How to successfully deal with the psychological scars of sports injury

Getting injured sucks! No two ways about it. If you’re an athlete participating in sport at any level then the chances are you know all about the disappointment of being forced to stop doing what you enjoy as a result of pain and injury. Unfortunately the risk of injury is inherent to participating in sport. Just look at the numbers; circa 8 injuries per 1000 hours play in football, 12 injuries per 1000 hours in field hockey and a staggering 47 per 1000 hours in senior amateur rugby! 

Of course, not all injuries are equal. A dead leg from a collision doesn’t compare with an ACL rupture for example. Some injuries can be managed with some TLC and some require in depth treatment, maybe surgery and at times a few mental barriers to overcome as well.

It is something the sports and exercise medicine world has become more aware of in recent years, that injuries don’t just  leave physical scars but mental ones too. After a significant injury it can often leave us with question marks over the future  and even financial burden regardless of what level you compete at. Getting back into sport after a significant injury isn’t just about tissue healing, muscles getting stronger and joints being flexible and robust. Sometimes it’s about addressing the psychological readiness to get back out there and compete in our respective sports. 

Research investigating the psychological effects of injury has concluded that psychological problems tend to fall under the headings of; re-injury anxiety, depression and loss of athletic identity. Re-injury anxiety is defined within literature as; an irrational and debilitating fear or anxiety that physical movements will result in painful reinjury. One of the big issues with this is that it seems to become a self-fulfilling prophecy. Athletes who display re-injury anxiety also demonstrate poorer concentration levels, lower self-confidence, increased distractibility and higher levels of pain awareness. Additionally, they tend to show heightened arousal levels by way of increased heart rate, generalised muscle tension and possibly more significantly guarding of the injured area. Muscle guarding tends to change our movement patterns and may actually increase the likelihood of injury because we start moving and performing tasks in abnormal ways.

As well as re-injury anxiety, depression can frequently affect us when we’re injured. Research would suggest that the severity of depression symptoms is linked to the extent of the injury and specifically the limitations of mobility, length of rehabilitation and the delay in being able to return back to our sports. The cause of these depression symptoms links to feelings of frustration, injustice, isolation, worry about loss of skill or opportunities and overall absence from participation which can then lead to a loss of athletic identity. 

Why is it important to know about these problems? Well they can have an impact on how well we engage with rehabilitation and ultimately result in us requiring additional support and intervention techniques in order to achieve a successful return to sport. Some research has shown that the way an injury is perceived by the athlete has a critical role in influencing the emotional and psychological responses to the injury. Those athletes who demonstrate higher fear of re-injury also showed greater levels of hesitancy when performing tasks, not committing 100% to rehab and avoiding perceived injury-provoking situations during rehab.  

So how do we overcome these issues?

From available literature psychologically informed practice has been advocated for patients with low back pain, chronic musculoskeletal pain and knee osteoarthritis. The approach involves measuring key psychological factors that are likely to affect outcome and including them as part of the treatment. Interventions with successful outcomes include education to reduce fear avoidance beliefs, quota-based exercise and graded exposure.  

Ultimately this means we need to explore some of the fears and pain beliefs we have around our injury. This enables us to incorporate some of these challenges into the rehabilitation process and establish a hierarchy of concerns leading towards the greatest fear. For example, let’s take someone who ruptured their ACL and now has a concern about turning and sprinting. Once this fear has been identified a graded exposure technique would see the athlete start at straight line walking or jogging, moving up through side stepping, to turning slowly on the spot then jogging all the way up to turning and sprinting in a very sport specific way. Of course there would likely be many more steps involved and this process may take days, weeks or, in the example of the ACL, months.

Ultimately injuries leave us with more than just physical imprints of injuries and to experience psychological doubts after injury is common. Once we acknowledge and explore them we can start to combat them too.

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