Abstract :
This randomized controlled trial investigated the role of fear of re-injury and self-efficacy as mediators of training load and competitive performance in adolescent athletes with tennis elbow. Forty-seven competitive racquet sport athletes aged 13–19 years with clinical lateral epicondylitis were recruited for the study. Participants with baseline Tampa Scale for Kinesiophobia scores >20 were randomized into either intervention group (cognitive-behavioral therapy plus standard rehabilitation) or the control group (standard rehabilitation only). The 8-week intervention consisted of weekly psychological skills training sessions of graded exposure, self-efficacy enhancement, and cognitive restructuring. Assessments were made at baseline, week 4, week 8, and at 4-week follow-up. Primary outcomes included Fear of Re-Injury, Self-Efficacy, training load and competitive performance metrics. The PROCESS macro was used to conduct a mediation analysis testing the mediating role of psychological factors. Significant reductions in fear of re-injury and improvements in self-efficacy were observed in the intervention group compared to controls (p < 0.001). These changes significantly mediated improvements in training load tolerance (indirect effect = 544.0, 95% CI: 289.3–856.1) and competitive performance (indirect effect = 12.0, 95% CI: 5.7–20.4). Effect sizes were large for fear reduction (Cohen's d = 1.56) and self-efficacy enhancement (d = 1.48). Psychological intervention effectively reduces fear of re-injury and enhances self-efficacy in adolescent athletes with tennis elbow. These psychological changes directly mediate improvements in training load and competitive performance. Findings support integrating psychological skills training into standard rehabilitation protocols. Future research should examine long-term sustainability and dose-response relationships.