Return to Sport after Injury:  The relationship between 
an athlete’s type of motivation and a recurrence of 
injury 
 
 
A dissertation by 
 
Johan Human 
Student number: 1996354757 
 
Submitted in fulfilment of the requirement for the degree in  
 
M.Sc. Physiotherapy 
 
In the Department of Physiotherapy 
School of Allied Health Professions 
University of the Free State 
 
February 2017 
 
STUDY LEADER: 
Dr. C. Brandt 
 
 
 
DECLARATION 
 
I, Johan Human, certify that the report hereby submitted for the degree 
M.Sc.Physiotherapy at the University of the Free State is my independent 
effort and had not previously been submitted for a degree at another 
university/faculty.  I furthermore waive copyright of the report in favour of the 
University of the Free State. 
 
________________     13 February 2017  
   
Johan Human                                                             
Researcher      Date 
 
 
 
 
I, Dr. C. Brandt, approve submission of this dissertation for the 
M.Sc.Physiotherapy degree at the University of the Free State.  I further 
declare that this dissertation has not been submitted as a whole or partially 
for examination before. 
 
      13 February 2017 
Corlia Brandt 
Study-leader     Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
Acknowledgements 
 
It is with appreciation that the researcher acknowledges the contributions of 
the following people: 
 
Dr. C. Brandt 
Department of Physiotherapy 
Faculty of Health Sciences 
University of the Free State 
Bloemfontein 
My supervisor, for her patience, guidance and support.   
 
Mr. F.C. van Rooyen 
Researcher: Biostatistics 
Faculty: Health Sciences 
University of the Free State 
Bloemfontein 
For his professional input and prompt processing of data. 
 
Mrs. H. Roos 
English Teacher 
Grey College Secondary 
For language editing and advice. 
 
 
 
 
 
 
 
 
 
 
 
    TO GOD BE THE GLORY   
 
 
 
 ii 
Abstract 
 
Dr. C. Brandt; Johan Human 
Return to Sport after Injury:  The relationship between an athlete’s type 
of motivation and a recurrence of injury 
 
Introduction and goal 
Development of the decision-based return to sport model attempts to address 
a lack of objective criteria in the literature to determine an athlete’s readiness 
to return to sport (Creighton, Shrier, Shultz, Meeuwisse and Matheson.  
2010). The model reveals motivational factors that may modify complex return 
to sport decisions, often the responsibility of physiotherapists.  An athlete with 
extrinsic motivation to return to sport may persuade the physiotherapist and/or 
coach to return to sport too soon which may lead to the athlete being re-
injured.  The aim of this study was to establish coaches’ expectations from 
physiotherapists regarding motivational factors for athletes to return to sport, 
athletes’ type of motivation to return to sport, and a relation to recurrence of 
injury.     
 
Methodology 
A descriptive and cohort-analytical design were used to collect quantitative 
data from two populations.  Six track and field coaches of elite athletes older 
than 18 years, participated in structured interviews.  The data collected with 
the structured interviews included the coaches’ expectations and views with 
regards to physiotherapists’ role in return to sport decisions.  Fifteen injured 
elite athletes, older than 18 years, returning to sport after injury were tested 
with an adapted revised sport motivation scale to determine their type of 
motivation to return to sport and follow-up phone calls were used to determine 
if their return to sport was successful. 
 
Results 
Coaches were of the opinion that their elite athletes often return to sport too 
soon due to pressure from persons, sponsors or institutions and indicated that 
a recommendation regarding the type of motivation of an athlete to RTS will 
 iii 
be of value.  The Kruskal-Wallis test and Wilcoxon two sample test indicated 
that type of motivation was not found to statistically influence injury 
recurrence.   
 
Summary 
Although higher scores for extrinsic types of motivation was not found to 
statistically influence injury recurrence for elite track and field athletes in 
Bloemfontein, the noted trend of higher scores in these types of motivation 
needs further investigation on larger populations from different ages and 
types of sport.  Track and field coaches of these athletes were of the opinion 
that their athletes often return to sport too soon due to motivational factors 
and did mention that they would value input from physiotherapists regarding 
motivational factors prevalent in their athletes that may cause further harm.  
Physiotherapists who cleared an elite athlete for return to sport based on the 
decision-based return to sport model, could modify their decisions and referral 
to an appropriate healthcare professional could benefit the athlete with a 
successful return to sport.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 iv 
List of abbreviations 
 
AFS   Athletics Free State 
ASA   Athletics South Africa 
BRSQ   Behavioural Regulation in Sport Questionnaire 
CECS   Coaches Education and Certification System 
CT-scans   Computed Tomography-scans 
IAAF   International Association of Athletics Federations 
I-PRRS  Injury-Psychological Readiness to Return to Sport 
KOOS   Knee injury and Osteoarthritis Outcome Score 
MRI   Magnetic Resonance Imaging 
ROM   Range of motion 
RTS   Return to sport 
SD   Standard Deviation 
SDT   Self-determination theory 
SMS   Sport Motivation Scale 
SMS-II  Revised Sport Motivation Scale 
UFS   University of the Free State 
USSA-athletics University Sport South Africa – athletics 
 
List of terminology 
 
Decision modifiers:  Factors that may influence the decision about an 
athlete’s return-to-sport when the athlete has been cleared for return-to-sport 
based on medical factors and sport risks e.g. financial conflict of interest. 
(Creighton et al.  2010)  
 
Intrinsic motivation:  Intrinsic motivation is to perform an activity for the 
inherent satisfaction of performing the activity (Ryan and Deci 2000). 
 
Extrinsic motivation: Extrinsic motivation  is when the type of behaviour 
expressed is  driven by the satisfaction of an external demand/reward (Ryan 
and Deci 2000). 
 
Return to sport:  Return to participation in sport after recovering from an 
injury (Creighton et.al. 2010). 
 v 
Table of Contents 
 
Abstract .............................................................................................................. iii 
List of abbreviations ......................................................................................... v 
List of terminology............................................................................................. v 
List of Figures ..................................................................................................... x 
List of tables ...................................................................................................... xii 
FOREWORD ..................................................................................................... xiii 
 
Chapter 1 .................................................................................................................... 1 
INTRODUCTION AND BACKGROUND .......................................................... 1 
1.1 Introduction................................................................................................... 1 
............................................................................................................................. 2 
1.2 Physiotherapy and RTS ............................................................................. 3 
1.3 Decisions regarding RTS .......................................................................... 3 
1.4 Psychological aspects of RTS ................................................................. 5 
1.5  Research problem ...................................................................................... 5 
1.6 Aim and objectives of this study ............................................................ 6 
1.6.1 Objectives: ................................................................................................. 6 
1.7 Addressing the research problem .......................................................... 6 
1.8 Outline of the thesis ................................................................................... 6 
 
Chapter 2 .................................................................................................................... 9 
LITERATURE REVIEW ...................................................................................... 9 
2.1 Introduction................................................................................................... 9 
2.2  Track and field in South Africa ............................................................. 10 
2.2.1 Athletics in Bloemfontein and athletics in the world. .................. 10 
2.2.2 Age groups for National and International Competitions ........... 11 
2.2.3 Selection for Provincial and National Teams ................................. 13 
2.3 The role and background of track and field coaches ...................... 13 
2.3.1 Interaction between coaches and physiotherapists .................... 14 
2.3.1.1 Trust between coaches and physiotherapists ............................ 15 
2.3.1.2 Coaches’ expectations of physiotherapists as regards RTS . 15 
2.3.1.3 Guidance from the physiotherapists regarding training ......... 16 
2.4 Re-injury of athletes ................................................................................. 16 
2.5 Complexities of beneficence .................................................................. 18 
2.6 The Decision Based RTS Model ............................................................ 19 
2.6.1 Step 1:  Evaluation of Health Status ................................................. 20 
 vi 
2.6.2 Step 2:  Evaluation of participation risk .......................................... 23 
2.6.3 Step 3: Decision Modification ............................................................. 24 
2.7 Self-determination theory ....................................................................... 27 
2.7.1 The Sport Motivation Scale ................................................................. 28 
2.7.2 The Revised Sport Motivation Scale ................................................. 28 
2.8 Conclusion .................................................................................................. 29 
 
Chapter 3 .................................................................................................................. 30 
METHODOLOGY ............................................................................................... 30 
3.1 Introduction................................................................................................. 30 
3.2 Research methodology ............................................................................ 30 
3.2.1 Study design ........................................................................................... 30 
3.2.2  Study population ................................................................................... 31 
3.2.2.1  Track and field coaches ................................................................... 31 
3.2.2.2  Athletes ................................................................................................ 32 
3.2.3  Sample ..................................................................................................... 33 
3.2.4  Inclusion and exclusion criteria ........................................................ 34 
3.2.4.1  Coaches ............................................................................................... 34 
3.2.4.2  Athletes ................................................................................................ 34 
3.2.5  Data collection tools ............................................................................ 35 
3.2.5.1  Measuring instrument for data collected from coaches ......... 35 
3.2.5.2  Measuring instrument for data collected from athletes .......... 36 
3.2.5.2.1 The revised SMS-II .......................................................................... 37 
3.2.5.2.2  Follow-up phone calls ................................................................... 38 
3.2.6  Data collection procedures ................................................................ 38 
3.2.6.1  Data collection from coaches ........................................................ 38 
3.2.6.2 Data collection from athletes .......................................................... 39 
3.2.7  Pilot study ............................................................................................... 40 
3.2.7.1  Interviews with coaches .................................................................. 41 
3.2.7.2  Athletes - SMS-II and data sheet ................................................... 41 
3.3 Measurement and methodology errors ............................................... 42 
3.3.1  Interviews with coaches ...................................................................... 42 
3.3.2  Athletes - SMS-II and data sheet ....................................................... 43 
3.4  Data handling and analysis ................................................................... 45 
3.5  Ethical aspects .......................................................................................... 45 
3.5.1  Ethical aspects with regards to the SMS-II and data sheet ....... 46 
3.5.2  Ethical aspects with regards to the interviews ............................. 47 
 vii 
3.6  Conclusion ................................................................................................. 48 
 
Chapter 4 .................................................................................................................. 49 
RESULTS ............................................................................................................ 49 
4.1 Introduction................................................................................................. 49 
4.2 Results from the interviews with coaches ......................................... 49 
4.2.1 General coaching experience and involvement ............................ 49 
4.2.2 Coaches’ expectations of physiotherapists ................................... 51 
4.2.3 Referrals ............................................................................................... 56 
4.2.4 Identifying the need for motivation to be considered before 
an athlete is cleared for RTS ..................................................................... 56 
4.3 Results from the adapted SMS-II and data sheets ....................... 58 
4.3.1 General and demographic information about the athletes ..... 58 
4.3.2 Diagnostic and RTS information about the participants ......... 59 
4.3.3 Type of motivation of the athletes (Appendix H and I) ............ 60 
4.3.4 Re-injury of the athletes (Appendix I). .......................................... 62 
 
Chapter 5 .................................................................................................................. 65 
DISCUSSION, LIMITATIONS AND RECOMMENDATIONS ................. 65 
5.1 Introduction............................................................................................. 65 
5.2 Interviews with coaches ...................................................................... 65 
5.2.1 Variables that could have influenced the results from the 
interviews with the coaches ...................................................................... 66 
5.2.2 The coach, the athlete and the physiotherapist ........................ 66 
5.2.2.1 Decisions regarding continuation of participation ................ 67 
5.2.2.2 Coaches’ expectations from physiotherapists ....................... 68 
5.2.2.3 Referrals ............................................................................................ 70 
5.2.2.4 Identifying the need for motivation to be considered before 
an athlete is cleared for RTS ..................................................................... 72 
5.3 The type of motivation of elite athletes returning to sport. ....... 73 
5.3.1 Variables that could have influenced the results of the elite 
athletes returning to sport. ........................................................................ 74 
5.3.2 The type of motivation of athletes about to RTS ....................... 75 
5.3.3 Re-injury of athletes .......................................................................... 77 
5.4 Limitations of this study ...................................................................... 80 
5.5 Recommendations/Implications for future research ................... 83 
 
Chapter 6 .................................................................................................................. 85 
CONCLUSION ................................................................................................ 85 
 viii 
6.1 The coach, the athlete and the physiotherapist ............................ 85 
6.2   Type of motivation and re-injury of elite athletes ...................... 85 
 
REFERENCES ............................................................................................... 87 
 
Appendix A ........................................................................................................... A 
Application for approval as well as permission:  Head of sport - UFS ........ A 
Appendix B ........................................................................................................... B 
Application for approval as well as permission:  General manager - AFS . B 
Appendix C ........................................................................................................... C 
Application for approval as well as permission:  Director Student Life – 
UFS and Vice Rector Research – UFS ........................................................... C 
Appendix D ........................................................................................................... D 
Application for approval as well as permission: Report Evaluation 
Committee – research (School for allied health professions) ...................... D 
Appendix E ........................................................................................................... E 
Application for approval as well as permission: Health Sciences research 
Ethics Committee. ............................................................................................... E 
Appendix F ............................................................................................................ F 
Approval – Mr FC van Rooyen (Department of Biostatistics) ....................... F 
Appendix G ........................................................................................................... G 
Informed consent letter to participant athletes ............................................... G 
Appendix H ........................................................................................................... H 
Adapted revised Sport Motivation Scale (SMS-II) ......................................... H 
Appendix I .............................................................................................................. I 
Data sheet and information form physiotherapist ........................................... I 
Appendix J ............................................................................................................. J 
Informed consent letter to participant coaches ................................................ J 
Appendix K ........................................................................................................... K 
Structured interview – coaches ......................................................................... K 
 
 
 
 
 
 
 
 
 ix 
List of Figures 
 
Figure 1.1 Background for this research study .................................................... 2 
Figure 1.2 Decision Based RTS Model (Creighton et al. 2010) ........................ 4 
Figure 1.3 The interrelated discussion of concepts within the study context. 7 
Figure 2.1 Organogram of the relevant structures responsible for the 
management of athletes and coaches in Bloemfontein ................ 11 
Figure 2.2  The coach, the athlete and the clinician (Brukner and Kahn 2008)
  ................................................................................................................ 14 
Figure 2.3 Decision Based RTS Model - three steps (Creighton et al. 2010) .. 
  ................................................................................................................ 20 
Figure 2.4 Step 1 of the Decision Based RTS Model (Creighton et al. 2010) .. 
  ................................................................................................................ 21 
Figure 2.5 Step 2 of the Decision Based RTS Model (Creighton et al. 2010) .. 
  ................................................................................................................ 23 
Figure 2.6 Step 3 of the Decision Based RTS Model (Creighton et al. 2010) .. 
  ................................................................................................................ 24 
Figure 2.7 The Self-Determination Continuum illustrating Types of 
Motivation with their Regulatory Styles, Loci of Causality, and 
Corresponding Processes (Ryan and Deci 2000) .......................... 27 
Figure 3.1 Flow diagram of study design. .......................................................... 30 
Figure 3.2 Flow diagram to illustrate how the six coaches for this study were 
selected for inclusion .......................................................................... 32 
Figure 4.1 Representation of the coaches' coaching experience in years in 
the different specialist areas in track and field (n=6). .................... 50 
Figure 4.2 Individuals who are preferred by coaches to make RTS-decisions 
in their training groups (n=6). ............................................................ 52 
Figure 4.3 Coaches prefer to involve these persons in on the field decisions 
regarding the continuation of participation when the athlete is 
injured (n=6). ........................................................................................ 53 
Figure 4.4 Coaches’ referral of athletes with specific complaints (n=6). ....... 56 
Figure 4.5 Importance of factors that can influence RTS decisions (n=6). ... 57 
Figure 4.6 The specialist events in which the athletes who returned to sport 
intended to compete for the remainder of the season (n=15). ..... 59 
 x 
Figure 4.7 Diagnoses before RTS (n=15). ......................................................... 60 
Figure 5.1 Integration of aims and objectives .................................................... 65 
Figure 5.2 The sports medicine model (Brukner and Kahn 2008) ................. 76 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 xi 
List of tables 
 
Table 4.1  Representation of the age group distribution and team 
representation of the athletes coached by the coaches (n=6) 
during the 2014/2015 season. ........................................................... 51 
Table 4.2  Coaches’ expectations of a physiotherapist treating one of their 
athletes (n=6). ...................................................................................... 54 
Table 4.3  The time after RTS for re-injury to occur for seven of the 
respondents and the nature of this re-injury (n=15). ..................... 62 
Table 4.4 The p-values for the different types of motivation of respondents 
with no re-injury compared to respondents with re-injury after 1, 2 
and 3 weeks and 3 months. ............................................................... 64 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 xii 
FOREWORD 
 
Despite having suffered a Grade 1 tear of his hamstring muscle only six weeks 
earlier, 29-year-old Usain Bolt from Jamaica had fans on the edge of their 
seats when he lined up for the final in the 100m final event at the 2016 Rio 
Olympic Games (Perry  2016).  Bolt had only six weeks from sustaining an 
injury until returning to top-level competition, yet he had a successful return 
to sport (RTS) and did not only win his gold medal in the 100m, but completed 
a never-before accomplished triple-treble gold medal tally by also winning his 
eighth and ninth gold medals at the Olympic Games of Rio 2016 (Ingle 2016). 
 
The 29-year-old Australian hurdler, Sally Pearson, also sustained a hamstring 
tear seven weeks prior to the same Olympic Games.  Pearson had won silver 
at the Beijing Olympic Games in 2008 and gold at the Olympic Games in 
London 2012.  Pearson, however, returned to competition in Europe after 
fracturing and dislocating her left wrist 12 months earlier during a fall on the 
track.  Valente (2016) reported that Pearson was struggling to retain her form 
on her RTS and also complained of a niggly hamstring during the European 
meetings.  Pearson returned to Australia to work on her speed in preparation 
for the Olympic Games and tore her hamstring during training.  Unlike Bolt, 
Pearson decided to withdraw from the Olympic Games in Rio (Valente 2016). 
 
These examples illustrate how two prior Olympic champions with similar 
circumstances regarding participation at the Olympic Games made different 
decisions on RTS and accordingly, recorded significantly different outcomes. 
 
        ~ The researcher 
 
 
 
 
 
 
 xiii 
Chapter 1  
INTRODUCTION AND BACKGROUND 
 
 
1.1 Introduction 
 
This chapter provides introductory information about RTS after injury and the 
relationship between an athlete’s type of motivation and a recurrence of injury. 
  
Decisions regarding RTS and the complex nature thereof are well-known to 
physiotherapists working with elite athletes (Burgess 2011).  Political leaders 
expect exceptional performances from the athletes selected to represent the 
country at international events, “We do not like losers; our team has done us 
proud...” according to the South African Minister of Sport, on welcoming the 
South African team back from the 2016 Olympic Games (Wagner 2016). 
 
Slobounov (2011) mentions that enormous extrinsic pressure is placed on 
injured athletes to return to participation in sport as soon as possible.  
Sponsors expect decent coverage in print and broadcast media when 
sponsored athletes perform at competitions, in exchange for financial support.  
Coaches expect performances and titles to satisfy their employers.  
Spectators expect value for their money when they support athletes 
(Slobounov 2011).  Burgess (2011) warns that development in the medical 
field and effective rehabilitation cannot keep up with the increasing demands 
on athletes to RTS faster and continually perform better.     
 
Physiotherapists are first-line practitioners and are often responsible for 
making decisions regarding RTS (South African Society of Physiotherapy 
2012).  There is a definite lack of objective criteria for the physiotherapist to 
determine the athlete’s readiness to RTS (Millson 2015).  An extensive 
literature search revealed few books, journals and web pages reporting on 
the objective criteria specifically related to RTS.  Search engines such as 
Google and Medline were searched using key words on their own and in 
different combinations.  Key words included, “objective, criteria, RTP, RTS, 
 1 
return to play, psychological, modifiers, sport, ethics, guidelines, extrinsic, 
intrinsic, motivation, re-injury, self-determination theory”.  The fourth bi-annual 
sport physiotherapy congress presented opportunities to attend presentations 
by international experts such as Barb Hoogenboom (involved with the 
development of the Y-test for RTS) and Helen Millson (expert on medico-legal 
issues and RTS) (Hoogenboom 2015, Millson 2010, Millson 2015a and 
Millson 2015b).  The search was complemented by personal interviews and 
electronic communication with such experts on RTS.   
 
The literature highlights the lack of research and this lack of objective criteria 
served as motivation for the development of the decision-based return to sport 
model developed and proposed by Creighton et al. (2010).  Matheson, Shultz, 
Bido, Mitten, Meeuwisse and Shrier (2011) conducted a review on the 
available literature specific to the factors and components of this model and 
concluded that insufficient literature exists on the factors included in the 
model.   This lack of literature serves as motivation for further research.  
Chapter 1 provides the background for this research study (refer to Figure 
1.1). 
 
 
 
 
Figure 1.1 Background for this research study 
 
 
 
 2 
1.2 Physiotherapy and RTS 
 
Authors consider physiotherapists to be imperative participants in the 
athlete’s physical, emotional and psychological healing (Tracey 2008; Le 
Roux in Sutcliffe 2005).  Professional coaches from various sporting codes 
expect physiotherapists and medical practitioners to give the go-ahead for 
RTS after an injury (Podlog and Eklund 2007).  Guidance on the amount and 
extent of training allowed for the specific athlete is also expected from the 
medical practitioner/physiotherapist by these coaches (Podlog and Eklund 
2007).  Physiotherapists should always pursue beneficence when they guide 
and assist coaches with the process of returning an athlete to sport, but 
Burgess (2011) warns that the application of beneficence might be complex.  
According to Burgess (2011), the principle of beneficence might be in conflict 
with the autonomy and self-determination of an athlete who wants to RTS.  
The athlete might consequently RTS too soon and subsequently, increase the 
risk for re-injury (Slobounov 2008; Creighton, Shrier, Shults, Meeuwisse and 
Matheson 2010; Hoogenboom 2015). 
 
1.3 Decisions regarding RTS 
 
Premature RTS based on the clearance of symptoms as the only measure, 
places the athlete in a position of high risk for re-injury, but also in a position 
for development of permanent psychological trauma (Slobounov 2011).  The 
need to address the physical as well as the psychological aspects of an injury 
is widely recognised (Podlog, Dimmock and Miller in Burgess 2011). 
 
There is a need for objective criteria for RTS decisions (Millson 2015).   Myer, 
Paterno, Ford, Quatman and Hewett (2006) also identified a lack of 
standardised objective criteria to assist with assessment of an athlete’s ability 
to safe RTS.  The possible conflict between beneficence and autonomy of an 
athlete (refer to 1.2) also highlights the importance for physiotherapists to stay 
objective with decisions regarding RTS, but emotional involvement in the 
success of an athlete and pressure from various extrinsic sources may lead 
 3 
the physiotherapist to subjectivity (Johnson in Burgess 2011;  Brukner and 
Khan 2008). 
 
The need for objective criteria motivated Creighton et al. (2010) to develop a 
three-step decision based model (refer to Figure 1.2) to simplify decisions 
regarding RTS and they indicated that the model should serve as a basis for 
further research on each of the individual factors and components of the 
model.  The research would be integrated to serve as an evidence-based 
rationale for decisions regarding RTS.  
 
 
Figure 1.2 Decision Based RTS Model (Creighton et al. 2010) 
 
The three steps and the factors of each step are discussed and explained in 
2.6.   
 
Matheson et al. (2011) conducted a review on the available literature specific 
to the factors and components of the model.  They highlighted the need for 
more research on all the factors and components of the model but specifically, 
 4 
research on the steps concerned with Sport Risk Modifiers and Decision 
Modifiers.   
 
1.4 Psychological aspects of RTS 
 
Burgess (2011) is of the opinion that large financial rewards and increasing 
media attention play a role in the fact that there are higher demands on 
athletes to perform better all the time.  These higher expectations create 
intrinsic as well as extrinsic motivations to RTS after an injury (Kreiner-Phillips 
and Orlick 1993).  According to the self-determination theory (SDT), which is 
a theory of motivation, personality and optimal functioning, motivations can 
range on a continuum which includes amotivation, intrinsic and extrinsic 
motivation (Podlog and Eklund 2010; Tran 2014).  The SDT may be 
considered a valuable approach for coaches assisting athletes to RTS after 
an injury (Podlog and Dionigi 2010).  Podlog and Eklund (2007) explained that 
the motivation of an athlete to RTS might play an important role in perceptions 
among elite and sub-elite athletes.  An athlete with a positive view on RTS 
will engage in activities and rehabilitation programmes in order to have a more 
successful RTS.  In contrast, an athlete with extrinsic motivation and a 
negative view on RTS might not participate fully in the rehabilitation program 
and consequently, may have a less successful RTS (Podlog and Eklund 
2007).  The decision modifiers illustrated in Figure 1.2 also include pressure 
from the athlete and external pressure that are examples of intrinsic and 
extrinsic motivation.   
 
1.5  Research problem 
 
Podlog and Eklund (2010) suggested that due to the lack of research on the 
type of motivation of an athlete who RTS and related objective outcomes, 
more research is needed on the type of motivation and relevant objective 
outcomes.  Firstly, the dependence of coaches on physiotherapists for 
assistance regarding RTS-decisions and secondly, the need for more 
research expressed by Podlog and Eklund (2010), served as motivation to 
conduct this study. 
 5 
 
 
 
1.6 Aim and objectives of this study 
 
The study aimed to establish an athlete’s type of motivation to RTS and a 
relation to the incidence of re-injury. 
 
1.6.1 Objectives: 
 
1.6.1.1   To determine track and field coaches’ viewpoint on how motivational 
factors should be considered by physiotherapists in decisions 
regarding RTS by means of a structured interview,   
1.6.1.2    to investigate the type of motivation of athletes on RTS by means of 
an adapted version of the Sport Motivation Scale II (SMS-II), 
1.6.1.3 to determine subsequent re-injury of the athletes by means of an 
injury report form (Matheson et al 2012), 
1.6.1.4 to compare the scores of the adapted SMS-II on the type of 
motivation, between athletes that were re-injured and those who 
were not.   
 
1.7 Addressing the research problem 
 
Literature indicated a need for research on objective criteria in order to 
develop a model for RTS decisions.  The type of motivation of an athlete to 
RTS might play an important role in RTS decisions.  Literature indicated a 
lack of research on the type of motivation of an athlete to RTS and subsequent 
objective outcomes (Podlog and Eklund 2007). 
 
1.8 Outline of the thesis 
 
The first chapter describes the complexities of RTS decisions as concerns an 
elite athlete.  The role of physiotherapists in RTS decisions, the lack of 
objective criteria supporting these decisions and the psychological aspects 
 6 
regarding RTS led to the aims and objectives of this study (refer to Figure 1.1). 
The interrelated discussions of concepts in the first two chapters and the 
resulting infiltration of these discussions into the study are illustrated in Figure 
1.3. 
 
Figure 1.3 The interrelated discussion of concepts within the study 
context. 
The second chapter provides a comprehensive discussion of the literature 
regarding the above-mentioned concepts.  The training and competing 
environment of an elite athlete in Bloemfontein (and South Africa) is explained 
due to the role it may play in psychological aspects.  Role players and their 
 7 
relatedness to one another and the athlete are described, in order to establish 
the place of a physiotherapist in RTS decisions.  The decision based RTS 
model is explained as a developing objective tool to assist physiotherapists 
with RTS decisions.  The pressure on an athlete and extrinsic pressure to 
RTS are explored and existing tools to measure these factors are 
investigated.  The tools used to determine athletes’ type of motivation to RTS 
were identified from this section of the discussion.   
 
The methodology of the research is presented in chapter 3, where the 
sampling methods, measuring instruments, data collection procedures and 
ethical principles are discussed.  The methodology was designed to 
determine a need for the type of motivation to be considered in RTS decisions 
and to investigate the possible relation between the type of motivation for RTS 
of an elite athlete who was injured during the season, and the possible re-
injury of that elite athlete after RTS.  A structured interview was compiled in 
order to determine whether track and field coaches have a need for 
physiotherapists to determine the type of motivation of an athlete to RTS and 
secondly, a cohort-analytical study was used to collect data regarding the type 
of motivation of elite athletes who were about to RTS and subsequent re-
injury during the remainder of the season after RTS.   
 
The results of this study are presented in chapter 4.  The results are explained 
by graphs and tables depicting relevant information to gain insight into the 
interpretation of the results.  The statistical analysis used for each calculation 
is defined, and the results are presented in the context of normal values, 
where applicable and available. 
 
Chapter 5 concludes the study with a discussion of the objectives and 
subsequent outcomes of the study.  Results (described in chapter 4) are 
compared to literature (discussed in chapter 2).  Questions are answered, 
phenomena are explained, new questions are raised and recommendations 
and limitations are identified.  The dissertation concludes with chapter 6 
where a summary of the most important aspects of the study and outcomes 
is provided. 
 8 
Chapter 2  
LITERATURE REVIEW 
 
 
2.1 Introduction 
 
Continually higher levels of performance are expected from elite athletes 
(Burgess 2011).  Large financial rewards and increasing media attention 
amplify this public demand on athletes (Burgess 2011).  Kreiner-Phillips and 
Orlick (1993) warn that success brings not only expectations and demands, 
but also changing roles - from a private individual to a public hero.  Future 
success or failure can be the direct outflow of the way in which athletes deal 
with these demands.         
 
The conflicting role of a public asset and the demands on a winning athlete 
can influence the athlete’s future preparations for competitions (Philips and 
Orlick 1993).  According to Botha (2016), the more successful an athlete 
becomes, the more extrinsic demands there will be on the athlete.  Athletes 
have to be available for media launches, radio and television interviews, 
sponsor photoshoots, advertisement campaigns, public appearances and 
reward acceptances.   Botha (2016) mentions that all of these interfere with 
the normal preparation of the athlete for the next season.  Because of all the 
media attention, the demands on the athlete to perform even better, increase 
(Burgess 2011).   The increased demand from the public and media, but with 
less available time for proper preparation for exceptional performances, 
places immense pressure on the athlete, the coach and the medical and 
fitness support structure of the athlete (Botha 2016).  Botha (2016) also 
mentions that injuries are bound to occur.  While an athlete is unknown to the 
public, the management of these injuries and RTS after an injury is a more 
controlled, gradual process.  Burgess (2011) states that the public demand 
on an injured winning athlete to RTS is high.   
 
Injured athletes have different motivations to RTS.  These motivations include 
intrinsic as well as extrinsic motivations.  Podlog and Eklund (2010) define 
 9 
intrinsic motivation as the need for intrinsic pleasure and a sense of fulfilment.  
Pelletier, Rocchi, Vallerand, Deci and Ryan (2013) further elaborate that 
intrinsic motivation is when someone does something that is inherently 
interesting or enjoyable.  In contrast, extrinsic motivation is described by 
Pelletier et al. (2013) as something that is done as a means to an end.  
Financial encouragement by sponsors and associations on national and 
international levels, as well as sanctions, may act as extrinsic encouragement 
for athletes to RTS (Bianco in Podlog and Eklund 2010).   
 
2.2  Track and field in South Africa 
 
Various track and field athletes performing at national and international 
competitions and therefore, subject to the above motivations, are coached 
and prepared for their competitions at the University of the Free State (UFS) 
in Bloemfontein (Kovsie athlete 2015).  In order to understand how athletics 
in Bloemfontein fits into the framework of international/competitive athletics, 
and how the researcher assembled the samples from the populations for this 
study (refer to 3.2.2 and 3.2.3), the structures of athletics are explained in 
detail.  The explanation further enlightens the reader on a typical training 
season relevant for elite athletes, specifically from South Africa, due to the 
differences in the track and field seasons in the Southern and Northern 
hemispheres.     
 
2.2.1 Athletics in Bloemfontein and athletics in the world. 
 
Athletics is a broad term referring to cross country, road running and track 
and field.  Athletics South Africa (ASA) is the only member federation in South 
Africa affiliated with the International Association of Athletics Federations 
(IAAF).  ASA controls all athletics in South Africa.  Athletics Free State (AFS) 
is one of the 17 affiliated provincial members of ASA (ASA 2015a) (refer to 
Figure 2.1).   
 
University Sport South Africa - Athletics (USSA-athletics) is not considered to 
be a provincial member of ASA, but is an associated member.  The UFS 
 10 
athletics club is affiliated to USSA athletics but it is also managed by the 
provincial office in the Free State.  Bloemfontein is one of the magisterial 
districts managed by AFS - as illustrated in Figure 2.1.   
Athletes and coaches are members of ASA via their respective provinces.   
 
Figure 2.1 Organogram of the relevant structures responsible for 
the management of athletes and coaches in Bloemfontein 
 
This means that all coaches and athletes from Bloemfontein are members of 
ASA via registration managed by AFS (ASA 2015a).  Provincial 
championships are organised by provincial member offices and national 
championships are managed by ASA and organised by the relevant provincial 
member where the event takes place.  Different national championships are 
held for the different age groups of athletes registered with ASA (ASA 2016).   
 
2.2.2 Age groups for National and International Competitions 
 
Coaches in South Africa coach athletes of different age groups.  These age 
groups have the opportunity to participate at various national and international 
competitions that are stipulated on the annual fixtures published by ASA (ASA 
2016).  In order to clarify why athletes can participate at more than one 
national championship and various national and international events, the 
different age groups and competitions for track and field are discussed below.  
This is relevant to the study because elite junior and senior athletes are 
 11 
included in the study (see the populations for the study in 3.2.2) and their 
participation at various national and international events were investigated. 
 
The different age groups classified by the IAAF are: 
 Under 18 (Youth) – any athletes aged 16 and 17 years on 31 
December in the year of the competition, 
 Under 20 (Junior) – athletes aged 18 and 19 years on 31 December in 
the year of the competition, and  
 Master – any athlete who has reached his/her 35th birthday (IAAF 
2015). 
ASA also recognises the following additional age groups for national 
competitions, but the aim with these age groups is national development and 
not international participation: 
 Under 16 (Sub-Youth) – any athlete aged 15 and younger on 31 
December in the year of the competition, and 
 Under 23 – any athlete aged 20, 21 and 22 years on 31 December in 
the year of the competition (ASA 2016). 
 
The competition season for most elite South African athletes is from March to 
May of each year and can progress into an international season which can 
continue until September.  An athlete aged 19 registered at the UFS in 
Bloemfontein can compete at national championships organised for the junior 
age group, the senior age group and also students, while a 20-year-old athlete 
from the UFS can compete at the national championships organised for the 
under 23 group, the senior age group and also students (IAAF 2015 and ASA 
2016).  These national championships are held annually from March to May.  
Additional meets are organised for local athletes to allow them to compete 
and qualify for national teams.  National and aspiring national athletes also 
participate abroad at international meets organised under the rules and 
regulations of IAAF, until September (ASA 2016).   
 
 
 
 12 
2.2.3 Selection for Provincial and National Teams 
 
Athletes in this study are referred to as provincial and/or national athletes.  
Selection of athletes to represent their province and/or country is subject to 
selection criteria explained below. 
 
The age groups that are eligible for team selection by ASA are senior, junior 
and youth teams.  ASA selects preparation squads in August/September.  
From these squads ASA selects a preliminary team in April/May of the 
following year and then a final ASA team is selected three to eight weeks prior 
to the relevant international events (ASA 2015b).   
 
Athletes are considered for inclusion in the preparation squads if they are 
older than 15 years, achieved the IAAF qualifying standard for a specific event 
in the preceding year, have the potential to achieve the IAAF qualifying 
standard in future or if an athlete won a medal at the preceding IAAF 
Championships (ASA 2015b).  This means that athletes in the preparation 
squads who are injured after inclusion in the squad, can RTS and ensure that 
they are ready for inclusion in the preliminary team and then finally the ASA 
team.  Inclusion in the team to the Olympic Games held in Rio de Janeiro in 
2016 was the aim for many athletes and coaches during the past season and 
several athletes in Bloemfontein attempted to qualify for inclusion in this team, 
in both local and international competitions and events. 
 
2.3 The role and background of track and field coaches  
   
Not all athletics coaches were considered for inclusion in this study (refer to 
3.2.2.1).  Coaches in track and field are graded according to the Five-level 
IAAF Coaches Education and Certification System (CECS).  This system 
progresses a coach through experience and education, from a level 1 youth 
coach to a level 5 academy coach.  Level 1 coaches are usually based at 
schools and the objective for these coaches is to develop skills to organise 
Kids Athletics for 13 to 15-year-old athletes.   The highest level that can be 
achieved by a coach is level 5 and the aim for these coaches is to develop a 
 13 
professional specialisation in coaching.  These coaches are highly 
experienced and active coaches are usually based at universities and clubs 
(IAAF 2007).   
 
2.3.1 Interaction between coaches and physiotherapists 
 
Tracey (2008) found that injured athletes consider their physiotherapists and 
athletics coaches to be authoritative participants in their emotional and 
psychological healing.  The relationship according to Brukner and Kahn 
(2008) is shown in Figure 2.2.     
 
 
Figure 2.2 The coach, the athlete and the clinician (Brukner and Kahn 
2008) 
 
Brukner and Kahn (2008) explain the advantages of a trusting relationship 
between the physiotherapist and an athlete.  This includes a feeling of mutual 
trust and confidence, implying that the athlete will confide in the 
physiotherapist and the physiotherapist will trust the athlete to comply with 
his/her advice.   The coach is, however, responsible for the training and 
performance of the athlete.  Brukner and Kahn (2008) advise involving the 
coach in all medical decisions concerning the athlete.  
 
Physiotherapists in Bloemfontein most frequently have to make RTS-
decisions for rugby and athletics (Erasmus, Hay, Steyn, Theron, Rothmann, 
Wilson and Brandt 2014).  The physiotherapists in their study were, however, 
 14 
of the opinion that physiotherapists, biokineticists and sport doctors were the 
main professionals involved in RTS decisions.     
 
It is highlighted by Brukner and Kahn (2008) that the relationship between 
coaches and clinicians (including physiotherapists) is not always one of trust.  
They mention that coaches often feel that the main role of a clinician is to 
prevent the athlete from training and competing.  
 
2.3.1.1 Trust between coaches and physiotherapists 
 
It is important for the clinician (physiotherapist) to explain to the coach that 
he/she is also aiming to maximise the performance and health of the athlete.  
The agent of a professional athlete will also be involved when major injuries 
occur.  A good practitioner-coach relationship will assist in coaches seeking 
assistance from the physiotherapist when minor injuries occur and this will 
often help to prevent major injuries (Brukner and Kahn 2008).  Brukner and 
Kahn (2008) further explain that in a trusting relationship, discussions with the 
coach may assist in the identification of the cause of the injury.      
 
2.3.1.2 Coaches’ expectations of physiotherapists as regards 
RTS 
 
According to Podlog and Eklund (2007), professional coaches expect 
physiotherapists and medical practitioners to give the go-ahead for RTS after 
an injury.  Harrast, Laker and Maslowski in Braddom (2011) also consider 
clearance of an athlete to RTS after injury as one of the responsibilities of a 
physiotherapist or clinician.  In the research study by Erasmus et al. (2014), 
the authors concluded that physiotherapists in Bloemfontein have an 
important role in RTS decisions of injured athletes.  The majority of the 
respondents in this study indicated that physiotherapists are involved in inter-
disciplinary teams in Bloemfontein that decide when an athlete is ready for 
RTS.  Most of the respondents were also of the opinion that physiotherapists 
have authority to make non-urgent RTS decisions as well as urgent (same 
day on the field) decisions (Erasmus et al. 2014).  Shrier, Safai and Charland 
 15 
(2014) found that coaches and athletes consider physiotherapists most 
capable to assess risks for re-injury.     
 
2.3.1.3 Guidance from the physiotherapists regarding training 
 
Podlog and Eklund (2007) also explain that the coaches expect guidance from 
the practitioner or physiotherapist on the amount and extent of training 
allowed for the specific athlete, following an injury.  Most physiotherapists in 
Bloemfontein prefer to treat patients with injuries during regular follow-up 
visits and prescribe progressive activity participation until the athlete is ready 
for RTS (Erasmus et al. 2014).  According to Le Roux in Sutcliff (2005), a 
physiotherapist has become one of the greatest assets to any coach.  He 
explains that physiotherapists assist with the reinstatement of injured athletes 
in order to ensure the greatest prospects for success.  Brukner and Kahn 
(2008) also remind the physiotherapist that a coach involved in the decision-
making process will increase the compliance of the athlete.  Potential conflict 
may, however, arise when the coach wants an athlete to resume duty too 
soon after sustaining an injury (Millson 2015).   
 
This conflict may be even more complicated when some information cannot 
be disclosed to the coach.  Harrast, Laker and Maslowski in Braddon (2011) 
caution physiotherapists to remember that some information gained from the 
physiotherapist-patient relationship is confidential and cannot be discussed 
with the coach.  They explain that it is important to realise that the primary 
obligation is to consider the athlete as a patient first, in order to prevent re-
injury or further injury.  This means that one should discuss these matters with 
the athlete and the coach before these situations occur (Harrast, Laker and 
Maslowski in Braddon 2011). 
 
2.4 Re-injury of athletes 
 
Timpka, Jacobsson, Bickenbach, Finch, Ekberg and Nordenfelt (2014) define 
‘sports injury’ to denote the loss of bodily function or structure that is the object 
of observations in clinical examinations. 
 16 
 
Tissue that has not healed is usually weaker than before and is more likely to 
be re-injured (Creighton et al. 2010).  Brukner and Kahn (2008) explain that 
treatment of an injury ideally comprises treating the presenting injury, but also 
addressing the cause of the injury.  This could mean that an athlete’s injury 
may be healed but the athlete may be at high risk for re-injury if the cause of 
the injury has not been corrected.  It is thus important to treat the patient as 
an individual: an Olympic athlete who needs to perform at certain levels of 
criteria (explained in 2.2.3) may require different treatment to someone who 
participates in a weekly park run (Brukner and Kahn 2008).    
 
Brukner and Kahn (2008) explains that incorrect biomechanics need to be 
considered as a cause of an athlete being more prone to injury.  Incorrect 
biomechanics include the wrong technique, muscle weakness, decreased 
range of motion of joints, structural abnormalities and decreased stability.  
Hoogenboom (2015) adds hypermobility as a possible contribution to overuse 
injuries but concludes that more research is needed to confirm hypermobility 
as a factor.  Hoogenboom (2015), however, highlights concussion as a 
special type of injury because nearly all athletic endeavours pose a risk for 
concussion.  Although this injury is considered to be micro trauma, the author 
challenges this assumption.  Repeated micro trauma is a significant health 
concern, according to Hoogenboom (2015), and she explains that the 
recurrence of injuries and repeated overuse injuries can lead to high costs, 
lost participation time and high rehabilitation costs.  
 
Other factors that should be investigated in order to assist in the prevention 
of re-injury are proper and correct warm-up, appropriate stretching, taping and 
bracing, protective equipment, suitable equipment, appropriate surfaces, 
appropriate training, adequate recovery, psychology (which relates to the 
motivational aspects in this study) and nutrition (Brukner and Kahn 2008).  
The correct use of apparatus or equipment in sport also needs to be 
investigated (Brukner and Kahn 2008).  Creighton et al. (2010) explain that 
an athlete's dominance may also cause an injury to re-occur e.g. a high 
 17 
jumper who takes off from the same leg during jumps or a hurdler who has 
different actions for the leading leg and the trailing leg. 
 
Hoogenboom (2015) suggests that specialisation at a young age must be 
considered a contributory factor to possible re-injury, especially due to the 
higher incidence of overuse injuries in athletes who specialise before the age 
of 10 years.   Hoogenboom (2015) also mentions that adolescents and 
children are more vulnerable to injuries to their skeletal structures, which may 
have long-term sequelae, such as re-injury.  Marchi, Di Bello, Messi and 
Gassola (1999) found that permanent sequelae after sports injuries in 
specifically children and adolescents is high.  Sixty percent of their subjects 
still had sequelae 12 years after a sport injury incident.  The type of activity 
was not significant to the likelihood of sequelae, but the severity, the type and 
location of the lesion were.  Tursz and Crost (2000) found that the percentage 
of sequelae increased regularly with the age of the children, due to the 
increase and severity of sport injuries as children grow older.     
 
As explained in 2.3.1, a good relationship with the coach can be an advantage 
to a physiotherapist in identifying possible causes for the injury and to adjust 
these causes in order to prevent re-injury.   
 
2.5 Complexities of beneficence  
 
Possible conflicts may arise when the player wants to RTS too soon, the 
medical team does not want the player to RTS or when the player does not 
want to RTS and exacerbate a pre-existing injury (Millson 2015).  This is 
where the principle of beneficence might be in conflict with the self-
determination or autonomy of an athlete (Burgess 2011).  Beneficence as one 
of the core ethical principles should be pursued, but the application of 
beneficence might be complex (Millson 2015).  Early RTS might position the 
athlete at high risk of re-injury, but also for the development of permanent 
psychological trauma (Slobounov 2008).  
  
 18 
Brukner and Khan (2008) further warn that the involved clinical person might 
be under pressure from various sources to allow the athlete earlier RTS.  
Millson (2015) advises clinical personnel to be aware of what their contracts 
with their employers stipulate in these cases.  Due to the nature of one’s 
involvement with athletes during competitions, Millson (2015) also warns that 
one has to remain aware of subjectivity.  Subjective decisions on RTS can be 
caused by emotional involvement in the success of the athlete (Johnson in 
Burgess 2011).  If the clinical person cannot make an objective decision, 
Burgess (2011) advises that an external, unbiased professional must be 
consulted.  Millson (2010) identified a lack of standardised RTS procedures 
and protocols as problematic to these situations.  Myer et al. (2006) also point 
to a lack of standardised objective criteria to assist with assessment of an 
athlete’s ability to safe RTS.   
 
Millson (2015) proposed that standardised RTS procedures and protocols 
should be developed and implemented in order to support more objective 
clinical decisions by the clinical team.  It is, however, the responsibility of the 
lead physician to make RTS decisions.  As explained in 2.3.1, this 
responsibility is often that of the physiotherapist of the athlete.  Athletes may 
and should be referred to other specialists for further consultation on final 
clearance to RTS; however, this may complicate a situation when there is 
already conflict between the coach and the leading physician/physiotherapist 
(Harrast, Laker and Maslowski in Braddon 2011).  
 
2.6 The Decision Based RTS Model 
 
Creighton et al. (2010) developed and proposed the Decision Based RTS 
Model (refer to Figure 1.2) to assist with clinical decisions.  
 
The model consists of three steps as illustrated in Figure 2.3 and each step 
is determined by various factors and modifiers as illustrated in Figures 2.4, 
2.5 and 2.6.  Creighton et al. (2010) suggests that each one of these factors 
and modifiers should be topics for further research.   
 19 
 
Figure 2.3 Decision Based RTS Model - three steps (Creighton et al. 
2010) 
 
2.6.1 Step 1:  Evaluation of Health Status 
 
Evaluation of Health Status is done to evaluate the amount of healing that has 
occurred in order to determine how close to “normal” the athlete is.  Tissue 
that has not healed is usually weaker than before and is more likely to be re-
injured (Creighton et al 2010).  The Evaluation of Health Status of the athlete 
is the first step illustrated in Figure 2.3 of the Decision Based RTS Model.  
This requires the medical person to consider several medical factors 
 20 
illustrated in Figure 2.4, in order to assess an athlete’s recovery from 
biological, psychological and functional components of the injury.   
 
Figure 2.4 Step 1 of the Decision Based RTS Model (Creighton et al. 
2010) 
 
The first medical factor illustrated in Figure 2.4 that needs to be considered is 
Patient demographics.  The gender and age of an athlete are factors that can 
affect tissue healing (Millson 2015b).  According to Hoogenboom (2015), 
skeletal maturity is typically completed by the age of 18 in females and 21 to 
22 years in males.  Open epiphyses in these populations make them more 
vulnerable to injury.  Other examples of injuries related to age and gender are 
Achilles tendinopathy, patellofemoral dysfunction or pain and patellar 
tendinopathy (Cassel et al. in Hoogenboom 2015).  Symptoms (pain, oedema, 
sensation of instability and stiffness) are factors which may indicate that 
healing is not complete (Brukner and Kahn 2008). 
Brukner and Kahn (2008) also highlight the importance of considering the 
athlete’s family history and personal medical history which can be relevant 
to the recurrence of injuries.  Signs such as muscle strength and joint range 
of motion (ROM) should be clinically evaluated.  Creighton et al. (2010) 
suggest that due to discrepancies in the literature, these signs should be 
dealt with clinically by the medical practitioner until consensus is reached in 
the literature.  Laboratory tests such as X-rays, magnetic resonance imaging 
(MRI), computed tomography (CT-scans), bone scans and ultrasound 
imaging can assist healthcare professionals with objective evidence of 
structural and physiological abnormalities (Creighton et al. 2010).  
Hoogenboom (2015) mentions that several functional tests exist which can 
predict an athlete’s probability of re-injury.  These tests assess an athlete’s 
 21 
balance, proprioception, functional ROM and movement.  Creighten et al. 
(2010) also advises that stresses and forces which will be experienced 
during competition should be introduced during functional testing.   
Glaser (2009) explains that there is a higher risk for re-injury if the athlete 
experiences apprehension, fear and anxiety.  He also warns that these 
factors regarding psychological state can have a negative effect on an 
athlete’s performance. 
According to Creighton et al. (2010) the health status of an athlete can be 
potentially more serious for a concussion versus an ankle sprain, taking into 
account the specific sport that will be competed in.   
Some of these medical factors e.g. patient demographics, symptoms, 
personal medical history, signs, laboratory tests and potential seriousness, 
can be evaluated by existing objective scales and objective measures.  These 
include functional tests with measurable results (Gabriel 2011), scales such 
as the Activities of Daily Living Scale, the American Academy of Orthopaedic 
Surgeons Sports Knee Rating Scale, Knee Injury and Osteoarthritis Outcome 
Score (KOOS), Lysholm Knee Scale, Cincinnati Knee-Rating Scale, 
proprioception tests, ROM measurements, neural tests, neuromotor control 
tests, muscle length tests, Functional Movement Screen, and Y-Balance test 
(Allen, Martin and Place 2011; Millson 2015; Hoogenboom 2015).  Millson 
(2010), however, concluded that there is still a lack of consensus regarding 
RTS scales and scores. 
 
 
 
 
 
 
 
 
 
 
 22 
 
2.6.2 Step 2:  Evaluation of participation risk 
 
The second step of the model is represented in Figure 2.5 and entails the 
evaluation of participation risk (Creighton et al. 2010). 
 
Figure 2.5 Step 2 of the Decision Based RTS Model (Creighton et al. 
2010) 
   
Brukner and Kahn (2008) associate some injuries with certain types of sport.  
Patellar tendinopathy can be associated with high-jump athletes and tibia 
stress fractures, with long-distance runners.  Creighton et al. (2010) explain 
that collision sports such as rugby usually pose a higher risk for injury, 
compared to contact sport such as basketball.  Non-contact sports like 
swimming poses an even lower risk for injury but high-velocity sports like 
alpine skiing pose a high risk for serious injury.  Different positions within a 
specific sport may require different skills from players in the team.  This may 
expose the players of a specific sport to different injuries (Creighton et al. 
2010).  As explained in 2.4, an athlete's dominance may also cause an injury 
to re-occur.  Athletes with a higher competitive level are more likely to have a 
higher risk for injury (Creighton et al. 2010).  Hoogenboom (2015) 
consequently advises that specific intense training should be avoided before 
the age of 10.  Taping, bracing, splinting or padding may improve the ability 
to protect and reduce the risk of re-injury.  Various techniques of strapping 
are used to assist athletes to manage RTS (Brukner and Kahn 2008).  It is, 
however, interesting that Hoogenboom (2015) mentioned that an increase in 
the amount of protective equipment used appears to increase the rate of injury 
in males and decrease the rate of injury in females.   
 
 
 23 
 
2.6.3 Step 3: Decision Modification 
The third step or Decision Modifiers (Figure 2.6) may change the decision that 
would have been made if the risks were the only considerations.  There are 
three important considerations with Decision Modifiers.  Firstly, these 
modifiers can harm the athlete’s family, coach or even doctor if the athlete is 
allowed or prevented from RTS.  Secondly Creighton et al. (2010) 
acknowledge that not all the modifiers may be seen as appropriate by some 
clinicians and lastly, Decision Modification is set aside from the other two 
steps of the model.  Creighton et al. (2010) explain that Participation Risk 
does not provide information about Decision Modification and Participation 
Risk must be known before Decision Modification can be used. 
 
Figure 2.6 Step 3 of the Decision Based RTS Model (Creighton et al. 
2010) 
The decision modifiers illustrated in Figure 2.6 are: 
i. Timing and season: During the preparation phase of the season, 
there may be less benefit for the athlete to RTS compared to during 
the competition phase of the season.  As explained in 2.2.3, athletes’ 
need to qualify for ASA national teams and selection depends on 
performances at certain times of the season.  Erasmus et al. (2014) 
concluded that timing and season is the most important decision 
modifier during RTS-decisions. 
ii. Pressure from athlete: As explained in 2.5, the autonomy of an 
athlete to make his/her own decisions regarding RTS may be in conflict 
with the beneficence of a physiotherapist who recommends that an 
 24 
athlete does not RTS yet.  Harrast, Laker and Maslowski in Braddom 
(2011) also mention that athletes can legally challenge non-clearance 
decisions and may participate, despite medical judgment.  Millson 
(2015) advises clinicians to obtain informed consent from an athlete 
who decides not to adhere to the clinician’s recommendation regarding 
RTS.   
iii. External pressure: Coaches, teammates, relatives, team 
administrators, agents, sponsors, league officials, fans, and media 
may all benefit from an athlete’s RTS.  According to Millson (2015b) 
these groups may have the potential to influence the RTS decision.  
Consequently, the relationship between the coach and the 
physiotherapist, explained in 2.3.1, is of exceptional importance. 
iv. Masking the injury:  Creighton et al. (2010) consider cortisone 
injections, local anaesthetics and analgesics to mask injuries as very 
common in sport medicine.   
v. Conflict of interest: Millson (2015b) advises clinicians to familiarise 
themselves with their contractual obligations towards the management 
and other role players in the team, e.g. a coach may lose his/her job if 
the team does not perform and conflicts may arise between the 
clinician and the coach regarding a specific player’s RTS.  As 
mentioned in 2.6.3(iii) above, the relationship between the coach and 
the physiotherapist is also of importance with possible conflict of 
interest.   
vi. Fear of litigation: Millson (2015b) mentions that clinicians may be 
sued when an athlete is injured after RTS.  Harrast, Laker and 
Maslowski in Braddom (2011) support this statement and state that a 
physician might be held liable if an athlete is cleared for RTS despite 
the presence of a medically contra-indicated condition.  Millson 
(2015b) reminds clinicians of the importance of proper clinical notes 
and informing athletes of all the risks involved in RTS.     
 
Psychological factors and modifiers should also be evaluated by objective 
measures.  The psychological state, the level of competition, pressure from 
 25 
the athlete, external pressure, conflict of interest and the fear of litigation are 
modifiers included in the Decision Based RTS model that can have an 
influence on an athlete’s psychological readiness for RTS (Creighton et al. 
2010).  Podlog and Eklund (2007) mention that coaches are aware of 
psychological modifiers that can influence RTS and that coaches individualise 
their approach in assisting each athlete with psychological factors for RTS.  It 
was, however, mentioned that participants of the study might have presented 
themselves in a socially acceptable light and that discrepancies regarding 
assistance that coaches suggested they offer returning players, and the 
“actual” assistance offered may exist (Podlog and Eklund 2007).  This 
possible discrepancy motivates the need for transparent objective measures 
for psychological factors and modifiers. Matheson et al. (2011) also 
highlighted the lack of research on the factors and components of the model. 
 
As explained in 2.3.1.2, physiotherapists are trusted to provide objective 
opinions and instructions regarding RTS (Podlog and Eklund 2007).  
“Pressure from the athlete” and “external pressure” are two components of 
the proposed model that can modify a physiotherapist’s decision on RTS 
(Creighton et al. 2010).   
 
Glaser (2009) developed the Injury-Psychological Readiness to Return to 
Sport (I-PRRS) Scale.  This scale focuses on the confidence of an athlete and 
does not address all the mentioned psychological factors and modifiers in the 
Decision Based RTS Model (Creighton et al. 2010).    Most of the earlier 
scales to measure motivation did not include a measure of integrated 
regulation as described by the SDT (Pelletier, Tuson, Fortier, Vallerand, 
Briere and Blais 1995). 
 
 
 
 
 
 
 26 
2.7 Self-determination theory 
 
The SDT is a theory of motivation, personality and optimal functioning.  This 
theory is based on the assumption that humans strive for three innate 
psychological needs that are considered to be universal necessities. These 
are namely: greater competence, relatedness and autonomy (Tran 2014).  
Competence is when individuals have a desire to seek challenges, express 
their capacities and develop their confidence in order to master their 
environment.  Relatedness is a sense of belonging with others.  Autonomy is 
when an individual can act in ways that are in harmony with his or her own 
interests and values (Pelletier et al. 2013).   
 
 
Figure 2.7 The Self-Determination Continuum illustrating Types of 
Motivation with their Regulatory Styles, Loci of Causality, and 
Corresponding Processes (Ryan and Deci 2000) 
 
Ryan and Deci (2000) explain how the SDT consists of a continuum with 
amotivation on the far left, meaning no intention to act, and Intrinsic Motivation 
on the far right, namely performing an activity for the inherent satisfaction of 
performing the activity (Figure 2.7).  Ryan and Deci (2000) identify and 
describe four classifications of extrinsic motivations between Amotivation and 
Intrinsic Motivation, varying in their degree of autonomy. Externally motivated 
is behaviour that is least autonomous and is the type of behaviour expressed 
 27 
in order to satisfy an external demand or reward.  Introjected regulation is 
behaviour that is expressed in order to avoid guilt or anxiety.  An example of 
introjected regulation would be someone who demonstrates abilities or avoids 
failure in order to maintain a feeling of worth.  Identified regulation is more 
autonomous and is an action which is considered as personally important.  
Integrated regulation is the most autonomous form of extrinsic motivation.  
Although similar in many ways, integrated regulation activities can be 
distinguished from intrinsic motivation activities because they are performed 
to achieve distinguishable outcomes rather than for their natural pleasure. 
Mallett, Kawabata, Newcombe, Otero-Forero and Jackson (2007) criticise the 
Sport Motivation Scale (SMS) for not including a measure for integrated 
regulation as described in the SDT.   
 
2.7.1 The Sport Motivation Scale 
 
The Echelle de Motivation dans les Sports (Brière, Vallerand, Blais and 
Pelletier 1995) and the Sport Motivation Scale (Pelletier, Tuson, Fortier, 
Vallerand, Briere and Blais 1995) are French and English versions of the 
Sport Motivation Scale (SMS).  The SMS consists of 28 items and these items 
represent seven factors, with four items related to each factor.  The seven 
factors are three types of intrinsic motivation, three of the four types of 
extrinsic motivation explained in the SDT and amotivation.  Due to the 
effective and substantial use of the SMS there is now a better understanding 
of sport motivation (Pelletier et al. 2013).  It was, however, necessary to adjust 
and revise the SMS in order to represent all the constructs in the SDT (Mallett 
et al. 2007 and Pelletier et al. 2013).   
 
2.7.2 The Revised Sport Motivation Scale  
 
In 2010 a panel of experts on sport motivation and the SDT revised the 
structure of the SMS (Pelletier et al. 2013).  Existing items were critically 
discussed and new items were considered for inclusion in order to construct 
a revised scale which had less items and better represented the constructs in 
the SDT.  The number of items per factor was reduced to three in order to 
 28 
reduce the overall length of the scale.  The seven original factors mentioned 
in 2.7.1 were also decreased to six by replacing the original three types of 
intrinsic motivation with a single factor.  A fourth factor, integrated regulation, 
was added to the three existing extrinsic motivation factors.  These changes 
meant that 12 items related to intrinsic motivation (three factors with four items 
each) were changed to three items for intrinsic motivation (one factor with 
three items).  The total number of items was decreased to 18 from the original 
28.  The revised sport motivation scale (SMS-II) reflects an athlete’s 
motivation, from the least self-determined to the most self-determined, 
namely amotivation, external regulation, introjected regulation, identified 
regulation, integrated regulations and intrinsic motivation (Pelletier et al. 
2013).  According to Pelletier et al. (2013) the SMS-II is expected to 
demonstrate strong construct validity and reliability and the SMS-II will also 
demonstrate better support for the SDT.  Lonsdale, Hodge, Hargreaves and 
Ng (2014), however, question the superiority of the SMS-II compared to the 
Behavioral Regulation in Sport Questionnaire (BRSQ) and are of the opinion 
that further work needs to be done on both the SMS-II and the BRSQ. 
 
2.8 Conclusion 
 
Based on theory and research, the suggested research on the components 
of the proposed RTS decision based model explained in 2.6 served as 
motivation to determine whether athletic coaches have a need for the type of 
motivation of an athlete to be considered when decisions about RTS of an 
athlete are made.  This need was investigated and research was conducted 
on the type of motivation and subsequent re-injury of athletes who are 
returning to sport (Matheson et al. 2012).   
 
 
 
 
 
 
 
 29 
Chapter 3  
METHODOLOGY 
 
 
3.1 Introduction 
 
This chapter provides a description of the methodology, the research process 
as well as the steps taken in order to guarantee the validity of the study. 
 
3.2 Research methodology 
 
3.2.1 Study design 
 
Babbie (2007) advises that the best study design includes more than one 
research method in order to obtain maximum benefit from the strengths of 
different methods of research.  Creswell and Clark (2011) support this 
advice and state that a need often exists to enhance a study with a second 
method.   
 
 
Figure 3.1 Flow diagram of study design. 
 
 
In this study a descriptive and cohort-analytical design was used.  A cohort 
analysis entails the study of a specific sub-population over time (Babbie 
 30 
2007).  The flow diagram illustrated in Figure 3.1 illustrates how data from 
athletes was collected by means of an adapted revised version of the 
SMS-II (Appendix H).  Data obtained from athletes was entered onto a 
data sheet (Appendix I).  The analytical research was supported by means 
of a descriptive component.  The descriptive component consisted of 
interviews with coaches, including structured questions (Appendix K). 
 
3.2.2  Study population 
 
As mentioned in 3.2.1 both coaches and athletes in track and field were 
involved in this study.  Selection of elite athletes and their coaches in track 
and field for the populations provided for improved control over decision 
modifiers (refer to 2.6.3) that were not investigated by the researcher in 
this study.  Modifiers like “timing and season”, “conflict of interest” and 
“fear of litigation” were better controlled because the athletes had similar 
preparation and competition seasons (refer to 2.2) and athletes were 
exposed to similar pressure from clubs and authorities because they were 
all registered at AFS and was located in Bloemfontein (refer to 2.2).  The 
athletes were also treated by a smaller population of physiotherapists 
located in Bloemfontein and the physiotherapists from Bloemfontein was 
included in a pregraduate study to investigate their physiotherapeutic 
decisions with regards to RTS (Erasmus et al. 2014). 
 
3.2.2.1  Track and field coaches 
 
The data obtained to establish the need for the type of motivation of an 
athlete to be considered in decisions regarding RTS, was collected from 
track and field coaches in Bloemfontein.  Coaches had to be registered 
with Athletics Free State (AFS) and had to coach athletes in Bloemfontein 
older than 18 years, and who had represented their province and/or 
country during the previous track and field season  (refer to 2.2.1 and 2.3). 
 31 
 
List of registered 
coaches at AFS 
Coach 
junior and 
senior 
athletes
One coach preferred not to 
participate in the study
11 coaches 
Two did not coach provincial/national 
qualified for 
athletes recently
inclusion
Two was not available due to serious 
health conditions.
6 coaches 
included 
in the 
study
 
Figure 3.2 Flow diagram to illustrate how the six coaches 
for this study were selected for inclusion 
 
 
A contact list of registered coaches in Bloemfontein, who coach track and 
field athletes older than 18 years was obtained from the office of AFS 
(Swarts 2016).  In Figure 3.2 it can be seen that eleven coaches qualified 
for inclusion in the study.  The inclusion and exclusion criteria explained 
in 3.2.4 were used in order to determine which coaches were included in 
the study.  One of these coaches was excluded due to his/her 
unwillingness to participate in the study and another two were hospitalised 
during the execution of the study due to serious health issues and were 
not available for inclusion.  During the interviews it was also established 
that two of these remaining coaches had not recently (during the past ten 
years) coached athletes older than 18 years and they were excluded from 
the study (refer to 3.2.4).  The remaining six coaches were included in this 
study.  
 
3.2.2.2  Athletes 
 
The population of athletes used to determine the type of motivation and 
the possible subsequent recurrence of injury, consisted of 15 athletes who 
had sustained injuries during the current season and were about to RTS 
 32 
after treatment by a registered physiotherapist.  The number of injured 
athletes is considered to be high, as the team of athletes from the region 
who competed at national championships never exceeded 50 during the 
season.  This means that 15 of these 50 athletes were injured during the 
season and returned to sport during the season.  This population 
comprised injured elite athletes older than 18 years, who are registered at 
AFS and recently (during the seasons of 2015 and or 2016) represented 
the region and/or province at different competitions/championships.  The 
athletes had to be treated by a physiotherapist in Bloemfontein before 
RTS.   
 
3.2.3  Sample 
 
In this study the researcher had to deal with a small population size.  As 
explained in 3.2.2.1 and 3.2.2.2, the populations considered for inclusion 
in the study were small and the phenomenon of injured athletes occurred 
on a limited scale.  It is advised by De Vos et al. 2005 that in such a case, 
it is preferable to involve the whole population in the study.  Bless and 
Higson-Smith (2000) advises a sample that will represent all the 
properties of the population.  Sampling of the different populations was 
handled as follows:   
 
3.2.3.1  The whole population of available athletics coaches (total 
population sampling) was included in the sample if they met 
the inclusion criteria (refer to 3.2.2.1).  Names and contact 
details were obtained directly from the offices of AFS (Swarts 
2016).         
 
3.2.3.2    The whole population of injured elite athletes in Bloemfontein 
(total population sampling) was included in the sample of 
athletes, if they met the inclusion criteria.   
 
The following eligibility criteria were used to determine whether a coach or an 
athlete was to be included in the study. 
 33 
3.2.4  Inclusion and exclusion criteria 
 
3.2.4.1  Coaches 
 
(a)  Inclusion criteria for coaches: 
 Coaches had to be registered with AFS as track and field.coaches. 
 Coaches had to have coached athletes representing the 
province/country during the 2015/ 2016 seasons. 
 Coaches of all ages were considered for inclusion. 
 Male and female coaches were considered for inclusion. 
 Coaches of all races were considered for inclusion.  
 Coaches had to be confident in understanding and expressing 
themselves in English or Afrikaans. 
 
 
(b)  Exclusion criteria for coaches: 
 Coaches who did not coach athletes older than 18 years in the 2015 / 
2016 seasons. 
 Coaches who were not confident in either English or Afrikaans as a 
language of communication. 
 
3.2.4.2  Athletes  
 
(a) Inclusion criteria for athletes: 
 Athletes had to be registered as an athlete with AFS during the season 
when the injury occurred.   
 Athletes had to represent a region or a province in South Africa (or 
must have represented South Africa) in track and field during the 2015 
and/or 2016 seasons.   
 Athletes had to be diagnosed by a registered physiotherapist and/or 
physician, with an injury that prevented the athlete from participation in 
at least one athletics meet on the AFS calender.   
 The athlete had to be treated and cleared for RTS by a physiotherapist 
in Bloemfontein.   
 34 
 Male and female athletes of all races and older than 18 years, were 
included in the study.  
  
(b)  Exclusion criteria: 
 The questionnaire was available in Afrikaans and English and athletes 
who were not comfortable with at least one of these languages would 
not have been included in the study.  However,  no athletes were 
excluded from this study due to this criteria. 
 
3.2.5  Data collection tools 
 
Collection of the data was conducted in two different phases (refer to Figure 
3.1).       
 
3.2.5.1  Measuring instrument for data collected from coaches 
 
The questionnaire for the structured interview with the coaches (Appendix K) 
was compiled using data obtained by means of a thorough literature study, 
information obtained from keynote speakers’ presentations at the Sport 
Physiotherapy Congresses (Millson 2010a, Millson 2015a, Millson 2015b and 
Hoogenboom 2015) and a personal interview with a subject expert (Millson 
2010b).  The structured interviews were used to collect data regarding the 
need for the type of motivation to be considered during decisions on RTS.  
The questions were grouped as follows: 
  
i. general coaching experience and involvement 
ii. coaches’ expectations of physiotherapists 
iii. referrals, and 
iv. identifying the need for motivation to be considered before an athlete 
is cleared for RTS. 
 
Closed-ended questions ensure uniform responses and are popular for 
synoptic studies.  These are also easier to code than open-ended questions 
because responses can be directly coded (Babbie 2005).  Both types of 
 35 
questions were used in the interview (Appendix K).  The questions (Appendix 
K) were translated to Afrikaans to allow for individual preference.   
 
3.2.5.2  Measuring instrument for data collected from athletes 
 
An adapted version of the SMS-II (Appendix H) was used to collect data 
regarding the type of motivation of injured athletes. The initial SMS was used 
by Podlog and Eklund (2005) to determine athletes’ motivations for RTS.   
With coefficients ranging from .58 to .84, the scale has demonstrated 
sufficient test-retest reliability and internal consistency (coefficients ranging 
from .63 to .85), as well as construct validity (Ryan and Deci 2000). 
 
Podlog and Eklund (2005) made three modifications to the original SMS.  The 
original SMS measured the motivation of an athlete to participate in their 
sport.  Firstly, Podlog and Eklund (2005) adjusted the questionnaire stem 
from, “Why do you practise your sport?” to “I returned to sport following injury,” 
in order to measure the motivation for an athlete to RTS following an injury.  
The respondents’ responses were measured with a 7-point Likert scale with 
anchors of 1 (does not correspond at all), 4 (corresponds moderately), and 7 
(corresponds exactly). 
 
Secondly, two subscales were removed to reduce subject burden. Amoti-
vation (complete unmotivated action) was excluded because the purpose of 
the questionnaire was to ascertain why athletes RTS after a serious injury.  
Two of the three types of intrinsic motivation were deemed most relevant and 
the adapted version retained five of the original seven subscales (Podlog and 
Eklund 2005).  
 
Thirdly, two items of the SMS scale were modified to make them more 
appropriate for the purposes of the current investigation. The original item, 
“Because in my opinion, it is one of the best ways to meet people” was 
changed to, “Because I missed bonding with fellow teammates and/or other 
athletes competing in my sport.” In addition, the original SMS item, “Because 
it is one of the best ways to maintain good relationships with my friends” was 
 36 
reworded to, “Because I wanted to maintain good relationships with my 
friends, team mates and/or the coach.”  
 
3.2.5.2.1 The revised SMS-II 
 
      The revised SMS-II was compiled by Pelletier et al. (2013) and the original 
28 item scale was reduced to 18 items to better represent the criteria set 
by the SDT described in 2.7.  The following changes were made to the 
SMS-II in order to obtain similar results from the revised scale compared 
to the results obtained from the adapted SMS, adjusted by Podlog and 
Eklund (2005): 
 
 “Why do you practise your sport?” was also changed to, “I returned 
to sport following injury” for the same reason explained in 3.2.5.2 
above.  A 7-point Likert scale with anchors of 1 (does not cor-
respond at all), 4 (corresponds moderately), and 7 (corresponds 
exactly) was used for the athlete’s responses as recommended by 
the original SMS-II.   
 Secondly, only one subscale was removed.  Amotivation was 
removed because the aim was to measure the motivation for 
athletes to return to sport as explained in 1.1.2.   
 The scale was also translated to Afrikaans in order to make it 
easier for Afrikaans students to answer the questionnaires in a 
language known to them.  The original English SMS-II was 
translated to Afrikaans by an independent translator.  The 
translated Afrikaans version (Addendix H) was reviewed and 
translated back to English by an independent psychologist.  The 
psychologist concluded that the original content was retained and 
that no ambiguity was present.  No changes were made to the 
translated version. 
 
 
 
 37 
3.2.5.2.2  Follow-up phone calls 
 
As described in 3.2.6.2, follow-up phone calls were used to determine 
recurrence of injury.   The data was documented on a data sheet 
(Appendix I).   
 
3.2.6  Data collection procedures 
 
The following approaches were followed to collect data from the coaches and 
the athletes: 
 
3.2.6.1  Data collection from coaches 
 
Unstructured interviews often yield varying information from respondents that 
is difficult to compare (Silverman in Leedy and Ormrod 2005).  Structured 
questions were therefore asked in interviews (Appendix K) with the track and 
field coaches, to determine whether there is a need for a type of motivation to 
be considered by physiotherapists when decisions about RTS are made.   
 
Data was collected from April 2016 to October 2016.  A list of all the registered 
track and field coaches in Bloemfontein was obtained from AFS in 
Bloemfontein at the end of March 2016 (Swarts 2016).  Coaches who were 
included in the sample (explained in 3.2.3) were telephonically contacted to 
inform them of the study and to request their participation.  A suitable time 
and venue were agreed upon with each willing coach who complied with the 
inclusion and exclusion criteria described in 3.2.4.1.  Each respondent was 
personally invited by the researcher to participate in the study.  A brief 
explanation of the study was discussed with the respondent and informed 
consent (Appendix B) was signed by each respondent.  The structured and 
structured questions (Appendix K) were asked by the researcher and the 
answers were transcribed by the researcher on the pre-constructed data 
sheet (Appendix I).  Enough time was arranged that all the questions could 
be answered.  After completion of the interview the respondents had the 
 38 
opportunity to read the transcriptions and alter any answers if they felt that 
these did not accurately reflect their answers. 
 
3.2.6.2 Data collection from athletes 
 
Data about the type of motivation of athletes and re-injury of these athletes 
was collected from 31 March 2016 to the end of July 2016.  Two persons were 
involved with entries of Free State athletes at all national and international 
competitions.  Injured athletes had to report to them with a medical document 
for authorisation to withdraw from certain competitions and to request 
inclusion in later competitions.  These two persons were contacted after each 
national competition/championship by the researcher, in order to identify 
possible athletes for inclusion in the study.  Identified athletes were contacted 
by the researcher and were then invited to participate in the study. 
 
Participants were contacted telephonically during the last week before RTS 
to a track and field event on the official fixtures of ASA (ASA 2016).  The 
researcher made an appointment with the participant and organised for a 
quiet area where the participant completed the adapted SMS-II (Appendix H)  
and the demographic information on the data-sheet (Appendix I), without any 
distractions.  The researcher briefly explained to the respondent what 
participation in the study entailed and explained to the respondent that he/she 
could withdraw from participation in the study at any time.  The respondent 
signed informed consent (Appendix G).  The instructions were explained in 
detail by the researcher to each one of the respondents.  The researcher was 
available to answer any questions that arose, to ensure that the same 
assistance was given to different respondents when questions about the 
SMS-II or the data sheet might arise.  When the participants had completed 
the adapted SMS-II, the data sheet (Appendix I) was attached to the 
completed adapted SMS-II.  No personal details appeared on the 
questionnaires or data sheets.    
 
The respondents were members of the same track and field club, but during 
the period of the study there was no physiotherapist employed by the UFS or 
 39 
physiotherapist appointed to treat the athletes of the UFS on campus.  
Athletes were treated by physiotherapists in private practices of their own 
choice.  The researcher was also involved as a clinician and did treat and 
clear some of the athletes for RTS using clinical reasoning and RTS-criteria 
described in Brukner and Kahn (2008).    For athletes that were not treated 
and cleared for RTS by the researcher, the relevant data was obtained from 
their treating physiotherapists.  With the permission of these athletes, the 
athlete’s physiotherapists were contacted to disclose the relevant data for 
clearance for RTS and the correct medical diagnosis of the athlete’s injury.  
This data was added to the data sheet (Appendix I).   
 
The participants were telephonically contacted by the researcher on a weekly 
basis for the first month and on a monthly basis for the remainder of the 
competition season (31 March 2016 to end of July 2016) to determine whether 
they were competing unhindered by injuries, or whether any of them had 
experienced a recurrence of injury after RTS.  If an athlete had experienced 
a recurrence of injury, the nature of the injury was also determined from the 
athlete as either being identical to before RTS, related to the original injury or 
a new injury that could not be linked to the original injury.  This data was added 
to the data sheet (Appendix I) which was attached to the adapted SMS-II 
(Appendix H).  
 
3.2.7  Pilot study 
 
Babbie (1990) and Sarantakos in Strydom and De Vos (2005) distinguish 
between a pretest and a pilot study.  A pilot study is a “mini walk-through” of 
the complete study while a pretest is only the execution of a few aspects (e.g. 
the questionnaire or the interview) of the study.  Strydom in De Vos (2005) 
warns that one of the biggest mistakes made by researchers is to not  conduct 
a pretest or pilot study.  A pretest or pilot study improves the accuracy of a 
research study (McVurney in Strydom in De Vos, 2005).   
 
Pretests and a pilot study were executed to improve the quality of the 
measurement instruments as advised by Katzenellenbogen (1999).  Strydom 
 40 
(2005) advised that the complete questionnaires should be tested on 
respondents as close as possible to the populations that had to be included 
in the study.  Pretests were conducted during the last week in March 2016 
and a pilot study was conducted in May 2016. 
 
3.2.7.1  Interviews with coaches 
 
The pilot study included one track and field coach at the UFS athletics club in 
Bloemfontein.  The interview took place on 9 May 2016 at a quiet venue.  The 
coach had athletes in her training group who had been members of national 
teams during 2014 and or 2015.  She fulfilled the eligibility criteria stated in 
3.2.4.1.  The venue was booked for an hour and privacy was guaranteed.  The 
interview was conducted and noted by the researcher.  The respondent was 
requested to comment on the phrasing, clarity, order, redundancy and 
completeness of the questions (Strydom 2005).  No changes were made to 
the structured interview.    
 
3.2.7.2  Athletes - SMS-II and data sheet 
 
The adapted SMS had already been successfully used in the study of Podlog 
and Eklund (2005) to measure the motivation of athletes to RTS.  The athletes 
investigated by Podlog and Eklund (2005) also included track and field 
athletes competing at international and national level.  The athletes’ ages also 
ranged between 18 and 44.  Although athletes from other sporting codes, as 
well as less experienced athletes who competed only at provincial level were 
also inlcluded, the population and sample compared well with this study.  No 
further changes were suggested by Podlog and Eklund (2005) to measure 
motivation of athletes to RTS.  Similar changes to the changes made by 
Podlog and Eklund (2005) to the SMS were applied to the SMS-II (refer to 
3.2.5.2).   
 
Buchberger (2012) explained that very few elite athletes complete a season 
completely symptom-free.  Athletes older than 18 years training at the UFS-
track and field club were approached during the last week in March 2016 and 
 41 
were requested to participate in the pretest if they had minor injuries or niggles 
that did not prevent them from participation at competitions, but did influence 
their training to such an extent that they were not able to complete their 
sessions.  Six athletes (five Afrikaans and one English) were included in the 
pretest.   The athletes who preferred the Afrikaans version of the SMS-II 
received the translated version to complete and the one athlete that preferred 
the English version received the English version of the SMS-II to complete. 
 
According to Strydom (2005) respondents should be requested to comment 
on the phrasing, clarity, order, redundancy and completeness of the questions 
and/or items.  No changes were necessary to the measuring instruments. 
 
The data and findings of the pilot study in 3.2.7.1 above were included in the 
study because the respondents satisfied the inclusion and exclusion criteria 
stipulated in 3.2.4.1.  The data and findings of the pilot study in 3.2.7.2 were 
not included in the study because they had only minor injuries which did not 
prevent them from participation (refer to inclusion criteria in 3.2.4.2).   
 
3.3 Measurement and methodology errors 
 
The validity of the measuring instrument is the measure of the extent to which 
the instrument measures what it is supposed to measure (Leedy and Ormrod, 
2005, Maree, 2012).  Reliability is the consistency of a measuring instrument 
to deliver a specific result (2005).  The following important factors were 
considered to minimise possible measurement and methodology errors 
during the collection of data. 
 
3.3.1  Interviews with coaches 
 
A structured interview (Appendix K) was compiled because unstructured 
interviews require exceptional skills and experience (Leedy and Ormrod 
2005).    Leading interview questions were avoided in order to ensure an 
insightful interview (Shank in Leedy and Ormrod 2005).   
 
 42 
A pilot study was carried out on one of the coaches at the UFS identified for 
possible inclusion in the study (refer to 3.2.7.1).  The same researcher 
interviewed all five respondents involved in the main study as well as the one 
respondent involved in the pilot study.  Sufficient time was allowed for the 
respondents to participate in the interview.  The transcriptions were presented 
to the respondents for approval immediately after completion of the 
interviews.   
 
Coaches were interviewed during May to October 2016.  The same 
researcher interviewed all the respondents in this study.  Interviews took place 
in similar quiet conditions with as minimal as possible distractions.  The 
researcher gave the same guidance regarding the questions to all the 
respondents, but was willing to explain any aspect about the question that 
was not clear to the respondent. 
 
Sufficient time was allowed for the interviews with the coaches to ensure that 
respondents did not feel rushed to answer the questions (Gillham 2000).  
From the pilot study it was confirmed that 30 minutes was sufficient to allow 
respondents to answer all the questions in the interview.  It was decided to 
allow at least 60 minutes for the interview to ensure that the respondents were 
relaxed during the interview.   
 
Lastly, approval was obtained for the use of the structured questionnaire for 
the interview, from the Department of Biostatistics, the School for Allied 
Health Professions Evaluation Committee and the Health Sciences Research 
Ethics Committee of the UFS (Appendices D, E and F). 
 
3.3.2  Athletes - SMS-II and data sheet 
 
Pretests were carried out on six athletes from the UFS athletics club during 
the last week of March 2016.  No changes to the measuring instrument were 
necessary.   Approval for the use of the adapted version of the revised SMS-
II as well as the data sheet was obtained from the Department of Biostatistics, 
 43 
the School for Allied Health Professions Evalution Committee and the Health 
Sciences Research Ethics Committee of the UFS (Appendices D, E and F).   
   
Sufficient time was arranged for the respondents to answer the 15 items of 
the SMS-II and to complete the data sheet.  The researcher was available 
during the completion of the SMS-II and the data sheet in order to clarify any 
queries from the respondents.  The adapted revised version of the SMS-II 
was available in Afrikaans and English to allow for personal preference 
regarding the two languages. 
 
According to Pelletier et al. (2013) researchers recently questioned some of 
the item contents and psychometric properties of the SMS.  As described in 
2.7.2 the revised version of the scale (SMS-II) that consists of 18 items was 
compiled to measure the motivation for sport participation.  The revised 
version was used for this study.  Similar adaptations to those used by  Podlog 
and Eklund (2005) to the SMS, were applied to the SMS-II to ascertain 
athletes’ motivations to RTS after an injury.  Similar information needed to be 
obtained in this study by means of the adapted SMS-II (refer to 3.2.5.2.1).  
The original SMS had a good reliability and construct validity (refer to 2.7.1).  
The SMS-II was examined and the different subscales performed equally, if 
not better than the original SMS (Pelletier et al. 2013).  The reliability of the 
SMS-II was further increased by emphasising the importance of honest 
replies by the respondents, in order to prevent guessing that can influence 
the reliability of the instrument (Leedy and Ormrod 2005).   
 
From the pilot study it was clear that 20 minutes was sufficient for respondents 
to complete the SMS-II as well as the data sheet.  The respondents were 
requested to prepare for approximately 30 minutes to complete the SMS-II 
and the data sheet. 
  
In order to limit the fall-out of respondents, a minimum number of people was 
used to engage with the respondents.  The researcher contacted the two 
people responsible for entries at athletics meets in order to identify 
 44 
participants for the study and personally contacted each respondent during 
the study. 
 
The physiotherapist who treated the participants provided clearance for RTS 
and a medical diagnosis for the injuries that the athletes had before RTS. 
Obtaining this information from a medical professional increased the reliability 
of the diagnosis of the athlete.  It also improved the validity of the data on the 
injury of the athlete who is about to RTS, as the diagnosis was provided by 
the same medical professional who treated the athlete and cleared the athlete 
for RTS.   
 
3.4  Data handling and analysis 
 
Contributing to the validity and reliability of the results, the coding of the SMS-
II, data sheets and the interviews was attended to by the researcher according 
to the instructions of the Department Biostatistics at the UFS.  The coding was 
checked by the researcher for possible errors.  The data was entered and re-
entered on a Microsoft Excel spreadsheet according to the instructions of the 
Department of Biostatistics. 
 
The statistical processing of data was done by the Department of Biostatistics 
at the University of the Free State, using SASS software.  Descriptive 
statistics, namely averages and standard deviations of medians and 
percentiles for continuous variables, and frequencies and percentages for 
categorical variables were calculated.  The Kruskal-Wallis test and Wilcoxon 
two sample test were used to compare the type of motivation of athletes with 
the re-injury of athletes.      
 
3.5  Ethical aspects 
 
Soanes and Stevenson (2004) define ethics as the moral principles governing 
or influencing conduct.  According to Punch (2000), a good study incorporates 
ethical aspects that might be relevant to the study.  The researcher then has 
to reveal how these aspects were anticipated and dealt with. 
 45 
 
The proposal for this study was handed in at the Research Evaluation 
Committee of the School for Allied Health Professions of the UFS.  Permission 
to continue with the study was granted (Appendix D) and recommendations 
by the committee were incorporated into the final proposal that was presented 
to the Health Sciences Research Ethics Committee of the UFS.  Approval to 
start with the study was granted (Appendix E).  
 
Creswell and Clarke (2011) advises obtaining permission from possible 
gatekeepers to information after ethical clearance.  This may include 
individuals who are in charge of sites, people who provide information and 
campus-based institutional review boards.  Approval for the execution of the 
pilot study on athletic coaches of the UFS was also obtained from Head of 
Sport at the UFS (Appendix A), Director Student Life - UFS and Vice-Rector: 
Research (Appendix C).  Approval for execution of the study on coaches and 
athletes registered with AFS was obtained from the General Manager of AFS 
(Appendix B).   
 
3.5.1  Ethical aspects with regards to the SMS-II and data sheet 
 
According to Leedy and Ormrod (2005) participation in any study should be 
voluntary.  Babbie (2007) suggests obtaining consent from each individual 
participating in the study.  Babbie (2007) also states that the fundamental 
ethical rule is that there must be no harm for the respondents. 
 
Participants were therefore informed that they could withdraw from the study 
at any time and that their confidentiality would be guaranteed at all times.  An 
informed consent form (Appendices G and J) was required from each of the 
participants (refer to 3.2.6.1 and 3.2.6.2).  This form was compiled according 
to the guidelines described by Leedy and Ormrod (2005:102). This informed 
the participant about the aim of the study and also what participation in the 
study involved.  No names were required on the numbered data sheets 
(Appendix I) or the uniquely numbered data sheets (Appendices H and K).  
No contact information appeared on the data sheets.  The participants were 
 46 
notified that no renumeration would be awarded for participation in the study.  
No costs were involved for the participants. 
 
The physiotherapist who cleared a possible participant for RTS was also 
required to sign the letter of consent (Appendix G) of the specific athlete for 
inclusion in the study.  
 
The researcher’s contact information was provided to the respondents in the 
event of any possible further enquiries about the study and/or the results of 
the study. 
 
3.5.2  Ethical aspects with regards to the interviews 
 
Confidentiality is explained by Babbie (2007) as a guarantee by the 
researcher that responses will be identified only by the researcher and not by 
the public.  Participants in the interviews were guaranteed  confidentiality.  
Respondents were not forced to participate in the study and they were 
informed that they could withdraw from the interview and study at any stage 
(Babbie 2005).  Each one of the respondents was expected to sign an 
informed consent letter (Appendix J).  Manson and O’Neill (2007) warns that 
research without the consent of the respondent is likely to breach ethical 
norms.  The researcher especially ensured that no questions that could cause 
personal damage to the respondents were asked, for example questions that 
could cause the coach to feel responsible for athletes who RTS too soon 
(Babbie 2005).   Anonymity was also guaranteed with the dissemination of 
the information, in order to make the respondents feel even safer to participate 
in the study.    
 
Contact information of the researcher was provided should participants have  
any questions relating to the study or the results of the study.   
 
 
 
 47 
3.6  Conclusion 
 
In this chapter all the aspects regarding the research methodology pertaining 
to this study were discussed.  The processes used to gather information from 
coaches, physiotherapists and athletes regarding motivational aspects of 
RTS and re-injury were discussed here.  The results obtained from this study 
are discussed in detail in chapter 4.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 48 
Chapter 4  
RESULTS 
 
 
4.1 Introduction 
 
In this chapter the results obtained form this study are explained in detail.  The 
results obtained from the structured interviews with coaches (Appendix K) as 
well as the results obtained from the adapted SMS-II and data sheets 
(Appendices H and I) will be presented separately. 
 
4.2 Results from the interviews with coaches 
 
The results of the structured interviews are discussed according to the order 
of the questions in the structured interview namely: 
i. general coaching experience and involvement 
ii. coaches’ expectations of physiotherapists 
iii. referrals and 
iv. identifying the need for motivation to be considered before an athlete 
is cleared for RTS. 
 
4.2.1 General coaching experience and involvement 
 
Three male and three female coaches were interviewed.  These coaches 
registered with AFS, were identified for inclusion - as explained in 3.2.2.1.  
The coach with the least amount of coaching experience had 15 years’ 
experience compared to the coach with the most experience, who had 48 
years’ coaching experience.  The mean years of experience was 26.3 with a 
standard deviation (SD) of 12.4 years.  All six coaches considered themselves 
more involved with coaching track and field than any other sport.  Only one 
coach was also involved in coaching cross country and one coach was 
involved in coaching biathlon, triathlon and biathle. 
 
 49 
Some of the coaches had experience in more than one specialist area but all 
six of them had experience in all five specialist areas of track and field.  The 
collective experience of the coaches is presented in Figure 4.1. 
 
Figure 4.1 Representation of the coaches' coaching experience in 
years in the different specialist areas in track and field (n=6). 
 
Only one coach had experience in coaching the jumps for 10 years, but three 
of these coaches had experience in coaching sprints, with a total of 78 years 
of coaching experience between these three coaches.  Three of the coaches 
had experience in coaching middle and long distances, two coaches had 
experience in coaching throws and two, in coaching the hurdles events. 
 
As explained in 2.2.2 and 2.2.3, athletes can represent their province in five 
different age groups but their country, in only three of these five age groups.   
The coaches had athletes in their training groups across the age groups and 
some of these athletes represented South Africa.  The distribution of the age 
groups and provincial and national representation during the 2014/2015 
season in the coaches’ training groups are presented in Table 4.1.  Four of 
the coaches coached senior athletes who represented the country at 
international events during the 2014/2015 season.  All six coaches coached 
 50 
senior athletes who represented their province at national events in track and 
field during the previous season (2014/2015).  Five of the coaches had junior 
athletes who represented their province at national events, in their training 
groups and only one of the coaches had an athlete in the youth category, who 
represented the country at international events.   
  
Table 4.1 Representation of the age group distribution and team 
representation of the athletes coached by the coaches (n=6) during 
the 2014/2015 season. 
Age Groups Provincial National 
Sub youth 4  
Youth 4 1 
Junior 5 2 
Under 23 5  
Senior 6 4 
 
 
 
4.2.2 Coaches’ expectations of physiotherapists 
 
When asked who was responsible for most of the decisions regarding RTS of 
athletes in their training groups, most of the respondents (three) indicated that 
physiotherapists were more often responsible for RTS decisions compared to 
sport doctors (see figure 4.2).  The blue colours used in figure 4.2 represent 
parties that were responsible for most of the RTS decisions for athletes while 
the red colours represent parties that were never involved in RTS for athletes 
in the training squads of the involved coaches.  This was represented on a 
continuum from 1 to 9 and a gradual change from blue to green to red.  Two 
of the respondents preferred sport doctors to make RTS decisions and one of 
the coaches preferred him/herself to make the RTS decisions.   
 
Teachers or the persons in charge of athletics at the school or club and 
parents or guardians of the athlete were the least likely to make RTS 
decisions at the six respondents’ training groups.  Two respondents preferred 
 51 
that teachers or the persons in charge of athletics at the school or club make 
no RTS decisions at their training groups and another three respondents 
indicated that they should make the least number of RTS decisions at their 
training groups.  Two respondents indicated that parents or guardians should 
not have a say in RTS decisions at their training groups, but one of the 
respondents did value the RTS decisions of parents, allocating a third position 
to parents or guardians as regards RTS decisions. 
         
Individuals who are preferred by coaches to make 
RTS-decisions in their training groups (n=6)
1 1 1 1 1 1
2 2
1 1
2 2
3 3 1 1
3 1 3
2
3 1 3 1
2
1 1 1 1 1
Preferred to make RTS decisions 2 3 4 5 6 7 8 Never make RTS-decisions
 
Figure 4.2 Individuals who are preferred by coaches to make RTS-
decisions in their training groups (n=6). 
 
From Figure 4.3 it is clear that most of the respondents would prefer to have 
a physiotherapist, a sport doctor and the coach present when an athlete is 
injured during a competition and a decision needs to be made about the 
continuation of participation of the specific athlete.  One of the respondents 
would also like to include the parent/guardian in this decision. 
 
 52 
Coaches prefer to involve these persons in on the 
field decisions regarding the continuation of 
participation when the athlete is injured (n=6).
5 4
1
6
Coach Parents/guardians Physiotherapist Sport doctor
 
Figure 4.3 Coaches prefer to involve these persons in on the field 
decisions regarding the continuation of participation when the athlete 
is injured (n=6). 
 
In Table 4.2 the expectations of coaches of a physiotherapist who treats one 
of their athletes are represented. All six respondents expected 
physiotherapists who treat their athletes to identify possible areas that may 
lead to injuries during the season.  One of the coaches mentioned that if these 
areas could be communicated to the coach, the coach could adapt his/her 
training programme in order to prevent injuries. 
 53 
Table 4.2 Coaches’ expectations of a physiotherapist treating one 
of their athletes (n=6). 
 Yes No 
To evaluate athletes in the pre-season to identify possible 
6 0 
areas that may lead to injuries during the season.   
To decide when the athlete is ready to return to training. 6 0 
To at all cost prevent the athlete from returning to sport if 
there is even the slightest possibility that the injury can 6 0 
worsen.   
To provide advice about the handling of the athlete during 
training sessions in order to prepare the athlete for return 6 0 
to participation in sport. 
To decide when the athlete is ready to return to 
5 1 
participation in sport. 
To provide advice on how to prevent the athlete from 
6 0 
suffering similar injuries in future. 
To use the necessary modalities (e.g. strapping), to assist 
5 1 
athletes with minor injuries to participate in sport. 
To evaluate whether an athlete is not only physically 
5 1 
ready, but also psychologically ready to return to sport. 
To determine what the motivation for the athlete is to 
return to sport. In other words, is it really the athlete who 6 0 
wants to return to sport? 
 
 
All the respondents indicated that they expected the physiotherapist to decide 
when the athlete is ready to return to training.  They also expected the 
physiotherapist to at all cost prevent the athlete from RTS if there was even 
the slightest possibility that the injury could worsen.  One of the respondents 
did remark that this decision should be made in conjunction with the athlete’s 
biokineticist. All six the coaches expected the physiotherapist to provide 
advice about the handling of the athlete during training sessions in order to 
prepare the athlete for return to participation in sport. One of the respondents 
 54 
also expected the physiotherapist to guide the coach with suggestions about 
the intensity at which the athlete could safely train.  Five of the respondents 
indicated that they expected the physiotherapist to decide when the athlete 
was ready to return to participation in sport.  One of these respondents did 
mention that this decision should be taken consulting with the coach and 
another explained that he/she would expect this only if the physiotherapist 
had a keen interest in track and field. 
 
All the respondents expected the physiotherapist to provide advice on how to 
prevent the athlete from suffering similar injuries in future.  One of the 
respondents stated that they expected the physiotherapist to identify and also 
treat the cause of the injury and not only the symptoms of the injury.  Five of 
the respondents expected the physiotherapist to use the necessary modalities 
(e.g. strapping) to assist athletes with minor injuries to particpate in sport.  
One of the respondents stated that these modalities should be applied only if 
it would not be risky for the athlete to compete.  The coach who did not expect 
the physiotherapist to use strapping, stated that an athlete who needs 
strapping to compete should not compete at all. 
 
Five of the respondents expected the physiotherapist to evaluate whether an 
athlete was also psychologically ready for RTS and the sixth respondent said 
that he/she did not expect it from the physiotherapist, but that it would be of 
great help if the physiotherapist were able to disclose that information.  One 
of the coaches mentioned that the physiotherapist would be better equipped 
and experienced than a coach to evaluate whether the athlete was hiding any 
injuries.  All six coaches expected the physiotherapist to determine what the 
motivation for the athlete was to RTS.  Two of the coaches reasoned that the 
athletes might disclose to their physiotherapists if they felt pressured to RTS 
due to pressure from their parents and/or sponsors. 
 
 
 
 
 55 
4.2.3 Referrals 
 
The respondents were asked to which professionals they would refer athletes 
with specific complaints.  There responses are illustrated in Figure 4.4.  More 
respondents prefered to refer athletes to a physiotherapist if they had 
complaints or injuries to their muscles, joints or ligaments.  Sport doctors were 
the only other first-line practitioners mentioned for referrals for these 
complaints.  Equal amounts of respondents preferred to refer athletes to sport 
doctors and physiotherapists when the athletes had nerve related injuries or 
complaints.  Five of the respondents preferred to refer their athletes to a 
psychologist or sport psychologist if they struggled with motivation, but the 
sixth respondent mentioned that he/she would rather refer the athlete to 
another athlete who had previously struggled with the same problem.  
 
 
Figure 4.4 Coaches’ referral of athletes with specific complaints (n=6). 
 
4.2.4 Identifying the need for motivation to be considered before 
an athlete is cleared for RTS 
 
Motivational factors that can influence decisions regarding RTS are discussed 
in 2.6.3.  The responses concerning the importance of these factors in 
decisions regarding RTS according to the respondents are illustrated in 
Figure 4.5. 
 56 
Importance of factors that can influence 
RTS decisions (n=6)
6
5
4
3
2
1
0
Timing  and Pressure from Conflict of Fear of litigation External Masking the
season athlete interest pressure injury
most important 2 3 4 5 6 not applicable
 
Figure 4.5 Importance of factors that can influence RTS decisions 
(n=6). 
 
Five of the respondents considered timing and season as the most important 
factor that can influence RTS decisions.  Pressure from the athlete was 
indicated as the second most important factor that could influence RTS 
decisions, with one respondent indicating it as the most important, two 
respondents placing it second and two respondents placing it third.  
 
Masking the injury and external pressure were the least important factors, 
according to the respondents.  Four of the respondents indicated that they 
would not consider masking injuries with, for example, analgesics and they 
chose to describe this factor as ‘not applicable’.  Three respondents each 
decided to allocate ‘not applicable’ to fear of litigation and external pressure. 
 
All six of the respondents indicated that they were of the opinion that their elite 
athletes often return to participation in sport too soon due to pressure from 
persons, sponsors or institutions.  All six respondents also indicated that a 
recommendation regarding the type of motivation of an athlete to RTS will 
always be of value to them, as coaches.  The respondents motivated their 
answer with statements like “because it would be in the best interest of the 
 57 
athlete”, “teamwork is important in managing an elite athlete” and “you always 
try to do the best for your athlete”.   
 
4.3 Results from the adapted SMS-II and data sheets 
 
The results of the athletes will be discussed in the following order: 
i. General and demographic information about the athletes (Appendix I) 
ii. Diagnostic and RTS information about the participants (Appendix I) 
iii. Type of motivation of the athletes (Appendix H and I) 
iv. Re-injury of the athletes (Appendix I). 
 
4.3.1 General and demographic information about the athletes 
 
Forty percent of the participants in the study were female and 60% were male.  
All participants were between the ages of 18 and 25 on the date that they 
entered the study, with the mean age of the respondents 20,67 years with a 
SD of 2,05. 
 
The participants had to indicate to which specialised event(s) they were about 
to return to and intended to compete in for the remainder of the season.  The 
participants indicated anything from one to three different specialised events 
and the number of athletes per specialised event is illustrated in Figure 4.6.   
 58 
 
Figure 4.6 The specialist events in which the athletes who returned to 
sport intended to compete for the remainder of the season (n=15). 
   
 
Eight athletes intended to return to the sprint events, five to middle and long 
distances, three to the jumps, two to the throws and two to the hurdle events.  
Sixty-seven percent of the participants were provincial athletes and 33, 3% of 
the participants were national athletes and represented the country during the 
2014/2015 season.  The athletes competed in track and field, on average for 
10.07 years (SD of 3.63). 
 
4.3.2 Diagnostic and RTS information about the participants 
 
The diagnoses of the participants were provided by the physiotherapists who 
treated the patients before RTS (illustrated in Figure 4.7).  Four participants 
were diagnosed with grade 1 biceps femoris muscle strains and two of the 
participants were diagnosed with grade 1 adductor magnus muscle strains.  
All the other participants had unique different diagnoses.   
 59 
FIGURE 4.7 DIAGNOSES BEFORE RTS (N=15)
Anterior talo-fibular ligament sprain Gr I
Achilles tendinopathy
Medial Tibial Periostitis 11
1 Serratus posterior inferior strain
1
Gastrocnemius strain Gr II
1 Lumbar muscle spasm
Adductor Magnus 1
strain Gr I
2
Quadriceps strain Gr I
1
Biceps femoris strain Gr I
4
Biceps femoris 
Biceps femoris strain 
tendinopathy
Gr II
1
1  
Figure 4.7 Diagnoses before RTS (n=15). 
 
 
Both of the participants who returned to the throw events had injuries of the 
upper body.  Sixty three percent (n = 5) of the participants who returned to 
the sprint events had hamstring injuries.  The participants who returned to 
the jumps were treated for tendon and ligament injuries of the lower limb 
and one of the participants was treated for a hamstring strain.  Forty percent 
(n = 2) of the participants who returned to the middle and longer distances 
were treated for overuse injuries of the distal lower limb.  
 
The participants were treated for their injuries between two and 32 weeks 
before RTS with the median value, six weeks.  Seventy three percent (n = 11) 
of the participants were previously treated for similar types of injuries.  
 
4.3.3 Type of motivation of the athletes (Appendix H and I) 
 
Eighty percent of the participants mentioned that they themselves, together 
with their coaches, were responsible for the final decision to return to 
participation in track and field.  All fifteen of the athletes were recipients of 
bursaries from the UFS and two of these athletes had further contracts with 
companies who provided further sponsorships.  When asked if there was 
external pressure to return to participation, only one of the athletes mentioned 
 60 
that his/her parents pressured him/her to RTS, three of the athletes were 
pressured by their coaches to RTS and only one felt that the university 
pressured them to RTS.   
 
 
Figure 4.8 Mean scores by the athletes on each type of motivation 
tested by the adapted SMS-II (n=15). 
 
 
Represented in Figure 4.8 are the mean scores for the different types of 
motivation of the athletes before RTS.  Athletes can obtain a maximum of 21 
for each type of motivation.   
 
The population tested high on integrated (average 18, 80 and SD of 1, 47), 
identified (average 18, 27 and SD of 1, 98) and intrinsic (average 18, 20 and 
SD of 2, 34) motivation.  The population, however, tested lower on introjected 
(average 15, 13 and SD of 3, 93) and the lowest on external (average 10, 07 
and SD of 3, 33) motivation.  The respondents scored lowest for external 
motivation and the maximum score for the respondents’ external motivation 
was 14.  The respondents tested highest on integrated motivation and the 
minimum score for the respondents’ integrated motivation was 17.  These 
results indicate that athletes mainly had motivation for RTS that can be 
perceived as internal (see figure 2.7).       
 61 
 
4.3.4 Re-injury of the athletes (Appendix I). 
 
Forty-seven percent of the respondents in this study were re-injured within 
the first three months after RTS.  The time of re-injury and the nature of the 
injuries are represented in Table 4.3.   
 
Table 4.3 The time after RTS for re-injury to occur for seven of the 
respondents and the nature of this re-injury (n=15). 
 Nature of injury 
Time when re-injury Identical New New but 
occurred related 
First First week 1   
month Second 
1 1  
week 
Third week   1 
Fourth 
 1  
week 
Second  
   
month 
Third  
2   
month 
 
 
Five of the respondents were re-injured within the first four weeks after RTS.  
Two of these respondents experienced new injuries that could not be linked 
to the injury before RTS.  One of the athletes that returned to the throw events, 
one athlete that returned to the hurdles events, two athletes that returned to 
the sprint events and one athlete that returned to a jump event were re-injured 
within the first four weeks of RTS.   None of the athletes were re-injured during 
the second month after RTS.  Two of the respondents had a successful RTS 
but reported injuries identical to before RTS, three months after RTS.  This 
will be further discussed in 5.3.3.   
 
Similar mean values for the adapted SMS-II scores for the different types of 
motivation were obtained from the respondents who were re-injured, 
compared to those who were re-injured as represented in Figure 4.10.  
 62 
Respondents with injuries had higher mean values for all five types of 
motivation.  The difference in mean values (mean value for athletes who were 
not re-injured subtracted from the mean value for athletes who were re-
injured) for externally motivated (2.29) and introjected motivation (2.16) were 
greater than the difference for identified (0, 30), integrated (0, 64) and intrinsic 
motivation (0, 16).    
 
 
Figure 4.9 The mean adapted SMS-II scores for the different types of 
motivation for respondents who had no re-injury compared to 
respondents who were reinjured (n=15). 
 
 
 63 
The statistical meaning of these scores for the types of motivation for 
respondents with no re-injuries compared to those with re-injuries, are 
represented in table 4.4.  The p-values ranged between 0, 1368 and 1,000 
and no statistical significant differences (p<0.05) were found. 
Table 4.4 The p-values for the different types of motivation of 
respondents with no re-injury compared to respondents with re-
injury after 1, 2 and 3 weeks and 3 months. 
Type of p - value 
motivation 1 week 2 weeks 3 weeks 3 months 
External 0,1607 0,9266 1,000 0,1986 
Introjected 0,9072 0,9267 0,4642 0,4145 
Identified 0,2390 0,6422 0,1368 1,0000 
Integrated 0,1744 0,7682 0,7548 0,2170 
Intrinsic 0,7251 0,7811 0,1869 0,8147 
 
 
In conclusion the main findings in this chapter were that all the coaches 
expressed a need for the type of motivation of an athlete for RTS to be 
considered by physiotherapists during RTS-decisions. According to the 
coaches the timing and season were considered the most important factors 
that could influence RTS-decisions and pressure from the athlete, the second 
most important factor.  Athletes with extrinsic motivation can therefore apply 
sufficient pressure on coaches during the correct time of the season and 
consequently, modify RTS-decisions.   The elite athletes who were part of this 
study, scored higher on the types of motivation that can be perceived as 
internal motivation.  Athletes who were re-injured, however, compared to 
athletes who were not re-injured, scored higher on the types of motivation that 
can be perceived as external types of motivation.   These differences had no 
statistical significance and can merely be considered a possible trend.  An in-
depth discussion of these results and the relevance of these results are 
discussed in the following chapter.  
 
 
 
 64 
Chapter 5  
DISCUSSION, LIMITATIONS AND RECOMMENDATIONS 
 
 
5.1 Introduction 
 
The results of Return to Sport after Injury:  The relationship between an 
athlete’s type of motivation and a recurrence of injury is discussed in a similar 
order to the presentation of the results in chapter 4.  The type of motivation of 
an athlete to RTS to be considered, is followed by a comparison discussion 
of the type of motivation of elite athletes to RTS and the outcome of their RTS 
regarding re-injury (refer to Figure 5.1). 
 
 
Figure 5.1 Integration of aims and objectives 
 
Possible reasons for the results are discussed and the limitations identified 
during the execution of this study are also highlighted.  Further 
recommendations are made based on the results in chapter 4 as well as the 
findings from the literature study (Chapter 2).   
 
5.2 Interviews with coaches  
 
The athlete’s training and performance is the direct responsibility of the coach 
(Brukner and Kahn 2008).  Due to this responsibility and the relationship 
between a coach, the physiotherapist and the athlete (refer to Figure 2.2) it is 
imperative to consider the coaches’ views on motivation in this study.  It was 
mentioned in 3.2.2 that six coaches were included in the study.  These six 
 65 
experienced coaches have coached elite provincial and national athletes, 
representing all the different specialist areas in track and field during the 
2014/2015 season (refer to Figure 4.1).   
 
5.2.1 Variables that could have influenced the results from the 
interviews with the coaches 
 
All the respondents had experience in coaching track and field events, with 
the years of coaching experience ranging between 15 and 48 years.  Most of 
the respondents focussed all their coaching attention on track and field with 
only one of them also coaching cross country and another also coaching 
biathlon, triathlon and biathle.  
 
All six respondents had junior and senior provincial and national athletes in 
their training groups (see table 4.1) that corresponded with the population of 
athletes included in the second part of the study (compare 3.2.2.2 and 2.2.2).  
The respondents were therefore experienced and coached track and field 
athletes of similar age groups to the athletes involved in the second part of 
the study.    
 
5.2.2 The coach, the athlete and the physiotherapist 
 
The relationship and trust between a coach, physiotherapist and athlete are 
represented by Figure 2.2.  Trust and communication between these three 
involved parties were explained in 2.3.1.  Similar to the literature discussed in 
2.3.1, most of the decisions regarding RTS in the training groups of the 
respondents were made by physiotherapists (see Figure 4.2).   
 
As mentioned in 2.3.1.2, physiotherapists in Bloemfontein are involved in 
inter-disciplinary teams that make RTS decisions as part of teams but also 
have the authority to make these decisions independently (Erasmus et al. 
2014).  From the literature it is clear that coaches trust physiotherapists to 
make RTS decisions independently (see 2.3.1.2).  The coaches further 
mentioned the importance of the involvement of sport doctors and the 
 66 
coaches themselves as participants in decision-making regarding RTS 
(4.2.2).   Podlog and Eklund (2007) identified the need and benefits of an on-
site physiotherapist as concerns RTS.  This may include advice and guidance 
to athletes training under their coaches.   Hayden and Lynch (2011) supported 
a close relationship between the physiotherapist and coach and also 
explained that the physiotherapist can assist the coach to better communicate 
with the athlete by providing information acquired from the athlete during a 
session.  Podlog and Eklund (2007) did, however, warn against possible 
conflicting roles and ethical considerations and suggested further research on 
how these conflicts should be handled.  Erasmus et al. (2014) established 
that physiotherapists, biokineticists and sport doctors are the main 
professionals involved in RTS decisions in Bloemfontein (refer to 2.3.1).  
  
Most of the coaches (83%) did not value the input of parents and guardians 
as one of the three top involved parties in these decisions, however, one of 
the respondents did include parents and guardians in decisions regarding 
RTS.  The general response of the coaches to disregard parents and 
guardians in RTS decisions might be due to the composition of the training 
groups that included elite junior and senior athletes (see table 4.1) who were 
older than 18 years.  Subsequently, the parents and guardians were not as 
much involved with the athletes’ decisions compared to those of younger 
athletes.  Most of these athletes were independent students at the UFS and 
boarded in Bloemfontein, away from their support system at home.  This was 
also highlighted by the low mean scores on external regulated (average 10, 
07 and SD of 3, 33) and introjected regulated motivation (average 15, 13 and 
SD of 3, 93) of the respondents in the second part of the research study (see 
figure 4.9).   
 
5.2.2.1 Decisions regarding continuation of participation 
 
Respondents indicated that they would prefer to have a physiotherapist, a 
sport doctor and the coach present when an athlete is injured during a 
competition and a decision needs to be made about the continuation of 
participation of that specific athlete.  This is the ideal composition expressed 
 67 
by the respondents but might not be possible at all competitions due to 
financial implications.  Coaches regard themselves as key participants in 
decisions regarding RTS when an athlete is injured during a competition, but 
also when an athlete RTS following an injury (refer to figures 4.2 and 4.3).  
National and international championships are organised with medical staff 
available at the competition stadia, but this is not the case for provincial and 
local competitions where the prerequisite is that first aid and emergency care 
is available and not necessarily medical professionals that can assist with 
diagnosis (IAAF 2015).  Coaches often have to make on the field RTS 
decisions regarding their athletes when only first aid is available.        
 
5.2.2.2 Coaches’ expectations from physiotherapists  
 
Medical clearance from the doctor or physiotherapist is the main expectation 
from coaches of various sport codes identified by Podlog and Eklund (2007).  
Similar results were obtained for track and field coaches in this study and all 
six respondents indicated that they expected the physiotherapist to prevent 
an athlete from RTS at all cost if there is even the slightest possibility that the 
injury can worsen (refer to Table 4.2).   A coach was quoted in Podlog and 
Eklund (2007):  “...ultimately, we are bound by the professional decisions of 
the physio or the doctor. If the physio says don’t do something and the 
coaches feel we can do it, then we [still] can’t do it”.   
 
Respondents indicated that they expected physiotherapists to evaluate 
athletes in the pre-season to identify possible areas that may lead to injuries 
during the season.  Brukner and Kahn (2008) advise physiotherapists to base 
their approach on a model of potential causative factors for injury.  They 
explain that the systematic model considers the multifactorial nature of sport 
injuries as well as the time sequence of events leading up to the injury.  They 
advise that this type of analysis helps to identify possible areas that may lead 
to injuries during the season, in collaboration with the coach and the athlete, 
and to create a plan to implement preventative measures in order to prevent 
injuries.  One of the respondents in this study mentioned that if these areas 
 68 
can be communicated to the coach, the coach can adapt his/her training 
programme in order to prevent injuries (refer to 4.2.2). 
 
All the coaches (n=6) expected physiotherapists to advise coaches on when 
an athlete is ready to return to training, but also to advise the coach on the 
handling of the athlete in order to prepare the athlete for return to competition.  
As mentioned in 5.2.2, this need may be addressed with an on-site 
physiotherapist who can be actively involved with the coach in the training of 
injured athletes in order to prepare them for RTS.  The presence of an on-site 
physiotherapist and the accompanying conflicting roles are discussed in 5.2.2 
and need further research.  For an off-site physiotherapist, this need for 
advice by coaches also highlights the importance of effective and ongoing 
communication between the physiotherapist, the coach and the athlete.  The 
involvement of the physiotherapist should not stop when the patient leaves 
the treatment room to prepare for RTS under the supervision of the coach.  
The relationship mentioned in 5.2.2 and illustrated in figure 2.2 should ideally 
be a continuous relationship, even after successful RTS.  Five of the six 
respondents indicated that they expected physiotherapists to decide whether 
an athlete is ready for return to participation in sport.  This can only be 
accomplished if the physiotherapist is involved in continuous communication 
with the coach and the athlete, throughout preparation for return to 
participation.  Podlog and Eklund (2007) indicated that coaches consider the 
guidelines provided by physiotherapists regarding an athlete’s limitations and 
capabilities essential during the period of preparation for full RTS.  One of the 
coaches of this study further explained that it is important that the 
physiotherapist who provides the guidelines, should be an ex-athlete 
him/herself.  This was also one of the responses in the study of Podlog and 
Eklund (2007) and it was explained that a physiotherapist who competed in 
the same sport before, better understands the requirements for participation 
and return to the particular sport.  
 
All six respondents also indicated that they expected a physiotherapist to 
provide advice on how to prevent similar injuries in the future.  Similar to 
prevention of injuries discussed above, they also felt that prevention of re-
 69 
injury of an athlete should be a joint effort between the physiotherapist, the 
coach and the athlete (refer to 4.2.2). 
 
Five of the respondents expressed the need for physiotherapists to apply the 
necessary modalities in order to assist athletes with minor injuries, to 
compete.  The coach who did not express this need was of the opinion that 
an athlete who needed strapping or other modalities to safely compete, was 
not supposed to participate until he/she was completely free of injury (refer to 
4.2.2).  Buchberger (2012) is, however, of the opinion that most of the athletes 
competing at an Olympic Games are injured and mask the injuries with 
different modalities. 
 
Lastly, five of the respondents indicated that they expected a physiotherapist 
to evaluate whether an athlete is not only physically, but also psychologically 
ready to RTS. The sixth respondent indicated that he/she did not expect it 
from a physiotherapist, but that it would be an advantage if the physiotherapist 
were able to evaluate this.  All six the respondents indicated that they 
expected the physiotherapist to evaluate the athlete’s type of motivation for 
RTS.  One of the respondents pointed out that:  “...it would be easier for the 
physiotherapist to evaluate the real reason for the athlete to want to compete 
again, because the athlete can easily fool me [the coach]”.  Two of the 
respondents explained that the athletes might rather disclose to their 
physiotherapists if they feel pressured to RTS due to pressure from their 
parents and/or sponsors (refer to 4.2.2). 
 
5.2.2.3 Referrals 
 
Coaches and athletes should have easy referral access to a multidisciplinary 
team consisting of specific first-line medical professionals for various injuries.  
This may include sport doctors, physiotherapists, sport psychologists and 
dietitians (Le Roux 2005).  Russell and Tracey (2011) mentioned that both 
coaches and physiotherapists play an important role in the rehabilitation of 
both the physical as well as the psychological aspects of an injured athlete.  
As discussed in 2.3.1.1, Brukner and Kahn (2008) are of the opinion that with 
 70 
a good relationship between the physiotherapist and the coach, the coach will 
send athletes with minor complaints to the physiotherapist in order to prevent 
major problems.  The coaches in this study preferred to refer their athletes to 
a physiotherapist when they have complaints or injuries of their muscles, 
joints or ligaments (see figure 4.4).  The coaches did not indicate a clear 
favourite professional for nerve injuries and equal amounts of respondents 
indicated that they will refer athletes to either a sport doctor or a 
physiotherapist.   
 
Hayden and Lynch (2011) supported the importance of optimal relationships 
between physiotherapists and coaches and explained that physiotherapists 
would be in a better position to identify certain qualities of an injured athlete 
to contribute to other athletes in the training group, even while they are still 
injured and not ready for RTS.  Five of the six coaches preferred to refer their 
athletes to a psychologist or sport psychologist if they suffered with 
motivational problems but the sixth respondent indicated that he/she would 
refer the athlete to another athlete who had a similar experience and had 
successfully overcome the problem.  The coaches expected physiotherapists 
to evaluate the athletes’ psychological readiness to RTS (refer to 5.2.2.2) but 
did not consider referring an athlete to physiotherapists if they struggled with 
motivational problems.  Although motivational problems are not the primary 
focus for a physiotherapy session, identifying and addressing motivational 
problems can be an integral part of the holistic treatment of an injured athlete.  
Physiotherapists may be responsible for addressing motivational problems, 
but may not necessarily have the authority to do so (Matheson et al. 2011).  
Tracey (2008) explained that athletes saw their coaches and physiotherapists 
as an integral part of their emotional and psychological recovery after an 
injury.  Russell and Tracey (2011) did, however, identify a lack of literature on 
what an injured athlete expects from a physiotherapist regarding 
psychological support during rehabilitation of an injury.    
 
 71 
5.2.2.4 Identifying the need for motivation to be considered 
before an athlete is cleared for RTS 
 
Step 1 of the Decision-based RTS-model discussed in 2.6 is the evaluation of 
the health status of the athlete who is about to RTS.  Step 2 is the evaluation 
of the participation risk and step 3 is decision modification (refer to Figure 
2.3).  These factors that can influence and modify decisions regarding RTS 
are discussed in 2.6.3.  The responses about the importance of these factors 
in decisions regarding RTS according to the respondents are illustrated in 
Figure 4.5.   Five of the respondents considered timing and season as the 
most important factor that can influence RTS decisions.  In 2.2.2 the season 
of track and field in South Africa is explained in order to clarify why athletes 
can participate in more than one age group at different national 
championships.  This has an influence on the preparation of athletes and 
especially athletes returning from an injury, and who have to compete at top 
level at a number of consecutive meets in order to qualify for inclusion in 
various national teams (refer to 2.2.3).  Athletes preparing for international 
competitions might be under immense pressure to compete and perform at 
local national meets in order to qualify for inclusion in national teams that 
participate at international events.  This may be why respondents saw timing 
and season as the most important factor that can influence RTS decisions.  If 
the athlete does not compete, the athlete will not be included in these teams.  
If they compete and sustain minor injuries, they might qualify for a national 
team, with sufficient time to heal and RTS at one of the international events.  
Pressure from the athlete was the second most important factor identified in 
this study, that could influence RTS decisions.  This pressure from the athlete 
can be due to intrinsic or extrinsic factors explained in the SDT (refer to 2.7).  
An athlete who is dependent on the income from participation at international 
events might be more determined to RTS in order to earn an income, and 
may RTS too soon.     
This may explain why all six coaches indicated that they were of the opinion 
that their elite athletes often return to participation in sport too soon due to 
pressure from persons, sponsors or institutions.  As explained in 2.7, this 
behaviour can be described as externally motivated and is the least 
 72 
autonomous behaviour.  It is, however, interesting that none of the athletes 
who were injured during the second part of the study, scored high on external 
motivation (refer to Figure 4.8).  Most of these athletes were coached by the 
coaches from the first part of the study and it would be expected that this 
response from the coaches would predict at least some of the injured athletes 
to score high on external and/or introjected regulated motivation.     
 
From the existing literature discussed in 2.6.3 and research performed by 
Erasmus et al. (2014) on physiotherapists, it is clear that the need for more 
research on psychological factors as decision modifiers in the Decision-Based 
RTS model is necessary.  Matheson et al. (2011) concluded that there is a 
general lack of research on all three steps of the Decision-Based RTS model, 
and also speculated that the team physician should not be responsible for all 
three of these steps.  There is controversy especially about the person 
responsible person for step 3 (refer to 5.2.2.3).  According to Matheson et al. 
2011, currently the team physician may be responsible for step 3 but the 
physician may not have the authority to be responsible for step 3.  Matheson 
et al. (2011) subsequently suggested that more research is necessary on the 
current responsibilities and authorities of the responsible person in step 3 of 
the Decision-Based RTS-model.  From the results of this study discussed in 
4.2.4 it is clear that coaches communicated the need for the type of motivation 
of an athlete to RTS to be considered during RTS decisions.  From the 
discussion in 5.2.2.3 it is clear that 83% of the coaches preferred 
psychologists or sport psychologists to address the motivational problems of 
their athletes.  The coaches use motivations like “...because it would be in the 
best interest of the athlete...”, “...teamwork is important in managing an elite 
athlete...” and “...you always try to do the best for your athlete...”.   
 
5.3 The type of motivation of elite athletes returning to sport. 
 
All the athletes who participated in the study received bursaries from the UFS 
or incentives from other institutions in order to assist them with their expenses 
in track and field participation and training (refer to 4.3.3).   This implied that 
all the participants had factors that could be viewed as external motivation to 
 73 
perform in their sport.  Other factors that could have influenced the results of 
the elite athletes returning to sport are described below, followed by a critical 
discussion of the results on the type of motivation of the elite athletes to RTS 
and the recurrence of injury of these athletes. 
 
5.3.1 Variables that could have influenced the results of the elite 
athletes returning to sport. 
 
The mean age of the respondents was 20, 67 years with a SD of 2, 05. Injured 
athletes representing all the specialist events in track and field were involved 
in the study (refer to Figure 4.6).  All 15 of the athletes represented their 
province at national competitions and five of these athletes represented South 
Africa at international competitions during the 2014/2015 season.  These 
experienced and dedicated athletes competed in track and field on average 
for 10.07 years (SD = 3.63).    
 
Athletes presented with acute and chronic injuries of various body parts that 
prevented them from participation in at least one meet before RTS.  Throwers 
presented with injuries of the upper body, 63% of sprinters presented with 
hamstring injuries, jumpers presented mainly with tendon and ligament 
injuries and middle and long distance athletes mainly presented with overuse 
injuries of the distal lower limbs (refer to 4.3.2).  Seventy three percent of 
participants were treated for injuries similar to previous injuries. 
 
Injuries at a young age are known to have sequelae (refer to 2.4).  The high 
percentage of athletes (73%) that were treated for similar injuries to before 
could have been a reason for re-injury to occur, but it can be seen in the 
discussion in 5.3.3 below that there were no relevant implications for this 
study. 
 
All of these factors were considered in the planning of the study and the 
interpretation of the results.  The SMS-II is a newly developed tool to measure 
motivation.  Pelletier et al. (2013) expressed the need for the SMS-II to be 
tested on all ages to examine and confirm the stability of the structure of the 
 74 
SMS-II.  The youngest ages mentioned by Pelletier et al. (2013) was a study 
that confirmed the stability of the instrument for a mean age of 17.41 (SD = 
1.77).  The ages mentioned by Pelletier et al. (2013) and the age groups 
explained in 2.2.2 served as motivation for the researcher to exclude athletes 
who were younger than 18 years from the research study (refer to 3.2.4.2).   
 
Athletes from different specialised events or types of sport present with 
different types of injuries and the type of sport needs to be considered during 
the second step of the Decision-Based RTS model (refer to 2.6.2).  The 
specialised event(s) to which the athlete was about to return, was identified 
and the type of event was compared to the types of injuries that the athletes 
experienced (refer to 4.3.2).        
 
The respondents were experienced and dedicated athletes from the different 
specialised events in track and field.   
 
5.3.2 The type of motivation of athletes about to RTS 
 
Eighty percent (n=12) of the athletes indicated that they themselves, together 
with their coaches, usually had the final decision to return to participation in 
their respective track and field events (refer to 4.3.3).  All the respondents 
were cleared for RTS by a physiotherapist (refer to inclusion criteria at 
3.2.4.2).  This relates to the answers by the coaches that they expected 
physiotherapists to make the final decision regarding return to competition 
(refer to 5.2.2.2).  Physiotherapists in Bloemfontein also previously indicated 
that they were involved in interdisciplinary teams that make decisions 
regarding RTS (refer to 2.3.1.2), but the type of sport disciplines where these 
teams were involved, were not specifically mentioned in the study (Erasmus 
et al. 2014).   
 
On-site physiotherapists, as explained in 5.2.2, can be to the advantage of 
the coaches because the physiotherapist can assist and guide the coaches 
(a need expressed by coaches – refer to 5.2.2.2) with RTS of an injured 
athlete.  The roles of the coach and the physiotherapists must, however, be 
 75 
clearly described and ethical issues such as confidentiality need to be cleared 
in order to prevent tension in the ideal relationship between the 
physiotherapist, coach and athlete, as illustrated in Figure 2.2.  
 
Athletes involved in this study had an autonomous view on their RTS: even 
though they all had been cleared for RTS by a physiotherapist, they still felt 
that the final decision to RTS was their own, together with their coaches.  The 
possible conflicts of beneficence explained in 2.5 should be considered by the 
physiotherapist in making a RTS decision, but ultimately one should strive for 
autonomy of the athlete to decide if he/she is ready to RTS.    Dammyr (2011) 
explained that athletes should be nurtured in an environment that supports 
self-determined behaviour during training and competition.  He further 
explained that this environment can be influenced over time by coaches, 
parents, other athletes and supporting staff.  The respondents in this study 
also highlighted that very few of them felt pressured by external factors to 
RTS.  The sports medicine model illustrated in Figure 5.2 relates well with the 
experience of the athletes in this study as regards the athlete and coach who 
are centred in decisions concerning RTS, and different healthcare 
professionals who can influence the athlete and coach over time (Brukner and 
Kahn 2008).    
 
 
Figure 5.2 The sports medicine model (Brukner and Kahn 2008) 
 76 
 
The SDT and continuum of types of motivation are explained in 2.7.  The 
respondents in this study tested high on integrated, identified and intrinsic 
regulation.  The respondents, however, tested lower on introjected regulation 
and lowest on external regulation (refer to Figure 4.8).  All the respondents 
were representing similar types of motivation that leaned more towards the 
intrinsic type of motivation on the self-determination continuum illustrated in 
figure 2.7.  Identified regulation can be perceived as an internal motivation 
and RTS will be of personal importance to the respondent who tests high on 
this regulatory style.  Integrated regulation and intrinsic regulation can be 
viewed as internal motivation and intrinsic regulation of RTS because of the 
inherent satisfaction, interest and enjoyment of the sport (Ryan and Deci 
2000).  This is further evidence that the respondents did not feel pressured to 
RTS from external factors such as coaches, parents and the university or 
other sponsors - as explained above.       
 
5.3.3 Re-injury of athletes    
 
Proper healing of tissue helps to prevent re-injury of the specific tissue, but 
other factors that contribute to possible injury, such as biopsychosocial 
factors, also need to be addressed in order to have a successful RTS (refer 
to 2.4).  Timing and season was perceived by the coaches in this study as the 
most important factor that could influence RTS decisions (refer to 5.2.2.4).  
Timing and season was also considered as the most important factor that 
could influence RTS decisions by physiotherapists in Bloemfontein (refer to 
2.6.3) (Erasmus et al. 2014).   In the inclusion criteria (refer to 3.2.4.2) it was 
explained that all the athletes had to be cleared for RTS, but the level which 
these athletes had to return to was at national championship level (refer to 
2.2.2).  This could mean that athletes, besides from being physically ready, 
had to be mentally ready to have confidence in the physical abilities of the 
healed injury, to compete at elite level (refer to 2.4).   There was no time to 
gradually enter participation at less important meets to build confidence in 
their healing.  They had to return immediately to top level participation.  The 
view of the coaches explained in 5.2.2.4 and the lack of research expressed 
 77 
by Matheson et al. (2011) on the factors and components of the Decision-
Based model in 2.6.3, motivates for the influence of the competitive level of 
RTS entry to be more fully investigated.   
 
The athletes in this study (n = 15) were treated between 2 and 32 weeks 
before RTS (refer to 4.3.2).  Only one of the athletes received treatment for 
more than ten weeks and the rest of the athletes (n = 14) were treated 
between 2 and 10 weeks with a median value of 6 weeks.  Being separated 
from competition for 32 weeks could have an influence on the motivation of 
this one athlete to RTS, but none of the athletes had scores for type of 
motivation that were significantly different from other athletes (refer to 4.3.3) 
and this lengthy time for treatment did not seem to have an influence on the 
type of motivation to RTS.     
 
Seventy three percent of the participants were treated for similar injuries 
before (see 4.3.2).  As explained in 2.4, Marchi et al. (1999) found that 
permanent sequelae after sports injuries in specifically children and 
adolescents is high.  Sixty percent of their subjects still had sequelae 12 years 
after a sport injury incident.  This could also contribute to the 46, 67% (n=7) 
of athletes who were injured within three months after RTS (refer to 4.3.4).  A 
percentage of 13, 33% (n=2) of the respondents had new injuries after RTS 
that could not be linked to their previous injuries (refer to 4.3.4).  Thirty three 
percent of athletes were re-injured or had injuries that could be related to their 
injuries that they were treated for before RTS.  The athletes that were re-
injured could not be categorised to athletes participating in a specific event, 
nor did they represent athletes with a specific injury.  These athletes 
presented with re-injury that was identical to the original injury before RTS but 
also athletes who RTS, but experienced injuries that were not related to the 
injury before RTS.    
 
None of the athletes who returned to sport after injury were reinjured during 
the second month after RTS.  Most of the returning athletes (n = 12) did not 
compete internationally after RTS and completed their track and field season 
within one month of RTS.  Three of the athletes did continue with an 
 78 
international season and four of the five athletes that returned to middle and 
long distances (refer to figure 4.6) switched to cross country.  It is clear that 
the second month after RTS was a time of rest for the athletes that were 
finished with their track and field season and this explains that there were no 
athletes that were re-injured during the second month after RTS.    
 
As mentioned in 4.3.4, two of the injured athletes had a successful RTS but 
were re-injured three months after RTS.  Neither of these athletes were 
included in national teams to compete in international events during the 
current season (2015/2016).  Both of these athletes competed in middle and 
long distances.  Both of these athletes, however, switched from participation 
in the middle and long distances in track and field to cross country for the 
winter season.  They were injured in a different sporting code of athletics (refer 
to 2.2.1) and not in track and field.  Cross country has a different season to 
track and field and only starts when track and field finishes.  The distances for 
cross country are longer and the surfaces on which they compete are uneven.  
Coaches adjust training and the athletes have to run longer distances on 
uneven surfaces that can prepare them for competition.  Sudden adjustments 
to longer distances and the surface on which the athlete trains are factors that 
can cause injury (Brukner and Kahn 2008).  This could be the reason for the 
athletes’ successful RTS but re-injury with similar new injuries during their 
participation in cross country (refer to 2.4). 
 
As discussed in 4.3.4, similar mean values were obtained for the adapted 
SMS-II scores for the different types of motivation by athletes who had no re-
injury (n=8) compared to those who were re-injured (n=7).  Two of the three 
athletes who reported that they felt pressure from their coaches to RTS were 
re-injured, but these two athletes did not score higher on the external 
regulation and introjected regulation types of motivation, compared to the 
other athletes who were re-injured.  It is possible that the other athletes did 
not want to report that they felt pressure from their coaches, and that the 
scores from the measuring instrument revealed similar scores for those 
athletes who were re-injured and reported that they felt pressured by their 
coaches, compared to those who were re-injured but did not report that they 
 79 
felt pressured by their coaches.  It was surprising that respondents with 
injuries had higher mean values for all five types of motivation.  Although not 
statistically meaningful comparisons (refer to table 4.4), Figure 4.9 does 
illustrate a difference in the mean values of all five types of motivation for 
athletes who were re-injured compared to athletes who were not re-injured.  
External regulation and introjected regulation are the types of motivation that 
are perceived as the types of motivation with external causes on the self-
determination continuum and identified, integrated and intrinsic regulation are 
the types of motivation that are perceived to have more internal causes on 
the self-determination continuum (see figure 2.7).  Although the difference in 
the scores obtained by athletes who were re-injured within three months after 
RTS compared to athletes who were not re-injured represented a trend for 
higher scores for the respondents with external causes for motivation, 
compared to athletes with the more internal causes for motivation (refer to 
4.3.4) the difference had not statistical significance.   Hayden and Lynch 
(2011) explained that even if physical signs of an injury can be successfully 
treated, psychological signs often remain.  Athletes who are unable to 
manage these types of stressors can expect poor performance (Hayden and 
Lynch 2011).  As explained above, the athletes in this study had to return to 
top-level competition and poor performance was not an option for these 
athletes    
 
5.4 Limitations of this study 
 
The quality, validity, strengths and limitations of the research design and 
techniques have mainly been discussed in chapter 3.  Upon reflection on the 
execution of the study, some limitations of this study have been identified and 
critically evaluated.    
 
Firstly, coaches’ responses were insightful with regards to track and field, but 
the small sample size of coaches and demographic area was not 
representative.  The coaches involved in this study were experienced and 
coached athletes on provincial and national level, but future studies may also 
investigate the views of less experienced coaches and coaches who coach 
 80 
younger and non-elite athletes.  Coaches’ perspectives with regards to 
athletes’ who decide to RTS themselves were not considered in this study 
(refer to appendix K – Question 10).  It may be insightful to determine from 
coaches how often athletes decide to RTS without the proper clearance of the 
involved parties to RTS.   
 
The athletes who were involved in the study represented a small population.  
None of the athletes scored high on external and introjected regulation and 
larger populations may include athletes who may score high on these types 
of motivation.  It will be of value to compare these athletes’ occurrence of re-
injury to athletes with high scores on identified, integrated and intrinsic 
regulation.  The athletes in this study did not show relatedness with previous 
similar injuries which may also be attributed to the small sample size.     
 
The age groups, as explained in 2.2.2, could not all be included in the study.  
Youth and sub-youth athletes have their national championships before the 
end of March and do not have consecutive opportunities to participate at 
national competitions, compared to junior and senior athletes that have more 
than one opportunity to compete at national and international competitions.  
Secondly, the SMS-II still needs further research (refer to 2.7.2) and 
especially the appropriate language that should be used in the items of the 
SMS-II in order for younger athletes to fully comprehend the meaning of these 
items.  Future studies should therefore include the youth and sub-youth age 
groups together with standardisation of the SMS-II in this population. 
 
In 5.3.3 the possibility of how the time of season when athletes had to RTS 
during the execution of this study could influence the results, was explained.  
Only elite athletes that had to RTS during the national and international 
championships were involved in the study.  Future studies can include elite 
athletes that RTS earlier during the season due to an injury during the 
previous season, off-season or preparation phase.   
 
Some of the coaches who were considered for inclusion in the study were 
also not available for interviews until after completion of the athletics season.  
 81 
It was, however, possible to interview coaches after completion of the track 
and field season in this study but it should be considered when planning future 
studies.  Results for this study were consequently not influenced, but for future 
studies with populations that are small and where time for the execution of 
the study is limited, the availability of coaches may have a significant influence 
on the research study.   
 
In 5.3.4 it was concluded that all the respondents of this study had similar 
types of motivation.  This can be attributed to the fact that the respondents in 
this study were all members of the same athletics club in Bloemfontein.  The 
emphasis at the club is to assist athletes to achieve individual top 
performances rather than winning team competitions (refer to comments at 
5.2.2.4).  Future studies can include athletes from various athletics clubs in 
order to include athletes who might experience more external pressure from 
their clubs to perform well in team competitions.  It was mentioned in 4.3.3 
that all the athletes were bursary holders at the UFS, but it will also be helpful 
to determine whether the athletes ever experienced a decrease in their 
bursary amount as a result of poor performance. 
 
The type of injury was not controlled during this study, only the severity was.  
This was considered by the researcher, but due to the small population 
available to the researcher during the time of execution, different types of 
injuries were included in the analysis.  The athletes from different specialist 
fields in track and field also experienced similar types of injuries (refer to 
4.3.2).  A percentage of 63% (n = 5) of the participants who returned to the 
sprint events had hamstring injuries.  Future studies can control the results 
even more by focusing on a specialist field in track and field and considering 
similar types of injuries for these athletes.   
 
Due to the researcher’s personal involvement and interest in track and field 
as coach but also as physiotherapist, the respondents were all well-known to 
the researcher.  This familiarity induced very relaxed interviews.  Babbie 
(2007), however, cautions interviewers that they need to be neutral; their 
presence in the data collection process must have no effect on the responses 
 82 
to questionnaire items.  Although efforts were made to control the possibility 
of this bias, it cannot be excluded.  Respondents were guaranteed 
confidentiality (refer to 3.5.2), but the possibility that some of these coaches’ 
answers may have been influenced by the presence of the researcher cannot 
be ignored.  
 
The next section concludes the critical discussion by referring to 
recommendations and implications for future research not yet mentioned. 
   
5.5 Recommendations/Implications for future research  
 
The study included only elite athletes from track and field.  In 2.3.1 it was 
mentioned that physiotherapists in Bloemfontein most frequently have to 
make RTS decisions for track and field athletes and rugby players.  As 
discussed in 5.4 above, the athletes in this study had similar types of 
motivation to RTS.  Emphasis on the team effort and dependence on team 
members may, however, have different results.  Future studies can therefor 
include sports from both individual and team sporting codes, for example track 
and field, swimming, judo, karate compared to netball, hockey, rugby, cricket 
and football.       
 
Due to the alarming number of sequelae identified in studies mentioned in 
2.4, future studies must pay attention to this phenomenon.  Although 
respondents in this study did not show specific relatedness to previous similar 
injuries (refer to 5.3.3), future studies may exclude athletes with sequelae and 
focus on athletes that RTS after an injury sustained for the first time.  This 
may, however, lead to a significant decrease in the size of the population.   
 
Reaching athletes in person who are about to RTS is often difficult.  Athletes 
who were about to RTS at international competitions, were included in this 
study but were often rushed to complete the testing instrument in time before 
departure.  The use of electronic questionnaires and web-interfaces for 
research could be utilised in order to make it easier for researchers to reach 
these athletes in time for future studies. 
 83 
 
Although the results regarding the type of motivation compared to the 
occurrence of re-injury of this study was not specific and conclusive; the trend 
of higher scores in external regulation and introjected regulation for athletes 
who were re-injured was noted (refer to 5.3.3).   Further research on the 
specific scores of athletes’ type of motivation and recurrence of injury is 
necessary and this research should include larger population sizes.   Further 
research is also necessary in order to determine whether an athlete’s high 
score for external regulation and introjected regulation can be related to re-
injury.  As explained in 5.4, none of the athletes scored high on these types 
of motivation and future studies must compare athletes who score high on 
external regulation and introjected regulation with the occurrence of re-injury.  
This may be uncovered if the population size is larger, if athletes of younger 
ages are included and athletes from different sporting codes are included 
(refer to 5.4).  This may suggest that physiotherapists could use the adapted 
SMS-II to determine the scores of athletes’ type of motivations to RTS.  The 
specific scores for external regulation and introjected regulation that may 
predict possible re-injury need further investigation with studies that include 
larger population sizes.  Coaches may be informed about the athletes’ type of 
motivation and the necessary referrals to the appropriate professional or 
training partner(s) may be necessary (refer to 5.2.2.3) in order to assist with 
an improved RTS.      
 
 
 
 
 
 
 
 
 
 
 84 
Chapter 6  
CONCLUSION 
 
 
 
 
The literature review in chapter 2 highlighted the relevancy of research on the 
different factors of the Decision-Based RTS model.  Currently, the model and 
aspects of RTS is a relevant topic for research and it is clear from the 
numerous authors mentioned in chapter 2 as well as the respondents of the 
first part of this study, that research is needed on the type of motivation and 
its relatedness to the re-injury of athletes (refer to 5.2.2.4).  
 
6.1 The coach, the athlete and the physiotherapist 
 
The track and field coaches involved in this study expressed the need for the 
type of motivation of an athlete during RTS decisions to be considered.  These 
coaches explained (refer to 5.2.2.2) that physiotherapists would be in a better 
position to evaluate the real reason why athletes would like to return to sport 
compared to themselves because coaches could be tricked easily by the 
athletes.  The coaches of this study preferred to include themselves, sport 
doctors and physiotherapists in on-the-field decisions regarding continuation 
of participation and similarly preferred themselves, sport doctors and 
physiotherapists to make RTS decisions in their training groups.  Coaches 
expect physiotherapists to consider the type of motivation of an athlete to RTS 
while dealing with RTS decisions.  In order to maintain a good relationship 
between the coaches, the athlete and the physiotherapist, the type of 
motivation and re-injury need further research.   
 
6.2   Type of motivation and re-injury of elite athletes   
 
Seventy three percent of the participants were treated for similar injuries 
before (see 4.3.2).  The athletes that were re-injured could not be categorised 
 85 
to athletes participating in a specific event, nor did they represent athletes 
with a specific injury.   
 
The respondents in this study tested high on integrated, identified and intrinsic 
regulation.  All the respondents were representing similar types of motivation 
that leaned more towards the intrinsic type of motivation on the self-
determination continuum illustrated in figure 2.7.  A trend of a difference in the 
mean measured types of motivation of athletes who were re-injured after 
RTS, compared to those athletes who were not re-injured after RTS (refer to 
5.3.3) was noticed, but these results were not statistically significant.  Larger 
population sizes with different demographic compositions should be included 
in future studies in order to determine more exact clinical scores for the 
adapted SMS-II.   This study therefore serves as basis for further research 
where the limitations and recommendations (refer to 5.4 and 5.5 above) 
should be considered. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 86 
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 94 
 
 
 
Personal communication: 
 
Millson, H.  2010b. Personal discussion with Mrs Helen Millson regarding 
RTS after a presentation at the first South African Sports Physio 
Congress: From Plinth to Podium.  Objective Criteria Rehabilitation / 
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 95 
 
 
 
 
 
 
 
 
 96 
Appendix A 
Application for approval as well as permission:  Head of sport - 
UFS  
 
 
Appendix A.pdf 
  
 A 
Appendix B 
Application for approval as well as permission:  General manager 
- AFS 
 
Appendix B.pdf 
  
 B 
Appendix C 
Application for approval as well as permission:  Director Student 
Life – UFS and Vice Rector Research – UFS 
 
Appendix C.pdf  
 C 
 
Appendix D  
Application for approval as well as permission: Report Evaluation 
Committee – research (School for allied health professions) 
 
Appendix D.pdf  
 D 
 
Appendix E 
Application for approval as well as permission: Health Sciences 
research Ethics Committee. 
 
Appendix E.pdf  
 E 
 
Appendix F 
Approval – Mr FC van Rooyen (Department of Biostatistics) 
 
Appendix F.pdf  
 F 
 
Appendix G  
Informed consent letter to participant athletes 
 
Appendix G.pdf  
 G 
 
Appendix H  
Adapted revised Sport Motivation Scale (SMS-II) 
 
Appendix H A.pdf 
Appendix H E.pdf  
 H 
 
Appendix I  
Data sheet and information form physiotherapist 
 
Appendix I A 1.pdf 
Appendix I A 2.pdf 
Appendix I E 1.pdf 
Appendix I E 2.pdf  
 I 
 
Appendix J  
Informed consent letter to participant coaches 
 
Appendix J.pdf  
 J 
 
Appendix K 
Structured interview – coaches 
 
Appendix K - Afrikaans.pdf 
Appendix K - English.pdf 
 K 
Dear Mr Prinsloo 
 
This study aims to launch an in-depth investigation into the relations between athlete 
motivation for returning to sport after injury, and the recurrence of injury.  The research will 
be conducted by means of an interview to determine what coaches expect from 
physiotherapists regarding decisions on return to sport after injury. 
 
Hereby I request approval for the pilot study of the study: “Return to Sport after Injury:  
Investigation of Motivation and Recurrence of injury” to be performed on coaches from the 
Kovsie athletics club.  Individual interviews will be organised with the coaches in order to 
determine what coaches expect from physiotherapists regarding decisions about return to 
sport after injury.  If little or no changes to the questions in the interview need to be done 
following the pilot study, the results will be included in the main study. 
 
Attached to this letter of approval is the complete protocol for the study, which will be handed 
in to the ethics committee in February 2016.  When the study is approved by the ethics 
committee, a copy of the letter of approval will be sent to you.   
 
I request approval regarding the following: 
Permission to organise interviews with coaches during February 2016.  Respondents will be 
contacted by me personally and respondents will be asked to comment about the questions 
in the interview.    
 
Participants will be completely aware about what will be expected from them and will receive 
letters of consent to sign.   
 
If you have any further questions about the research you are welcome to contact me 
telephonically at 083 228 1153. 
 
I will appreciate it if you can provide me with written approval of the study for documentation 
purposes. 
 
Thank you in advance 
Johan Human 
 
 
 
Dear Mr Gerrit Coetzer 
This study aims to launch an in-depth investigation into the relations between athlete 
motivation for returning to sport after injury, and the recurrence of injury.  The research will 
firstly be conducted on athletes returning to sport after injury by means of a questionnaire 
(the Adapted Sport Motivation Scale) to determine what the motivation of the athlete is to 
return to sport and will then be contacted first on a weekly basis and after one month on a 
monthly basis telephonically to determine if re-injury occurred. The research will secondly be 
conducted by means of an interview with coaches registered at AFS to determine what 
coaches expect from physiotherapists regarding decisions on return to sport after injury.  
Hereby I request approval for the study: “Return to Sport after Injury:  The relationship 
between an athlete’s type of motivation and a recurrence of injury” to be performed on 
provincial and national athletes registered with FSA from 20 March 2016 to 30 May 2016 
and on coaches from Bloemfontein registered with FSA during April and May 2016. 
Questionnaires will be completed anonymously by athletes in order to determine the 
motivation of the athlete and the athletes will be contacted telephonically using details 
recorded on a data sheet.  The contact details for each participant will only appear on the 
contact data sheet used only by the researcher and only a unique identification number will 
appear on the data list and questionnaire of each respondent. 
Secondly coaches will be asked about their expectations from physiotherapists regarding 
decisions on return to sport after injury in individual interviews with the researcher.    
Attached to this letter of approval is the complete protocol for the study, as handed in to the 
ethics committee in February 2016.  When the study is approved by the ethics committee, a 
copy of the letter of approval will be sent to you.   
I request approval regarding the following: 
 Permission to hand questionnaires to all provincial and national athletes registered 
with FSA who return to sport participation after injury. 
 Permission to contact them one week, two weeks, three weeks, four weeks  and on a 
monthly basis after return to sport until the end of their respective seasons to determine 
if re-injury occurred. 
 Permission to organise interviews with coaches during March and April 2016.  
Respondents will be contacted by me personally to organise a suitable time and venue 
for the interview.    
Participants will be completely aware about what will be expected from them and will receive 
letters of consent to sign.   
If you have any further questions about the research you are welcome to contact me 
telephonically at 083 228 1153. 
I will appreciate it if you can provide me with written approval of the study for documentation 
purposes. 
 
Thank you in advance 
 
Johan Human 
 
Department Physiotherapy 
University of the Free State 
March 2016 
University of the Free State 
 
Dear Mrs C Faasen 
 
This study aims to launch an in-depth investigation into the relations between athlete motivation for 
returning to sport after injury, and the recurrence of injury.  The research will be conducted by means 
of an interview to determine what coaches expect from physiotherapists regarding decisions on return 
to sport after injury. 
 
Hereby I request approval for the pilot study of the study: : “Return to Sport after Injury:  The 
relationship between an athlete’s type of motivation and a recurrence of injury”  to be performed on 
coaches from the Kovsie athletics club.  Individual interviews will be organised with the coaches in 
order to determine what coaches expect of physiotherapists regarding decisions about return to sport 
after injury.  If little or no changes to the questions in the interview need to be done following the pilot 
study, the results will be included in the main study. 
 
Attached to this letter of approval is the complete protocol for the study, which will be handed in to the 
ethics committee in February 2016.  When the study is approved by the ethics committee, a copy of the 
letter of approval will be sent to you.   
 
I request approval regarding the following: 
Permission to organise interviews with coaches during the last week of March 2016.  Respondents will 
be contacted by me personally and respondents will be asked to comment about the questions in the 
interview.    
 
Participants will be completely aware about what will be expected from them and will receive letters of 
consent to sign.   
 
If you have any further questions about the research you are welcome to contact me telephonically at 
083 228 1153. 
 
I will appreciate it if you can provide me with written approval of the study for documentation purposes. 
 
Thank you in advance 
Johan Human 
 
Department Physiotherapy 
University of the Free State 
March 2016 
 
University of the Free State 
 
Dear Prof RC Witthuhn 
 
This study aims to launch an in-depth investigation into the relations between athlete motivation for 
returning to sport after injury, and the recurrence of injury.  The research will be conducted by means 
of an interview to determine what coaches expect from physiotherapists regarding decisions on return 
to sport after injury. 
 
Hereby I request approval for the pilot study of the study: : “Return to Sport after Injury:  The 
relationship between an athlete’s type of motivation and a recurrence of injury”  to be performed on 
coaches from the Kovsie athletics club.  Individual interviews will be organised with the coaches in 
order to determine what coaches expect of physiotherapists regarding decisions about return to sport 
after injury.  If little or no changes to the questions in the interview need to be done following the pilot 
study, the results will be included in the main study. 
 
Attached to this letter of approval is the complete protocol for the study, which will be handed in to the 
ethics committee in February 2016.  When the study is approved by the ethics committee, a copy of the 
letter of approval will be sent to you.   
 
I request approval regarding the following: 
Permission to organise interviews with coaches during the last week of March 2016.  Respondents will 
be contacted by me personally and respondents will be asked to comment about the questions in the 
interview.    
 
Participants will be completely aware about what will be expected from them and will receive letters of 
consent to sign.   
 
If you have any further questions about the research you are welcome to contact me telephonically at 
083 228 1153. 
 
I will appreciate it if you can provide me with written approval of the study for documentation purposes. 
 
Thank you in advance 
Johan Human 
 
 
 
 




 














 
 
Return to Sport after Injury:  The relationship between 
an athlete’s type of motivation and a recurrence of 
injury 
 
Informed consent 
Dear Participant 
We, Johan Human (researcher) and Corlia Brandt (study leader) are doing research on the 
motivation of athletes when returning to sport and the recurrence of injury.   In this part of 
the study we would like to determine if there are any correlation between the type of 
motivation for return to sport after an injury and re-injury. 
We invite provincial and national athletes who are returning to sport participation after 
injury to participate in this research study.   
The participant will be asked to complete the questions in the Adapted Sport Motivation 
Scale to determine his/her motivation for returning to sport participation.  Completion of 
the list should take about 30 minutes.  The athletes’ contact details will only be recorded on 
a contact data list with a unique data number for each participant.  The participant will be 
contacted by the researcher to determine if re-injury occurred after one week, two weeks, 
three weeks, four weeks and on a monthly basis until the end of the season, after return to 
sport. The name of the participant will not appear on the completed data sheet or the 
Adapted Sport Motivation Scale, but only on the contact data list.  The participant may 
withdraw from the study at any time.  The results of the study may be published or 
presented.  There are no costs or payments involved for the participants.  There are no risks 
to the coach participating in this study. 
Feel free to contact the researcher with any further questions regarding the study: Johan 
Human 083 228 1153 
To report about complaints/problems the contact details of Secretariat and Chair: 
Committee of the Faculty of Health Sciences, University of the Free State:  051 – 405 2812 
Thank you for your consideration in this regard. 
Johan Human 
If you consent to participate in the research as described above, please complete the form 
below and return to the researcher. 
The research study, including the above information has been described to me.  I 
understand what my involvement in the study means and I voluntarily agree to participate. 
 
 
 
 
 
Name: 
________________________________________________________________________ 
 
Signature: _________________________________ Date: ____________________________ 
 
Consent from Physiotherapist: 
Please indicate if you consent to the athlete participating in the study:   Yes/No 
 
Physiotherapists name: ____________________________________________________ 
Physiotherapists signature: _________________________________________________  
 
 
 
 
 
 
 
 
 
 
 
 
 
Terugkeer tot sportdeelname na besering:  Ondersoek 
na die verwantskap tussen die ‘n atleet se tipe 
motivering en die voorkoms van herbesering. 
Ingeligte toestemming 
Geagte deelnemer 
Ons, Johan Human (navorser) en Corlia Brandt (studieleier) doen navorsing oor die 
motivering van atlete wanneer hul terugkeer na sport en herbesering van die atlete.  In 
hierdie gedeelte van die studie wil ons bepaal of daar enige ooreenkoms is tussen die tipe 
motivering vir terugkeer na sport na ‘n besering en herbesering.   
Ons nooi provinsiale en nasionale atlete wat na afloop van ‘n besering terugkeer na 
sportdeelname om deel te neem aan hierdie navorsingstudie.     
Die deelnemer sal versoek word om vrae in die Aangepaste Sport Motiveringskaal te 
beantwoord om vas te stel watter tipe motivering hy/sy het om terug te keer na 
sportdeelname.  Voltooiing van die vorm sal ongeveer 30 minute neem.  Die atleet se 
kontakbesonderhede sal slegs op ‘n aparte datalys neergeskryf word met ‘n unieke 
datanommer vir elke deelnemer.  Die deelnemer sal deur die navorser gekontak word om 
vas te stel of herbesering voorgekom het een week na terugkeer, twee weke, drie weke en 
daarna op ‘n maandelikse basis tot aan die einde van die seisoen.  Die naam van die 
deelnemer sal nie op die voltooide datalys of die Aangepaste Sport Motiveringskaal van die 
betrokke deelnemer verskyn nie, maar slegs op die kontak datalys. Die deelnemer kan op 
enige stadium van deelname aan die studie onttrek.  Die resultate van die studie mag 
gepubliseer word of tydens ‘n aanbieding vertoon word.  Daar is geen kostes of betalings vir 
die deelnemers van hierdie studie nie.  Daar is geen risiko vir die afrigter wat deelneem aan 
hierdie studie nie.   
U kan gerus voel om die navorser met enige navrae oor die studie te kontak: Johan Human 
083 228 1153 
Om enige klagtes/probleme aan te meld kan u die Sekretariaat en Voorsitter: Komittee van 
die Fakulteit Gesondheidswetenskappe, Universiteit van die Vrystaat kontak:  051 – 405 
2812 
Baie dankie  vir u oorweging. 
Johan Human 
Indien u toestemming gee vir deelname aan die navorsing soos beskryf hierbo, voltooi 
asseblief die vorm hieronder en gee dit terug aan die navorser.   
Die navorsingstudie, insluitende bostaande inligting is aan my verduidelik.  Ek verstaan wat 
deelname aan die studie behels en ek gee vrywilliglik toestemming vir deelname aan die 
studie.   
 
 
 
Naam: 
________________________________________________________________________ 
 
Handtekening: _________________________________ Datum: _______________ 
 
Toestemming van ouer/voog: 
Dui asseblief aan of u toestemming gee vir die atleet om deel te neem aan die studie:   
Ja/Nee 
 
Ouer/Voog se naam: _____________________________________________________ 
Ouer/Voog se handtekening: _______________________________________________  
 
Toestemming van fisioterapeut: 
Dui asseblief aan of u toestemming gee vir die atleet om deel te neem aan die studie:   
Ja/Nee 
 
Fisioterapeut se naam: _____________________________________________________ 
Fisioterapeut se handtekening: _______________________________________________  
 
Terugkeer tot sport na besering:  Ondersoek na die verwantskap tussen 
'n atleet se tipe motivering en die voorkoms van herbesering
U is versoek om aan 'n navorsingstudie deel te neem. Neem asseblief kennis dat deur hierdie vraelys te beantwoord, u vrywilliglik daartoe instem om aan hierdie 
studie deel te neem.  U sal anoniem bly en u data sal ten alle tye konfidensieel hanteer word.  U mag op enige oomblik van hierdie studie onttrek terwyl u die vraelys 
invul.  Die resultate van hierdie studie mag gepubliseer word.
Ek het na sport terug gekeer na besering:
Deur van die skaal hieronder gebruik te maak, dui asseblief aan tot watter mate elkeen van die Vir amptelike gebruik
volgende items ooreenstem met die redes waarom jy huidiglik na sportdeelname terugkeer.
R T P 1-2
Stem glad nie Stem presies 
ooreen nie Stem matig ooreen ooreen
1 Want dit is vir my genotvol om meer van my sport te leer. 1 2 3 4 5 6 7 3
4
2 Want ek sal sleg voel oor myself as ek nie die tyd neem om dit te doen nie. 1 2 3 4 5 6 7
5
3 Want ek het die sport gekies as 'n manier om myself te ontwikkel. 1 2 3 4 5 6 7
4 Want mense rondom my beloon my wanneer ek dit doen. 1 2 3 4 5 6 7 6
7
5 Want deur sport leef ek in belyning met my diepste beginsels. 1 2 3 4 5 6 7
6 Want deelname aan sport is 'n integrale deel van my lewe. 1 2 3 4 5 6 7 8
9
7 Want ek vind dit genotvol om nuwe strategiee te ontdek om te presteer. 1 2 3 4 5 6 7
Want ek het gevind dat dit 'n goeie manier is om die aspekte van myself wat ek 10
8 1 2 3 4 5 6 7
waarde aan heg, te ontwikkel.
11
9 Want dit is baie interessant om te leer hoe ek kan verbeter. 1 2 3 4 5 6 7
10 Want ek dink ander sal 'n afkeur in my he as ek nie. 1 2 3 4 5 6 7 12
Want dit is een van die beste maniere wat ek gekies het om ander aspekte van 13
11 1 2 3 4 5 6 7
myself te ontwikkel
12 Want ek sal nie waardevol voel as ek nie. 1 2 3 4 5 6 7 14
13 Want mense oor wie ek omgee sal omgekrap met my wees as ek nie. 1 2 3 4 5 6 7 15
14 Want ek voel beter oor myself as ek doen. 1 2 3 4 5 6 7 16
15 Want om aan sport deel te neem reflekteer die essensie van wie ek is. 1 2 3 4 5 6 7 17
Return to Sport after Injury:  The relationship between an athlete’s 
type of motivation and a recurrence of injury
You have been asked to participate in a research study.  Please note that by completing this questionnaire you are voluntarily agreeing to participate 
in this research study.  You will remain anonymous and your data will be treated confidentially at all times.  You may withdraw from this study at any 
given moment during the completion of the questionnaire.  The results of the study may be published.
I returned to sport following injury.
For official use:
Using the scale below, please indicate to what extent each of the following items corresponds to 
one of the reasons for which you are presently returning to your sport.
R T P 1-2
Does not 
correspond at Corresponds Corresponds 
all moderately exactly
1 Because it gives me pleasure to learn more about my sport. 1 2 3 4 5 6 7 3
4
2 Because I would feel bad about myself if I did not take the time to do it. 1 2 3 4 5 6 7
5
3 Because I have chosen this sport as a way to develop myself. 1 2 3 4 5 6 7
4 Because people around me reward me when I do. 1 2 3 4 5 6 7 6
7
5 Because through sport, I am living in line with my deepest principles. 1 2 3 4 5 6 7
6 Because participating in sport is an integral part of my life. 1 2 3 4 5 6 7 8
9
7 Because I find it enjoyable to discover new performance strategies. 1 2 3 4 5 6 7
10
8 Because I found it is a good way to develop aspects of myself that I value. 1 2 3 4 5 6 7
11
9 Because it is very interesting to learn how I can improve. 1 2 3 4 5 6 7
10 Because I think others would disapprove of me if I did not. 1 2 3 4 5 6 7 12
Because it is one of the best ways I have chosen to develop other aspects 13
11 1 2 3 4 5 6 7
of myself
12 Because I should not feel worthwhile if I did not. 1 2 3 4 5 6 7 14
13 Because people I care about would be upset with me if I did not. 1 2 3 4 5 6 7 15
14 Because practicing sports reflects the essence of whom I am. 1 2 3 4 5 6 7 16
15 Because I feel better about myself when I do. 1 2 3 4 5 6 7 17
Data bladsy
R T P 1-2
Voltooi asseblief die volgende:
1 Vandag se datum: (bv 2015/03/15) Y Y Y Y / M M / D D 3-10
2 Wat is jou geboortedatum? (bv 1990/05/26) Y Y Y Y / M M / D D 11-18
3 Wat is jou geslag? Manlik Vroulik 19
4 Na watter disiplines in atletiek, beplan jy om terug te keer vir deelname gedurende die res van die seisoen? 20-21
1 Naellope (100m, 200m en/of 4x100m aflos)
2 Hekkies (90m, 100m, 110m, 300m en/of 400m)
3 Spronge (hoogspring, verspring, driesprong en/of paalspring)
4 Worpe (gewigstoot, spiesgooi, diskus en/of hammergooi)
5 Middelafstande (400m en/of 800m)
6 Langafstande (meer as 1000m)
7 Gekombineerde items (veelkamp)
5 Op watter vlak verteenwoordig jy die sport? 22
1 Provinsiaal
2 Nasionaal
6 Hoe lank neem jy al deel in hierdie sport?
__________________jaar
23-24
7 Vir watter tipe besering is jy nou behandel?
25-26
8 Hoe lank was jy vir hierdie besering behandel? 27-28
_______________ weke
9 Was hierdie die eerste keer dat jy vir hierdie tipe besering behandel is? Ja Nee 29
10 Wie het die finale besluit gehad oor of jy gereed was om terug te keer na sportdeelname? 30-31
1 Jyself
2 Afrigter
3 Bestuurder
4 Dokter
5 Biokinetikus
6 Ouers
7 Fisioterapeut
8 Ander
As ander, spesifiseer:
11 Ontvang jy enige van die volgende vergoeding vir jou deelname aan hierdie sport (Merk met X):
Beurs van skool/universiteit 32
Borgskap van instansies/persone 33
Geen 34
12 Word jy onder druk geplaas om terug te keer na sport deur enige van die volgende (Merk met X):
Ouers 35
Afrigter 36
Vriende 37
Skool 38
Universiteit 39
Ander
Indien u ander gekies het spesifiseer asb. 40-41
Opvolg-data
11 Week 1 :herbesering? Ja Nee 42
Omvang van besering Identies Nuut Verwant 43
12 Week 2 :herbesering? Ja Nee 44
Omvang van besering Identies Nuut Verwant 45
13 Week 3 :herbesering? Ja Nee 46
Omvang van besering Identies Nuut Verwant 47
14 Week 4 :herbesering? Ja Nee 48
Omvang van besering Identies Nuut Verwant 49
15 Maand 2 :herbesering? Ja Nee 50
Omvang van besering Identies Nuut Verwant 51
16 Maand 3 :herbesering? Ja Nee 52
Omvang van besering Identies Nuut Verwant 53
Terugkeer tot sport na besering:  Ondersoek na die verwantskap tussen 'n 
atleet se tipe motivering en die voorkoms van herbesering
U pasiënt is versoek om aan 'n navorsingstudie deel te neem. Neem asseblief kennis dat deur hierdie vraelys te beantwoord, u vrywilliglik daartoe 
instem dat u pasiënt aan hierdie studie deelneem.  U en die pasiënt sal anoniem bly en u data sal ten alle tye konfidensieel hanteer word.  U en/of die 
pasiënt mag op enige oomblik van hierdie studie onttrek terwyl u die vrae beantwoord.  Die resultate van hierdie studie mag gepubliseer word.
Inligting bekom vanaf Fisioterapeut wat atleet behandel het: For official use:
R T P 1-2
1 Wat was die diagnose van die atleet? 3-4
2 5
Is die atleet volgens u gereed om terug te keer na deelname aan sport?
1 Ja
2 Nee
3 Watter van die volgende mediese faktore het u in ag geneem om te 
besluit of die atleet gereed is om terug te keer na sportdeelname?
Demografie van pasiënt (bv. ouderdom, geslag) 6
Simptome (bv. pyn) 7
Persoonlike Mediese Geskiedenis (bv. herhalende besering) 8
Tekens (fisiese ondersoek) (bv. swelling, swakheid) 9
Laboratoriumtoetse (X-strale, MRB) 10
Funksionele toetse 11
Psigologiese toestand (bv. depressief) 12
Potensiële ernstigheid (bv. konkussie) 13
4
Watter van die volgende sport risiko veranderlikes het u in ag geneem 
om te besluit of die atleet gereed is om terug te keer na sportdeelname?
Tipe Sport (bv. kontak/nie-kontak) 14
Posisie (bv. voorry of agterry) 15
Dominansie van ledemate 16
Vlak van deelname (bv. rekreasie of professioneel) 17
Vermoë om te beskerm (bv. strapping) 18
5
Watter van die volgende besluitnemingsveranderlikes het 'n rol gespeel 
om te besluit of die atleet gereed is om terug te keer na sportdeelname?
Tyd van seisoen (bv. proewe of nasionale kampioenskappe) 19
Druk deur die atleet self (bv. om deel te neem) 20
Eksterne druk (bv. ouers, afrigter) 21
Wegsteek van besering (bv. analgetika) 22
Konflik van belange (bv. finansieel) 23
Vrees vir vervolging (bv. toelaatbaarheid om met 'n besering deel te neem) 24
Data sheet For official use:
R T P 1-2
Please complete the following:
1 Today's date: (eg 2016/03/15) Y Y Y Y / M M / D D 3-10
2 What is your date of birth? (eg 1990/05/26) Y Y Y Y / M M / D D 11-18
3 What is your gender? Male Female 19
4 In which disciplines of athletics, do you intend to return to compete in, during the rest of this season? 20-21
1 Sprints (100m, 200m and/or 4x100m relay)
2 Hurdles (90m, 100m, 110m, 300m and/or 400m)
3 Jumps (high jump, long jump, tripple jump and/or pole vault)
4 Throws (shot put, javelin, discus and/or hammer through)
5 Middle distances (400m and/or 800m)
6 Long distances (more than 1000m)
7 Combined events (pentathlon and or decathlon)
5 On which level do you represent this sport? 22
1 Provincial
2 National
6 For how long have you been competing in this sport? 23-24
__________________ years
7 What type of injury were you treated for now? 25-26
8 For how long were you treated for this injury? 27-28
_______________ weeks
9 Was this the first time that you were treated for this type of injury? Yes No 29
10 Who had the final say to allow you to return to sport participation? 30-31
1 You
2 Coach
3 Manager
4 Doctor
5 Biokineticist
6 Parents
7 Physiotherapist
8 Other
If other, please specify:
11 Do you receive remuneration from any of the following for participating in this sport (Mark with X):
Bursary from school/university 32
Sponsorship from institutions/persons 33
None 34
12 Are you pressured to return to sport by any of the following (Mark with X):
Parents 35
Coach 36
Friends 37
School 38
University 39
Other
If your selected other, please specify: 40-41
11 Week 1 :reinjured? Yes No 42
Extent of injury? Identical New injury New but related 43
12 Week 2 :reinjured? Yes No 44
Extent of injury? Identical New injury New but related 45
13 Week 3 :reinjured? Yes No 46
Extent of injury? Identical New injury New but related 47
14 Week 4 :reinjured? Yes No 48
Extent of injury? Identical New injury New but related 49
15 Month 2 :reinjured? Yes No 50
Extent of injury? Identical New injury New but related 51
16 Month 3 :reinjured? Yes No 52
Extent of injury? Identical New injury New but related 53
Return to Sport after Injury:  The relationship between an athlete’s type of 
motivation and a recurrence of injury
Your patient has been asked to participate in a research study.  Please note that by completing this questionnaire you are 
voluntarily agreeing to participate in this research study.  You will remain anonymous and your data will be treated 
confidentially at all times.  You and/or your patient may withdraw from this study at any given moment during the answering of 
the quetions.  The results of the study may be published.
Information obtained from physiotherapist that treated the athlete: For official use:
R T P 1-2
1 What was the diagnosis of the athlete? 3-4
2 5
Is the athlete, according to you, ready for return to participation in sport?
1 Yes
2 No
3 Which of the following medical factors did you consider to decide if the 
athlete is ready to return to participation in sport?
Patient demographics (e.g. age, sex) 6
Symptoms (e.g. pain) 7
Personal medical history (e.g. recurrent injury) 8
Signs (physical exam) (e.g. swelling, weakness) 9
La Tests (e.g. x-ray, MRI) 10
Functional Tests (e.g. x-ray, MRI) 11
Psychological State (e.g. depressed) 12
Potential seriousness (e.g. concussion, tennis elbow) 13
4 Which of the following sport risk modifiers did you consider to decide if 
the athlete is ready to return to participation in sport?
Type of sport (e.g. collision, non-contact) 14
Position Played (e.g. goalie, forward) 15
Limb Dominance (e.g. MSK alignment) 16
Competitive Level (e.g. recreational, professional) 17
Ability to Protect (e.g. padding) 18
5 Which of the following Decision Modifiers  played a role to decide if the 
athlete is readey to return to sport?
Timing & Season (e.g. playoffs) 19
Pressure from Athlete (e.g. desire to compete) 20
External Pressure (e.g. coach, athlete family) 21
Masking the injury (e.g. effective analgesia) 22
Conflict of Interest (e.g. financial) 23
Fear of Litigation (e.g. if restricted or permitted) 24
Return to Sport after Injury:  The relationship between 
an athlete’s type of motivation and a recurrence of 
injury 
Informed consent 
Dear Participant 
We, Johan Human (researcher) and Corlia Brandt (study leader) are doing research on the 
motivation of athletes when returning to sport and the recurrence of injury.   In this part of the study 
we would like to determine what athletic coaches expect from physiotherapists regarding decisions 
taken about return to sports participation, following an injury. 
We invite Bloemfontein athletics coaches to participate in this research study.   
The study will consist of an interview by the researcher in your preferred language in Afrikaans or 
English. The coaches will be asked questions about what they expect from physiotherapists in 
decisions regarding return to sport after injury.  The participant may withdraw from the study at any 
time.  The results of the study may be published and presented.  There are no costs or payments 
involved for the participants.  There are no risks to the coach participating in this study. 
Feel free to contact the researcher with any further questions regarding the study: 
Johan Human 083 228 1153 
To report about complaints/problems the contact details of Secretariat and Chair: Committee of the 
Faculty of Health Sciences, University of the Free State:  051 – 405 2812 
 
Thank you for your consideration in this regard. 
 
Kind regards  
Johan Human 
If you consent to participate in the research as described above, please complete the form below 
and return to the researcher. 
The research study, including the above information has been described to me.  I understand what 
my involvement in the study means and I voluntarily agree to participate. 
 
Name: ________________________________________________________________________ 
 
 
Signature: _________________________________ Date: ____________________________ 
Terugkeer tot sportdeelname na besering:  Ondersoek 
na die verwantskap tussen die ‘n atleet se tipe 
motivering en die voorkoms van herbesering. 
Ingeligte toestemming 
Geagte deelnemer 
Ons, Johan Human (navorser) en Corlia Brandt (studieleier) doen navorsing oor die motivering van 
atlete wanneer hul terugkeer na sport en herbesering van die atlete.  In hierdie gedeelte van die 
studie wil ons vasstel wat atletiek afrigters van fisioterapeute verwag omtrent besluite rakende 
terugkeer na sportdeelname, na beserings.   
Ons nooi Bloemfonteinse atletiekafrigters uit om deel te neem aan die studie.   
Die studie sal ‘n onderhoud deur die navorser behels waartydens vrae oor wat afrigters verwag van 
fisioterapeute rakende besluite oor die terugkeer van atlete na sportdeelname na herstel van ‘n 
besering.  Die deelnemer kan op enige stadium van deelname aan die studie onttrek.  Die resultate 
van die studie mag gepubliseer word of tydens aanbiedings vertoon word.  Daar is geen kostes of 
betalings vir die deelnemers van hierdie studie nie.  Daar is geen risiko vir die afrigter wat deelneem 
aan hierdie studie nie.   
U kan gerus voel om die navorser met enige navrae oor die studie te kontak: 
Johan Human 083 228 1153 
Om enige klagtes/probleme aan te meld kan u die Sekretariaat en Voorsitter: Komittee van die 
Fakulteit Gesondheidswetenskappe, Universiteit van die Vrystaat kontak:  051 – 405 2812 
 
Baie dankie vir u oorweging. 
 
Vriendelike groete 
Johan Human 
Indien u toestemming verleen om deel te neem aan die navorsing soos hierbo beskryf, voltooi asb 
die vorm hieronder en gee dit terug aan die navorser. 
Die navorsingstudie, asook die die bostaande inligting is aan my verduidelik.  Ek verstaan wat my 
deelname aan die studie behels en ek besluit vrywillig om deel te neem aan die studie. 
 
Naam: ________________________________________________________________________ 
 
 
Handtekening: _________________________________ Datum: ____________________________ 
Terugkeer tot sport na besering:  Ondersoek na die verwantskap tussen 'n 
atleet se tipe motivering en die voorkoms van herbesering
Instruksies: Vir amptelike gebruik:
Merk die gepaste blokkies met 'n X of skryf die antwoord in die spasie daarvoor gelaat. R T S 1-2
1 Wat is u geslag? 3
1 Manlik
2 Vroulik
2 Ongeveer hoeveel jaar ondervinding het u ten opsigte van atletiekafrigting? 4-5
jaar
3 By watter ander sportsoorte is u betrokke ten opsigte van afrigting?  U kan meer as een sport aandui. 6-7
8-9
1 Rugby 10-11
2 Gimnastiek
3 Netbal
4 Hokkie
5 Swem
6 Landloop
7 Muurbal
8 Pluimbal
9 Sokker
10 Tafeltennis
11 Fietsry
12 Krieket
13 Golf
14 Oosterse vegkuns
15 Waterpolo
Ander, spesifiseer:
4 12
Sou u, uself as meer betrokke beskou by atletiekafrigting, as by die afrigting van enige van bogenoemde sportsoorte?
1 Ja
2 Nee
5 Hoeveel jaar ondervinding het u met die afrigting van die volgende spesialisvelde?
Spronge jaar 13-14
Worpe jaar 15-16
Naellope jaar 17-18
Hekkies jaar 19-20
Middel en langafstande jaar 21-22
6 Het u gedurende die afgelope seisoen (2014/2015) enige atlete afgerig wat sy/haar provinsie in atletiek 
verteenwoordig het?
1 Ja 23
2 Nee
7 Indien u ja geantwoord het op die vorige vraag, in watter ouderdomsgroepering(s) het hierdie atlete die provinsie 
verteenwoordig? 
Subjeug 24
Jeug 25
Junior 26
Senior 27
8
Het u gedurende die afgelope seisoen (2014/2015) enige atlete afgerig wat Suid-Afrika in atletiek verteenwoordig het?
1 Ja 28
2 Nee
9 Indien u ja geantwoord het op die vorige vraag, in watter ouderdomsgroepering(s) het hierdie atlete Suid-Afrika 
verteenwoordig? 
Subjeug 29
Jeug 30
Junior 31
Senior 32
10
Wanneer een van u atlete beseer word, moet iemand besluit of die atleet weer gereed is om terug te keer na 
sportdeelname.  Rangskik die volgende belangegroepe in volgorde van die persoon wat volgens u die meeste besluite 
neem rakende die terugkeer na sportdeelname van u atlete tot die persoon wat die minste besluite neem rakende 
terugkeer na sportdeelname.  Skryf 'n 1 langs die persoon wat die meeste besluite neem, 2 langs die persoon wat die 
tweede meeste besluite neem ens.  Indien daar 'n belangegroep is wat nooit betrokke is by besluite rakende terugkeer 
na sportdeelname van u atlete nie, kan u 'n nul (0) langs die groep skryf.
Uself, die sportafrigter 33
Ouers/voogde van die atleet 34
Fisioterapeut 35
Biokinetikus 36
Algemene praktisyn (huisdokter) 37
Sportgeneesheer 38
Onderwyser/persoon aan beheer van atletiek by die skool/klub 39
Sielkundige / Sportsielkundige 40
11 Sou u die volgende van 'n fisioterapeut verwag wat een van u atlete behandel het vir 'n besering?
11.1 Om te besluit wanneer die atleet gereed is om terug te keer na oefening. 41
1 Ja 42-43
2 Nee 44-45
Bykomende opmerkings:
11.2 Om te besluit wanneer die atleet gereed is om terug te keer na deelname aan sport. 46
1 Ja 47-48
2 Nee 49-50
Bykomende opmerkings:
11.3 Om advies te gee oor die hantering van die atleet tydens oefening, om die atleet gereed te kry vir terugkeer na 
sportdeelname. 51
1 Ja 52-53
2 Nee 54-55
Bykomende opmerkings:
11.4 Om advies te gee om te probeer verhoed dat die atleet dieselfde besering weer opdoen? 56
1 Ja 57-58
2 Nee 59-60
Bykomende opmerkings:
11.5 Om die nodige modaliteite in te span (bv. Strapping) om atlete wat slegs geringe beserings opgedoen het,  gereed 
te kry vir deelname? 61
1 Ja 62-63
2 Nee 64-65
Bykomende opmerkings:
11.6 Om ten alle koste die atleet te verhoed om terug te keer na sportdeelname indien daar selfs die geringste 
moontlikheid is dat die atleet se besering kan vererger? 66
1 Ja 67-68
2 Nee 69-70
Bykomende opmerkings:
11.7
Om atlete in die voorseisoen te evalueer om sodoende moontlike areas te identifiseer wat kan lei tot beserings?
1 Ja 71
2 Nee
72-73
Bykomende opmerkings: 74-75
11.8
Om te evalueer of 'n atleet, nie net fisies nie, maar ook psigies gereed is om terug te keer na sportdeelname? 76
1 Ja 77-78
2 Nee 79-80
Bykomende opmerkings:
11.9 Om vas te stel wat die tipe  motivering vir die atleet is om terug te keer na sportdeelname? 1
1 Ja 2-3
2 Nee 4-5
Bykomende opmerkings:
12 Na watter tipe gesondheidsprofessie sou u 'n atleet met die volgende tipe besering eerder verwys vir evaluering en 
behandeling?
12.1 Ligamentbesering of klagtes?
6
1 Fisioterapeut
2 Biokinetikus
3 Algemene praktisyn (huisdokter)
4 Sportgeneesheer
5 Onderwyser/persoon aan beheer van atletiek by die skool/klub
6 Ander
Spesifiseer:
12.2 Spierbesering of klagtes?
7
1 Fisioterapeut
2 Biokinetikus
3 Algemene praktisyn (huisdokter)
4 Sportgeneesheer
5 Onderwyser/persoon aan beheer van atletiek by die skool/klub
6 Ander
Spesifiseer:
12.3 Gewrigsbeserings of klagtes?
8
1 Fisioterapeut
2 Biokinetikus
3 Algemene praktisyn (huisdokter)
4 Sportgeneesheer
5 Onderwyser/persoon aan beheer van atletiek by die skool/klub
6 Ander
Spesifiseer:
12.4 Senuweeweefselklagtes?
9
1 Fisioterapeut
2 Biokinetikus
3 Algemene praktisyn (huisdokter)
4 Sportgeneesheer
5 Onderwyser/persoon aan beheer van atletiek by die skool/klub
6 Ander
Spesifiseer:
12.5 Atlete wat sukkel met motiveringsprobleme 10
1 Fisioterapeut
2 Biokinetikus
3 Algemene praktisyn (huisdokter)
4 Sportgeneesheer
5 Onderwyser/persoon aan beheer van atletiek by die skool/klub
6 Sielkundige / Sportsielkundige
7 lewensafrigter ("life coach")
8 Ander
Spesifiseer:
13 Indien een van u atlete beseer raak tydens 'n belangrike atletiekbyeenkoms, watter belangegroepe sou u graag wou 
betrek by besluite of die atleet deelname behoort te staak by die betrokke byeenkoms of indien die atleet kan 
voortgaan met deelname?
1 Uself, die sportafrigter 11-12
2 Ouers/voogde van die atleet 13-14
3 Fisioterapeut 15-16
4 Biokinetikus 17-18
5 Algemene praktisyn (huisdokter) 19-20
6 Sportgeneesheer 21-22
7 Onderwyser/persoon aan beheer van atletiek by die skool/klub 23-24
8 Sielkundige / Sportsielkundige 25-26
9 Die atleet self 27-28
29-30
Ander, spesifiseer:
14 Vir atlete met dieselfde kondisie en dieselfde risiko, kan terugkeer-na-sport besluite beïnvloed word deur 
omstandighede.   Wanneer hierdie faktore geëvalueer word, rangskik asseblief elk van hierdie faktore van 1 tot 6 
gebaseer op die belangrikheid wat u daaraan toeskryf.  Gebruik elke nommer slegs een keer met 1 as die 
belangrikste.  Gebruik 0 as u glad nie die faktor toepaslik ag nie.
Tydsberekening en seisoen (bv. proewe)
Eksterne druk (bv. afrigter, atleet se gesin) 31
Druk van atleet (bv. begeerte om deel te neem) 32
Konflik van belange (bv. finansieel) 33
Vrees vir vervolging (bv. indien beperk of toegelaat) 34
Verskuiling van besering (bv. effektiewe analgetika) 35
36
15 Dink u dat van u elite atlete soms vroeër terugkeer na deelname aan sport a.g.v. persone, borge of instansies wat 
druk plaas op die betrokke atlete om terug te keer na sportdeelname? 37
1 Nooit
2 Soms
3 Gereeld
4 Altyd
16 Sal 'n aanbeveling omtrent die atleet se tipe motivering om terug te keer na sport vir u as afrigter van waarde 38
wees?
1 Nooit
2 Soms
3 Gereeld
4 Altyd
17 Motiveer asseblief u antwoord op vraag 16:
39-40
41-42
43-44
Baie dankie vir u deelname.
Return to Sport after Injury:  The relationship between an 
athlete’s type of motivation and a recurrence of injury
Instructions Official use
Mark the appropriate blocks with a X or write down the answer in the space. R T S 1-2
1 What is your sex? 3
0 Male
1 Female
2 About how many years of experience do you have with regards to coaching athletics? 4-5
years
3 With which other sports are you involved in with regards to coaching?  You may indicate more than 
one option. 6-7
8-9
1 Rugby 10-11
2 Gymnastics
3 Netball
4 Hockey
5 Swimming
6 Cross country
7 Squash
8 Badminton
9 Socker
10 Table tennis
11 Cycling
12 Cricket
13 Golf
14 Martial Arts
15 Water polo
Other, specify:
4 Do you consider yourself as being more involved with coaching athletics than coaching any of the 12
above mentioned types of sport?
1 Yes
2 No
5 How many years of experience do you have with the coaching of the following specialist fields in 
athletics?
Jumps years 13-14
Throws years 15-16
Sprints years 17-18
Hurdles years 19-20
Middle and long distances years 21-22
6 Did you, during the past season (2014/2015) coach any athletes that represented their province in 
athletics? 23
1 Yes
2 No
7 If you answered yes to the previous question, in which age group(s) did this/these athlete(s) 
represent their province? 
Sub-youth 24
Youth 25
Junior 26
Senior 27
8 Did you, during the past season (2014/2015) coach any athletes that represented South Africa in 
athletics? 28
1 Yes
2 No
9 If you answered yes to the previous question, in which age group(s) did this/these athlete(s) 
represent South Africa? 
Sub-youth 29
Youth 30
Junior 31
Senior 32
10 When one of your athletes is injured, your have to decide when the athlete is ready to return to 
participation in sport.  Arrange the following involved groups in order from the person, that 
according to you, take most of the decisions regarding return to sport of your athletes to the 
person that takes least of the decisions regarding return to sport.  Write a 1 next to the person with 
the most decisions, 2 next to the person with the second to most decisions etc.  If there are any 
groups that never take any decisions regarding return to sport of your athletes you may write a 
zero (0) next to this group. 
Yourself, the sport coach 33
Parents/guardians of the athlete 34
Physiotherapist 35
Biokineticist 36
General practioner 37
Sport doctor 38
Teacher/person in charge of athletics at the school/club 39
Psychologist / Sport psychologist 40
11 Would you expect the following from a physiotherapist that treats one of your athletes with an 
injury?
11.1 To decide when the athlete is ready to return to training. 41
0 Yes 42-43
1 No 44-45
Additional remarks:
11.2 To decide when the athlete is ready to return to participation in sport. 46
0 Yes 47-48
1 No 49-50
Additional remarks:
11.3 To provide advice about the handling of the athlete during training sessions in order to prepare 
the athlete for return to participation in sport. 51
0 Yes 52-53
1 No 54-55
Additional remarks:
11.4
To provide advice on how to prevent the athlete from suffering similar injuries in future. 56
0 Yes 57-58
1 No 59-60
Additional remarks:
11.5 To use the necessary modalities (e.g. strapping) to assist athletes with minor injuries  to 
participate in sport. 61
0 Yes 62-63
1 No 64-65
Additional remarks:
11.6 To at all cost prevent the athlete from returning to sport if there is even the slightest possibility 
that the injury can worsen.  66
0 Yes 67-68
1 No 69-70
Additional remarks:
11.7 To evaluate athletes in the preseason to identify possible areas that may lead to injuries during 
the season.  71
0 Yes 72-73
1 No 74-75
Additional remarks:
11.8 To evaluate if an athlete is not only physically ready, but also psychologically ready to return to 
sport. 76
0 Yes 77-78
1 No 79-80
Additional remarks:
11.9 To determine what the motivation for the athlete is to return to sport. In other words is it really 
the athlete that wants to return to sport? 1
0 Yes 2-3
1 No 4-5
Additional remarks:
12 To which type of health professional would you rather refer an athlete with the following type 
of injury?
To which type of health professional would you rather refer an athlete with the following type 
of injury?
12.1 Ligament injury or complaints? 6
1 Physiotherapist
2 Biokineticist
3 General practitioner
4 Sport doctor
5 Teacher or person in charge of athletics at the school/club
6 Other
If other, specify:
12.2 Muscle injury or complaints? 7
1 Physiotherapist
2 Biokineticist
3 General practitioner
4 Sport doctor
5 Teacher or person in charge of athletics at the school/club
6 Other
If other, specify:
12.3 Joint injury or complaints? 8
1 Physiotherapist
2 Biokineticist
3 General practitioner
4 Sport doctor
5 Teacher or person in charge of athletics at the school/club
6 Other
If other, specify:
12.4 Nerve injury or complaints? 9
1 Physiotherapist
2 Biokineticist
3 General practitioner
4 Sport doctor
5 Teacher or person in charge of athletics at the school/club
6 Other
If other, specify:
12.5 Athletes who struggles with motivation 10
1 Physiotherapist
2 Biokineticist
3 General practitioner
4 Sport doctor
5 Teacher or person in charge of athletics at the school/club
6 Psychologist / Sport psychologist
7 Life coach
8 Other
If other, specify:
13 If one of your athletes is injured during an important athletics meeting, which persons involved, 
would you prefer to involve to decide if the athlete should stop participation at the meeting or 
if the athlete may continue with participation?
If one of your athletes is injured during an important athletics meeting, which persons involved, 
would you prefer to involve to decide if the athlete should stop participation at the meeting or 
if the athlete may continue with participation?
1 Yourself, the sport coach 11-12
2 Parents/guardians of the athlete 13-14
3 Physiotherapist 15-16
4 Biokineticist 17-18
5 General practioner 19-20
6 Sport doctor 21-22
7 Teacher/person in charge of athletics at the school/club 23-24
8 Psychologist / Sport psychologist 25-26
9 The athlete, him/herself 27-28
29-30
Other, specify:
14
For athletes with the same condition and the same risk, return to sport decisions can be 
influenced by circumstances.  When these factors are evaluated, please arrange each of these 
factors from 1 to 6 based on their importance according to you.  Use every number once, 
starting with 1 as the most important.  Gebruik 0 for non-applicable factors.
Timing and season (e.g. playoffs) 31
External pressure (e.g. coach, athlete family) 32
Pressure from athlete (e.g. desire to compete) 33
Conflict of interest (e.g. financial) 34
Fear of litigation (e.g. if restricted or permitted) 35
Markin the injury (e.g. effective analgesia) 36
15 Do you think that some of your elite athletes return to sport earlier due to pressure to return to 
participation in sport from persons, sponsors or institutions? 37
1 Never
2 Sometimes
3 Often
4 Always
16 Will a recommendation regarding the type of motivation of an athlete to return to sport be of 38
any value to you as a coach?
1 Never
2 Sometimes
3 Often
4 Always
17 Please motivate your answer to question 16:
39-40
41-42
43-44
Thank you for your participation