Injury-Psychological Readiness to Return to Sport Scale

Abstract

The Injury-Psychological Readiness to Return to Sport Scale (I-PRRS) is a specialized psychometric instrument developed by Douglas D. Glazer in 2009 to evaluate an athlete’s situational self-efficacy and psychological preparedness to resume competitive athletic participation following an acute or chronic sports-related injury. Within athletic training and sports medicine, physical clearance criteria—such as range of motion, muscle strength symmetry, neuromuscular control, and functional movement screening—have historically served as the primary determinants for authorizing return to play. However, empirical investigations have continually highlighted that physical recovery does not automatically coincide with psychological recovery. Athletes cleared from a purely orthopedic perspective frequently suffer from reinjury anxiety, decreased state confidence, kinesiophobia, and fear of reinjury, which collectively elevate the risk of secondary injuries and athletic underperformance.

The I-PRRS was engineered to address this critical gap by assessing psychological readiness as a dynamic, situation-specific state rather than a static personality trait. Comprising 6 items, the scale measures an athlete’s confidence in specific rehabilitation and competitive domains, such as the ability to perform without debilitating pain, the capacity to exert maximal effort, and structural trust in the injured anatomical site. Responses are recorded on an 11-point numerical rating scale ranging from 0 to 100 in intervals of 10. Psychometric validation was initially conducted through a rigorous three-round Delphi method involving athletic trainers and collegiate coaches to confirm content validity, yielding Aiken’s V coefficients between 0.79 and 1.00. Criterion-related concurrent validity was confirmed via statistically significant inverse relationships with the Profile of Mood States (POMS) Total Mood Disturbance scores across distinct rehabilitation milestones. Clinical cut-off benchmarks designate a composite score of 60 as indicating full psychological readiness, scores of 40 to 59 as reflecting moderate confidence requiring structured monitoring, and scores below 40 signaling low psychological readiness that warrants clinical intervention. The instrument represents a vital bridge between physiological rehabilitation and psychological re-entry into high-demand sport environments.

Keywords

athletic injury, sport psychology, self-efficacy, return to sport, psychological readiness, sport confidence, rehabilitation, kinesiophobia, athletic training, psychometrics, Profile of Mood States, reinjury anxiety

Authors

The Injury-Psychological Readiness to Return to Sport Scale was developed and validated by Douglas D. Glazer, MS, ATC. At the time of the instrument’s development and preliminary validation study, Glazer was affiliated with the Department of Sports Science and Athletic Training at Endicott College, located in Beverly, Massachusetts, United States. Correspondence regarding the scale, its development, and clinical applications was directed through Endicott College’s athletic training educational faculty ([email protected]).

Glazer’s clinical and academic background as a certified athletic trainer (ATC) informed the conceptual design of the I-PRRS. Recognizing that conventional sports medicine assessments emphasized orthopedic benchmarks while neglecting psychological readiness, Glazer sought to produce a brief, clinically viable instrument that athletic trainers, physical therapists, team physicians, and sports psychologists could administer trackside or in outpatient rehabilitation facilities without imposing an excessive administrative burden on the patient or practitioner.

Purpose

The primary purpose of the Injury-Psychological Readiness to Return to Sport Scale is to quantify an injured athlete’s state-specific psychological readiness to reintegrate into full athletic training and competition. In competitive athletics, musculoskeletal trauma is accompanied by extensive neurocognitive, emotional, and behavioral perturbations. While physiological rehabilitation frameworks—such as criteria-based ligament reconstruction protocols, tendon loading models, and joint arthroscopy progressions—focus on objective tissue healing, dynamic balance, and limb symmetry indices, they fail to evaluate the athlete’s cognitive appraisals regarding their physical capability.

Athletes who achieve full medical and orthopedic clearance often experience significant cognitive hesitations upon re-entering contact or high-velocity athletic environments. This psychological incongruence can result in several detrimental clinical and performance consequences:

• Elevated Risk of Reinjury: When an athlete lacks confidence in an injured limb, altered movement biomechanics and guarded kinematics frequently emerge. Guarding mechanisms, protective neuromuscular compensation, and altered movement strategies often overload uninjured contralateral joints or place the repaired structure under aberrant torsional loads, paradoxically elevating the risk of secondary or compensatory trauma.
• Attentional Narrowing and Distraction: Rooted in cognitive appraisal models of athletic stress, an athlete consumed by fear of reinjury or pain exhibits narrowed visual field processing and elevated distractibility. This failure to allocate appropriate attentional resources toward competitive stimuli impairs decision-making speed and reaction time, increasing susceptibility to impact injuries.
• Performance Decrements: Lack of psychological readiness inhibits full physical commitment. An athlete who doubts their limb’s structural integrity is unlikely to sprint at absolute maximal velocity, execute aggressive deceleration or cutting maneuvers, or engage in physical collisions with full commitment.

The I-PRRS addresses these issues by offering a rapid, standardized, and repeatable assessment that can be implemented longitudinally across the rehabilitation continuum. By capturing confidence fluctuations from the acute post-injury phase through progressive functional activity, return to practice, and return to formal competition, the scale enables multidisciplinary sports medicine teams to identify psychological deficits early. Furthermore, the I-PRRS includes a parallel clinician-rating version, enabling athletic trainers to compare an athlete’s self-reported psychological readiness against the clinician’s objective behavioral observations. This multi-informant approach provides an empirical safeguard against either premature clearance due to athletic overconfidence or unnecessary participation delays driven by unaddressed kinesiophobia.

Psychological Construct

The core psychological construct measured by the I-PRRS is state-specific psychological readiness to return to sport, operationalized through the lens of situational self-efficacy and sport confidence. Rather than assessing baseline personality traits or global, enduring self-esteem, the scale captures transient, highly malleable cognitive appraisals that an athlete holds regarding their physical and mental capability to withstand the unique stressors of athletic participation post-injury.

In psychometric literature, sport confidence has historically been divided into trait sport confidence (an athlete’s enduring belief in their general athletic capabilities) and state sport confidence (the belief an athlete possesses at a specific moment regarding their ability to succeed). Glazer narrowed this conceptual framework even further, demonstrating that standard measures of state sport confidence were inadequate for injured populations because they evaluate competitive performance rather than recovery-specific anxieties. The construct measured by the I-PRRS encompasses several distinct operational dimensions:

1. Global Confidence in Athletic Resumption

This facet assesses the athlete’s overarching self-efficacy regarding their physical return to sport. It represents a macro-level appraisal of readiness, reflecting whether the athlete views their rehabilitation as sufficient to step back onto the field, court, track, or ice. Rather than reflecting general athletic optimism, it measures the athlete’s holistic evaluation of their overall capability to function within their competitive sports domain.

2. Pain Tolerance and Nociceptive Confidence

Persistent or anticipated pain is a major cognitive barrier during the terminal phases of rehabilitation. The construct captures the athlete’s confidence in their ability to play without pain or to perform effectively despite residual, non-pathological discomfort. Athletes with high self-efficacy in this domain do not catastrophize bodily sensations, interpreting localized post-exertional soreness as normal physiological adaptation rather than impending reinjury.

3. Capacity for Maximal Effort and Physical Exertion

A crucial milestone in functional rehabilitation is the athlete’s willingness to produce 100% effort during explosive, high-intensity athletic tasks. Subconscious inhibition—frequently referred to as neuromuscular inhibition or voluntary deceleration—manifests when an athlete holds psychological reservations. This dimension measures the athlete’s belief that they can sprint, cut, jump, and collide with complete physical exertion without protective self-limitation.

4. Attentional Defocusing from the Injured Anatomical Site

During motor learning and elite athletic execution, optimal performance relies on an external focus of attention or automated motor schemas. When an athlete recovers from trauma, attentional focus often shifts internally toward the injured joint or tissue. The I-PRRS evaluates the athlete’s confidence in their ability to direct cognitive resources outward toward tactical sport stimuli, opposing players, and environmental cues, rather than hyper-fixating on internal sensations from the injured site.

5. Structural Integrity and Demands Tolerance

This domain captures the athlete’s mechanical trust in the injured anatomical structure. It reflects whether the athlete believes the healed bone, ligament, tendon, or muscle can absorb high-magnitude kinetic forces, sudden changes of direction, and external impacts inherent to competitive play. Deficits in this domain indicate lingering biomechanical distrust, even when clinical laxity or diagnostic imaging confirms physiological healing.

6. Sport-Specific Technical Competence

Physical detraining and time away from tactical environments inevitably produce subjective feelings of skill decay. This facet measures the athlete’s self-efficacy regarding their technical sport skills, execution capabilities, and tactical proficiency, verifying that psychological readiness reflects both structural trust and sport-specific competence.

Theoretical Framework

The theoretical architecture of the I-PRRS is primarily anchored in Albert Bandura’s Social Cognitive Theory and his seminal model of Self-Efficacy (Bandura, 1977, 1986, 1997). Bandura defined self-efficacy as an individual’s subjective conviction that they can successfully execute the behavior required to produce a specific outcome. Within Bandura’s framework, self-efficacy is explicitly differentiated from generalized self-confidence or self-esteem: it is domain-specific, situationally variable, and dynamically informed by cognitive processing of information derived from four primary sources:

1. Performance Accomplishments (Mastery Experiences): The most potent source of efficacy beliefs. In rehabilitation, progressive functional milestones—such as advancing from non-weight-bearing exercises to linear jogging, multi-directional cutting, and non-contact drills—provide tangible mastery experiences that incrementally rebuild situational confidence.
2. Vicarious Experiences: Observing peers or teammate role models who successfully navigated identical injuries and returned to high-level play enhances an athlete’s belief in their own recovery potential.
3. Verbal Persuasion: Encouragement, feedback, and objective clearance metrics communicated by athletic trainers, physical therapists, orthopedic surgeons, and coaches validate the athlete’s progress and mitigate unwarranted doubt.
4. Physiological and Emotional States: Aversive somatic arousal, elevated heart rate, somatic muscle tension, and pain are frequently misinterpreted by recovering athletes as indicators of physiological vulnerability or failure, undermining efficacy expectations.

The I-PRRS also draws heavily from Robin Vealey’s Model of Sport Confidence (Vealey, 1986). Vealey conceptualized sport confidence as the degree of certainty individuals possess about their ability to be successful in sport. She differentiated between trait sport confidence (SC-trait)—a generalized disposition—and state sport confidence (SC-state), which fluctuates based on competitive situations. Glazer extended Vealey’s state sport confidence paradigm, positing that athletic injury creates a unique, highly threatening situational context that suppresses SC-state independently of an athlete’s baseline SC-trait. Consequently, assessing psychological readiness requires tools tuned directly to the somatic, cognitive, and functional demands of athletic re-entry.

Furthermore, the I-PRRS integrates concepts from the Stress and Injury Model proposed by Andersen and Williams (1988; Williams & Andersen, 1998) and the Integrated Model of Psychological Response to the Sport Injury and Rehabilitation Process developed by Wiese-Bjornstal, Smith, and LaMott (1995). These models postulate that cognitive appraisals of an injury determine emotional reactions (such as depression, anger, and reinjury anxiety), which subsequently govern behavioral adherence to rehabilitation regimens and post-recovery motor performance. By assessing the cognitive appraisal component of return-to-sport transitions, the I-PRRS directly evaluates the athlete’s cognitive-affective trajectory, identifying individuals trapped in maladaptive stress-response cycles prior to competitive exposure.

Validity

The psychometric validation of the Injury-Psychological Readiness to Return to Sport Scale utilized a structured, multi-phase methodological approach to establish content, concurrent, and external validity.

Content Validity and the Delphi Process

Content validity was established through a formal, three-round Delphi method designed to ensure that the initial item pool accurately reflected the target construct of post-injury psychological readiness. The expert panel comprised seven sports medicine professionals, consisting of four certified athletic trainers (ATCs) and three NCAA Division III collegiate head coaches. Over three sequential iterations, the panel reviewed an initial pool of 22 potential items derived from sport psychology literature, clinical observation, and existing sport confidence inventories.

Experts evaluated each item based on clarity, clinical relevance, and construct congruence. Items that failed to achieve consensus regarding domain representation were systematically refined or eliminated. Following the third round, the panel converged on a final 6-item scale. Content validity was quantitatively verified using Aiken’s Content Validity Coefficient (V) (Aiken, 1985). The items demonstrated high content relevance, with Aiken’s V values ranging from 0.79 to 1.00, surpassing the established statistical threshold for significance (p < .05) and confirming robust content validity.

Concurrent Criterion Validity

Concurrent validity was established by correlating I-PRRS scores with an established psychological criterion measure: the Profile of Mood States (POMS) short form (McNair et al., 1992). The POMS evaluates six affective mood states (Tension-Anxiety, Depression-Dejection, Anger-Hostility, Vigor-Activity, Fatigue-Inertia, and Confusion-Bewilderment) and generates a composite Total Mood Disturbance (TMD) score.

Glazer administered both the I-PRRS and the POMS to 22 collegiate varsity athletes across four distinct recovery phases:

• Phase 1: Baseline pre-injury or immediately post-injury (initial evaluation within the athletic training facility).
• Phase 2: Mid-rehabilitation (active participation in physical therapy and functional exercise progressions).
• Phase 3: Terminal rehabilitation / Pre-return (completion of functional testing and initial integration into non-contact practice).
• Phase 4: Full return to competitive sport (unrestricted clearance for practice and game situations).

Theoretical assumptions dictated that state psychological readiness should share an inverse relationship with total mood disturbance; as an athlete’s situational confidence and self-efficacy rebuild, negative affective states (anxiety, depression, and confusion) should decline. Bivariate Pearson correlation analyses confirmed this hypothesis, revealing statistically significant negative correlations between I-PRRS scores and POMS TMD scores across all evaluated rehabilitation milestones. Concurrently, I-PRRS scores were positively correlated with the POMS Vigor subscale, demonstrating strong convergent validity with adaptive psychological functioning.

External and Observational Validity

To examine whether self-reported I-PRRS scores accurately mirrored clinical presentations, Glazer developed a parallel clinician-rating version of the I-PRRS. Certified athletic trainers supervising the athletes’ daily rehabilitation independently completed the clinician-rated scale at each recovery phase, blinded to the athletes’ self-reported scores. Correlational analyses revealed strong, statistically significant positive correlations between athlete self-ratings and athletic trainer ratings. This congruence demonstrated external validity, confirming that the internal psychological readiness reported by the athletes mapped onto behaviors and physical readiness observable to trained sports medicine professionals.

Reliability

The evaluation of reliability for the I-PRRS requires understanding its conceptualization as a state measure. In classical test theory, instruments designed to assess stable psychological constructs (traits) prioritize high test-retest reliability across extended temporal intervals. In contrast, state measures are engineered to capture dynamic fluctuations over time in response to therapeutic interventions, physiological recovery, and environmental transitions.

In the foundational validation study by Glazer (2009), traditional internal consistency metrics—such as Cronbach’s coefficient alpha ($lpha$) or McDonald’s omega ($\omega$)—were not formally published for the composite 6-item scale, representing a known limitation of the preliminary pilot validation. However, the instrument demonstrated clinical sensitivity to change over time, which serves as a vital indicator of construct reliability for dynamic state scales:

• Immediately post-injury (Phase 1), athlete mean scores predictably troughed at their lowest levels, reflecting acute loss of physical capability, shock, and somatic apprehension.
• During mid-rehabilitation (Phase 2), scores exhibited an upward trajectory as functional recovery and mastery experiences restored foundational movement confidence.
• By the pre-return (Phase 3) and full-return (Phase 4) phases, scores climbed toward the upper limits of the scale, aligning with functional clearance criteria.

This predictable progression confirms that the scale consistently tracks clinical recovery milestones without exhibiting random measurement drift. Subsequent independent psychometric investigations examining adapted versions of the I-PRRS across diverse athletic cohorts have reported internal consistency coefficients ranging from Cronbach’s $lpha = .82$ to $.91$, demonstrating that the 6 items possess high internal homogeneity and reliably capture the overarching construct of psychological readiness.

Factor Analysis

In the original 2009 scale development study, neither Exploratory Factor Analysis (EFA) nor Confirmatory Factor Analysis (CFA) was conducted. This omission was primarily driven by sample size constraints: the foundational validation cohort comprised 22 collegiate varsity athletes (18 men, 4 women) aged 18 to 22 across NCAA Division II and Division III programs who had sustained athletic injuries resulting in at least one week of lost athletic participation.

In psychometric methodology, reliable factor analytic procedures typically necessitate participant-to-item ratios ranging from 5:1 to 20:1, or absolute sample sizes exceeding 100 to 200 respondents, to prevent matrix instability and spurious factor loadings. Given the clinical, longitudinal nature of Glazer’s pilot design, statistical dimension reduction was supplanted by the qualitative, three-round Delphi method. The expert consensus reached by the panel of certified athletic trainers and collegiate head coaches provided qualitative verification of unidimensionality, leading to the selection of the final 6 items from an initial 22-item candidate pool.

Because structural equation modeling was not utilized during the preliminary validation, conventional fit indices—such as the Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR)—were not calculated. Consequently, the I-PRRS is interpreted and scored as a strictly unidimensional construct representing global psychological readiness. Modern psychometric standards recommend that future large-scale investigations conduct confirmatory factor analyses on diverse athletic populations (varying across competition levels, injury types, and biological sex) to statistically verify this unidimensional structure or explore whether distinct latent sub-factors—such as somatic confidence versus cognitive confidence—warrant formal modeling.

Instrument / Measurement Tool

The Injury-Psychological Readiness to Return to Sport Scale is structured as a brief, self-administered psychological questionnaire designed for rapid implementation in sports medicine, physical therapy, and athletic training environments.

Test Specifications

• Test Type: Self-report psychological status questionnaire (accompanied by a parallel clinician-observation rating instrument).
• Construct Assessed: State-specific self-efficacy and psychological preparedness to resume sports participation following musculoskeletal trauma.
• Target Population: Competitive, recreational, collegiate, and professional athletes undergoing athletic injury rehabilitation.
• Applicable Age Group: Validated in young adults (18–22 years); widely adapted across adolescent, scholastic, and mature athletic populations.
• Item Count: 6 items.
• Administration Time: Approximately 2 to 3 minutes.
• Language: English (original validation).

Response Format and Scoring Mechanics

The scale employs an 11-point numerical rating scale format. Respondents rate their current confidence level for each item on a 0 to 100 scale in intervals of 10, anchored by defined verbal descriptors:

• 0%: No confidence
• 50%: Moderate confidence
• 100%: Complete confidence

The mathematical scoring algorithm is computed as follows:

1. Sum the raw numerical responses across all 6 items (raw score range: 0 to 600).
2. Divide the total sum by 10 to obtain the final scaled composite score (composite score range: 0 to 60).

Clinical Cut-off Scores and Diagnostic Interpretation

Glazer established clinical benchmark ranges to guide sports medicine teams in clearance decisions:

• Score of 60 (Utmost Psychological Readiness): Reflects full confidence across all measured recovery domains. The athlete demonstrates strong self-efficacy, an absence of debilitating reinjury anxiety, and full psychological readiness to resume unrestricted practice and competitive play.
• Score of 40 to 59 (Moderate Confidence / Conditional Readiness): Indicates partial psychological preparedness accompanied by lingering reservations regarding pain, maximal effort, or structural durability. Athletes scoring within this band typically require graduated, controlled athletic exposure (e.g., non-contact drills, limited scrimmage repetitions) alongside targeted psychological interventions such as cognitive restructuring, relaxation training, or guided imagery.
• Score of 0 to 39 (Low Confidence / Psychological Deficiency): Signifies marked psychological hesitation, pronounced fear of reinjury, or lack of trust in the injured anatomical site. Even if physical or orthopedic clearance has been attained, full return to competitive play is contraindicated due to elevated reinjury risk and performance impairment. Referral to a licensed sport psychologist or integration of formal psychoeducational rehabilitation strategies is recommended.

Permissions & Fee and Test Year

The Injury-Psychological Readiness to Return to Sport Scale was formally published in 2009 in the Journal of Athletic Training, the official peer-reviewed scientific journal of the National Athletic Trainers’ Association (NATA). The foundational study was titled “Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale” (Glazer, 2009).

Regarding permissions and clinical use:

• Fee Structure: The I-PRRS is non-commercial and free of charge for clinical, academic, and scientific research purposes.
• Permissions: The scale was published in an academic open-access context via the National Athletic Trainers’ Association. Practitioners, athletic trainers, physical therapists, and researchers may utilize and reproduce the scale items for non-profit clinical evaluation and empirical investigation, provided appropriate academic citation is credited to Douglas D. Glazer and the Journal of Athletic Training.
• Commercial Applications: Any commercial incorporation of the scale into proprietary digital medical software, electronic health record (EHR) modules, or monetization platforms requires formal copyright permission from the National Athletic Trainers’ Association and the author.

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13. Items of the Scale (Questionnaire)