The fear of returning to sport after an injury

Whether you’re a professional athlete representing your country or a weekend warrior playing for your local social team, there is a good chance that at some point in your athletic career you’ll end up being injured. For most athletes an injury is simply a physical event which prevents them from participating in their chosen activity, and while it might be frustrating, most athletes eagerly await their return to sport. However, for some this process becomes more difficult as the injury has both physical and psychosocial elements to it.1 This short blog entry aims to look at some of the emotional barriers faced by athletes and how the psychosocial components of recovery are often forgotten during rehabilitation.

Over the past two decades researchers and practitioners have identified that rehabilitation from an injury needs to be holistic and include both physical and psychosocial elements. The framework of self-determination theory (SDT) established by Ryan and Deci helped identify common issues which can increase an athlete’s anxiety after an injury and these elements remain the focus of ongoing research.2 A particular focus is devoted to; re-injury anxiety, concerns about an inability to perform to pre-injury standards, the feeling of isolation, insufficient social support, external pressures to return to play and finally self-presentational concerns.2

I’ve taken these key points and have identified a number of strategies that can be help overcome these barriers.

  1. Re-injury anxiety
    Re-injury anxiety represents one of the largest barriers for athletes to overcome when returning to play. This has the risk of leading to a self-perpetuating cycle of injury, as the stress of potentially re-injuring yourself can lead to an increased likelihood of injury, through increased muscular fatigue, reduced timing and diminished coordination.3

    It should be explained to players that there is no set timeframe to their rehabilitation and their progress will be structured around both physical and psychological assessments. Medical and support staff should map out stages of rehabilitation from the start so the athlete themselves can clearly see their progress. There are a number of functional assessments available that can help evaluate a player’s physical4 and psychological5 state during their recovery.If individuals adopt the role of the injured athlete; relaxation, imagery and modelling techniques can help reduce anxiety and build confidence.6 These techniques can include films, breathing exercises or referral to a sport psychologist.
  2. Not being able to perform at pre-injury standards
    Athletes will often stress that the injury has led to a reduction in of both fitness and skills associated with the activity. Often the anxiety surrounding this fear can lead to a reduction in confidence which only exacerbates the situation.7 Furthermore, they can experience stress surrounding the idea that fellow athletes are continuing to improve during their rehabilitation.8Coaches and athletes should take the opportunity to fine tune skills during rehabilitation which they wouldn’t normally have time to develop. This helps athletes overcome any anxiety surrounding a loss condition. A stepwise sequence and specific exercises can help make the athlete actually stronger than before and prevent future injuries.In the final stages of rehabilitation full recovery should be confirmed not only through functional testing but also high intensity training and return to competition. Athletes will often benefit from competing in a level that was below their pre-injured level to help gain confidence and reassurance that they can perform at pre-injury standards.
  3. Feeling of isolation and lack of athletic identity
    Athletes are people of habit and often find the most disruptive part of being active is the loss of routine that training brought. It can often lead to a sense of isolation and alienation, especially if they trained as part of a team.9 For many athletes, even ones that no longer participate in their chosen sport still label themselves as an athlete. For an individual that is injured, the idea that they might lose their identity is very distressing.10Rehabilitation shouldn’t be an isolated progress. Injured athletes should still continue to have the same training structure as before and when possible train in the same location. Furthermore, it is beneficial to structure your rehabilitation around the drills and training of your team or squad as athletes will prosper from the social support of coaches, teammates and significant others.A good strategy to overcome isolation is to pair up injured athletes so they can go through rehabilitation together of by having athletes that have previously experienced similar injuries mentor the athlete through their recovery.
  4. Insufficient social support
    Teammates and Coaches soon forgot what it’s like to be injured and can be very insensitive to injured athletes.11Athletes need to be educated about their injury so their expectations can be managed. It is important they remain motivated to returning to sport and this can be helped by giving the athlete an input into the course of their recovery and try to keep the athlete involved with the team or squad as much as possible.
  5. Pressure to return to sport
    Pressure to return to activity can come from all areas from a coach of a professional football team to your workout buddy. Often they draw on your non-injured state and assume you are both physically and mentally ready to return. Often an early return from injury can be motivated by the athletes/team’s competition schedule.
    It is important that athletes have an open forum where they feel comfortable discussing any fears they may have regarding returning to play. It may also be important for the medical staff to outline to the athlete and coaching staff the risks of returning to sport to soon.
  1. Concerns about the way you’ll look
    No one wants to look foolish and often athletes can have a genuine fear that they wont be able to demonstrate their skills as they could before. This fear can manifest into thoughts of how their reputation or image may be damaged. There is also the anxiety surrounding the notion of letting down teammates and coaching staff by not living up to one’s reputation.This can be avoided if athletes are given realistic targets to performance so their confidence doesn’t drop after possible poor initial performances. This can be especially difficult for elite athletes where there is often an attitude of winning at all costs. Simulation training in structured practice can help give athletes confidence.Confidence can also be developed by setting certain fitness goals so the athlete is able to see a longitudinal development through rehabilitation. However, it’s important that these goals are realistic, specific, measurable and action oriented.12

SDT helps us recognise that athletes sit on a continuum, with being anxious about returning to play at one end and being ready to return to play at the other. The individual’s behaviour is influenced by a number of external and internal motivations. By understanding this theory medical partitioners can recognise what support the athlete needs to enable them to get back to full fitness.

Every athletes experience of injury and return to sport is different and while the theoretical

Models provide a framework for understanding an individual’s motivations, it is up to the coaching and medical team to facilitate an individualised approach.

Understandably, most research focuses on elite and professional athletes. However, there is a small number of studies conducted by orthopaedic surgeons looking at the rate of amateur athletes returning to sport after an anterior cruciate ligament (ACL) tear and they found that only 50% of individuals return to sport.13 I would argue that many of the psychosocial barriers that face professional athletes exist for amateurs, with the anxiety surrounding re-injury being the largest barrier to returning to sport. However, you would expect the motivations to overcome these barriers to vary between these two groups. For many elite athletes sport is a major part of their lives, whereas amateur athletes may have a stronger focus on family, careers and relationships.

Currently, the research identifies a number of psychosocial stresses and anxieties common among professional athletes returning to sport following injury rehabilitation. Many of these papers then go on to suggest a number of ways to overcome or avoid these barriers.14 While this is important, most professional athletes have a large support team that are able to facilitate their physical and psychosocial rehabilitation. Whereas, my concern is for everyone else, the elite athlete through to the social athlete, who doesn’t have this support and ends up not returning to full activity because of it.

The main issue here is; whose responsibility is it to address or at least identify the emotional barriers faced by an amateur athlete during their rehabilitation? Many amateur athletes wont even see a physician unless the injury is serious enough and may just manage the injury themselves, others may have a number of sessions at a physiotherapist, while more severe injuries may need surgery. So is it something individuals themselves need to be aware of or can physiotherapists, physicians or even surgeons do more to manage the emotional needs of an athlete during rehabilitation.

I believe that the responsibility to actively manage both the physical and emotional side of an athlete’s injury doesn’t lie with any one individual. Medical practitioners, coaches and social support may have limited contact with an amateur athlete during their rehabilitation so it is vitally important that they are all proactive in taking a holistic approach to each patient’s management. A few simple modifications to a patient’s rehabilitation which address the athlete’s psychosocial needs can potentially avoid short term anxiety and the detrimental effects associated with not returning to sport at all.

References

  1. Bauman J. Returning to play: the mind does matter. The Journal of Clinical Sports Medicine. 2005;15:432-435
  2. Ryan R & Deci L. Self-determination theory and the facilitation of intrinsic motivation, social development and well-being. Am Psychol. 2000;55:68-78.
  3. Williams J. & Andersen B. Psychosocial antecedents of sport injury review and critique of the stress and injury model. Journal of Applied Sport Psychology 1998;10: 5e25.
  4. Abrams G. Harris J. Gupta A. McCormick F. Bush-Joseph C. Verma N. Cole B. and Bach B. Functional performance testing after anterior cruciate ligament reconstruction. Orthopaedic Journal of Sports Medicine. 2014;2(1):224-230
  5. Webster K. Feller J. & Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Physical Therapy in Sport. 2008;9(1):9-15
  6. Cupal D and Brewer W. Effects of relaxation and guided imagery on knee strength, reinjury anxiety, and pain following anterior cruciate ligament reconstruction. Rehabilitation Psychology. 2001;46;28-43.
  7. Podlog L. & Eklund C. A longitudinal investigation of competitive athletes’ return to sport following serious injury. Journal of applied sport psychology. 2006:18;44-68
  8. Tracey, J. The emotional response to the injury and rehabilitation process. Journal of Applied of Sport Psychology. 2003;15:279e293.
  9. Messner A. When bodies are weapons: masculinity and violence in sport. International Review for the Sociology of Sport. 1990;25:203e220.
  10. Bianco T. & Eklund C. Conceptual considerations for social support research in sport and exercise settings: the case of sport injury. Journal of Sport & Exercise Psychology. 2001;23:85e107.
  11. Johnston H. & Carroll D. (1998). The provision of social support to injured athletes: a qualitative analysis. Journal of Sport Rehabilitation. 1998;7:267.
  12. Messner A. When bodies are weapons: masculinity and violence in sport. International Review for the Sociology of Sport. 1990;25:203e220.
  13. Kvist J, Ek A, Sporrstedt K and Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee surgery Sports Traumatology Arthroscopy. 2005;13:393-397
  14. Podlog L, Dimmock J and Miller J. A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes. Physical Therapy in Sport. 2011;12:36-42
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