 professionals were included in the analysis, and only 124 of 1345 individuals were female highlighting a significant gender imbalance. Most studies (58%) were conducted in Europe, followed by 25% in Asia, Oceania and South America. Fifty per cent of the studies focused on football, with data collected from athletes participating in professional and recreational contexts.Psychological readiness emerged as a central theme in the RTS process but remains inconsistently addressed in the literature. Balc? & Ülkar (2020) found that criteria were consistently recognized and daily used by stakeholders, although assessment methods were no detailed. The importance of subjective perceptions in RTS has been highlighted by several studies. These identified many dimensions of psychological readiness, such as self-predicted recovery times, self-assessments, and perceptions during physical activities such as sprinting. Despite these observations, none of these studies provided a structured way to assess psychological readiness. Contextual stressors, including motivational and team-related factors, also may influence psychological readiness. These findings highlight the complex interplay between contextual and psychological factors, Pressure from athletes emerged as an important factor. Athletes often set unrealistic expectations for themselves, driven by fears of losing their position within the team. Team dynamics and communication within teams significantly influenced RTS decisions. These were also found to be influenced by institutional resources and cultural differences. Poor communication was another factor that contributed to inconsistent rehabilitation strategies and reduced psychological readiness. Social factors, although often underexplored, play a crucial role in RTS too. External pressures from the media, sponsors and agents often conflict with recovery protocols, as noted by Dunlop et al. (2019). Finally, the concept of psychological readiness remains poorly defined in the literature. Only 5 of the 12 studies analyzed explicitly addressed how psychological readiness should be conceptualized and defined.
Conclusions:
In conclusion, although the current literature recognizes the importance of psychological, social and contextual factors in RTS following hamstring injury, it exhibits notable heterogeneity, methodological limitations and a lack of standardized measurement tools. Evidence suggests that athlete feelings, social and hierarchical pressures, availability of resources and communication practices may all shape recovery trajectories. However, without consistent frameworks and validated tools, clinicians and researchers remain limited in their ability to integrate psycho-socio-contextual assessment into everyday practice.
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