Play it again, Sam.

Tennis great Andre Agassi sits in front of a piano, 2001

Humphrey Bogart never said, “Play it again, Sam.” In fact, the line his character Rick says in the movie Casablanca is, “Play it!” This may be the best way for us to approach return to sport (RTS) with athletes: “Play it!”

Often, more is made of the ‘return’ portion rather than the ‘sport.’ What I mean is, athletes, trainers, therapists and coaches focus on regaining what was lost and returning to a prior performance level. In reality, that place and time will never happen again. The sooner athletes come to terms with that, the more quickly they can focus on achieving what is needed to succeed in their sport.

Physiotherapist Tracy Ward looks at how this kind of psychological readiness plays a role in injury recovery and RTS in today’s feature article. Athletes return to sport more quickly when they have positive psychological states(1,2). Psychological responses may depend on an athlete’s expectations. The internet is full of tales of being ‘back in the saddle’ in just –insert impossible time line – weeks. If an athlete’s expectations are unrealistic, then their psychological state may suffer when these expectations aren’t met. It’s the job of the physio to educate athletes on realistic and scientifically sound timelines for physical healing as well as sport readiness.

Believe it or not, you don’t have to be a psychiatrist to guage psychological readiness for play. Certain physical limitations give hints that there may be mental barriers preventing optimal performance. Researchers at the University of Delaware recently discovered an association between asymmetry in the gait of athletes, post-anterior cruciate ligament (ACL) reconstruction, and their psychological readiness to return to sport. All athletes had full range of motion and greater than 80% quadriceps index score. However, athletes with greater asymmetry in knee flexion at initial contact and peak knee flexion between limbs showed less psychological readiness.

Ward explains that fear avoidance also plays a role in readiness to return to sport (see figure 1). In fact, a 2018 multicenter study discovered that self-reported fear could be predictive of re-injury. Researchers followed 40 athletes for 12 months after they were cleared to RTS post ACL repair4. They found that the chance of having a hop-test limb asymmetry was seven times more likely in those athletes that showed greater fear on pre-RTS testing. In addition, quadriceps asymmetry was six more times likely in those with greater measures of fear. After 12 months, those who suffered re-injury of the same knee had higher initial scores of fear of movement than those with stable knees after a year.

Figure 1: Fear avoidance model

Readiness to play after an injury involves more than just physical milestones. It requires an athlete to have confidence in her body to perform the way she wants it to. An athlete may hesitate to RTS because she perceives subtle asymmetries that she can’t articulate. To encourage confidence and manage fear, discuss expectations and dialogue with athletes on how they feel throughout the rehabilitation process. Help them understand they aren’t going back, but moving forward. Encourage them to, like Sam, just “Play it!”


  1. Br J Sports Med. 2013; 47: 1120-1126
  2. Br J Sports Med. 2014; 48: 1613-1619
  3. J Orthop Sports Phys Ther.2018 Jul 27:1-21
  4. Sports Health.2018 May/Jun;10(3):228-233




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